Caring for the mother-child dyad as a family physician

WHAT IS THE MOTHER-CHILD DYAD?

The mother-child dyad – the mother-offspring unit – share an intimate biological, social and psychological relationship. It is no surprise that infant social, emotional and neurological development is shaped by the bond established between mother and child. The quality of this attachment, often reflected in the level of maternal emotional availability, maternal sensitivity and responsiveness to infant cues, determines how infants learn, form relationships, experience the world and regulate their emotions. For example, young children demonstrate ‘social referencing’, in that they use parents’ emotional expressions as guides in approaching or withdrawing from physical and social stimuli.(1) In an unfamiliar situation, a mother’s emotional availability has a positive effect on the infant’s affective, social and exploratory behaviours. Conversely, a physically present but emotionally unavailable mother invokes displeasure and inhibits her child’s exploration.(2,3)

Infants who learn that their social initiatives are successful in getting a reciprocal response from their attachment figure are likely to be more secure, active and happy in their interactions; they also show more attentional engagement with their caregiver, fewer resistant behaviours and greater physiological regulation in response to stress.(4) Mothers do not need to be perfect, just ‘good enough’ to provide a secure base.(5)

WHY IS THIS IMPORTANT TO MY PRACTICE?

Maternal mental health is closely linked to child mental health and development. One in eight mothers experience postpartum depression.(6) Mothers with depression have been found to be less attuned to their infant’s needs, demonstrate poorer responsiveness to infant cues, and display more negative, hostile or disengaged parenting behaviours. This is in turn associated with lower cognitive functioning and adverse emotional development in their children.(7,8)

Short lapses in caregiving can be compensated for, but persistent attachment difficulties can cause longstanding ramifications. This is because neuroplasticity is highest in the first thousand days of a child’s life, beyond which it becomes progressively harder to reverse any adverse adaptations that the child may have made in response to its mother’s lack of attunement.(9) Children whose mothers had persistent and severe depression (as compared to children of mothers with transient postnatal depression) were at increased risk of behavioural problems by age 3.5 years, increased risk of depression in adolescence(10) and increased risk of stunted growth.(3,11)

WHAT ARE THE RED FLAGS AND RISK FACTORS TO LOOK OUT FOR?

Risk factors for dysfunction in the mother-child dyad include medical and psychiatric illness in both mother or child, as well as challenging socioeconomic circumstances.(12) Red flags to look out for include reduced maternal attunement, reduced child responsiveness to the mother, and restricted child growth and development (Table I). The family physician should also be cognisant of injury patterns suggestive of physical child abuse, which is beyond the scope of this article but was discussed in a previous Practice Integration and Lifelong Learning article on management of child abuse.(13)

Table I

Red flags for dysfunction in the mother-child dyad.

WHAT CAN I DO IN MY PRACTICE?

The family physician is well-positioned to identify at-risk or dysfunctional mother-child dyads, and intervene to change the trajectory through touchpoints such as scheduled well-child developmental assessments, the routine postnatal check and ad-hoc consultations for acute illnesses.

Simple tips to support the new mother (Box 1) are especially beneficial as a first step, and remain useful in mothers who decline referral to mental or emotional health services. The family physician can support mother-child interaction by encouraging the mother to talk positively in a gentle tone to the baby; this can nudge the dyad in a healthier direction.

Box 1

Tips for mothers on emotional wellness after childbirth:

Scheduled well-child developmental assessments are an opportune time for the family physician to screen the mother for postnatal depression, as recommended by the American Academy of Pediatrics.(14) In Connecticut, a well-established programme sited at a community health centre screens mothers for depression during pregnancy, at the routine six-week postpartum visit and during the infants’ well-child visits.(15) Locally, the Integrated Maternal Child Wellness Programme, a novel collaboration between SingHealth Polyclinics and KK Women’s and Children’s Hospital’s (KKH) Department of Paediatric Medicine and Women’s Mental Wellness Service, uses a two-question screen (Patient Health Questionnaire 2) for maternal depression during scheduled well-child visits at Punggol Polyclinic (Fig. 1).(16) If the mother is not present (e.g. if the child is accompanied by the grandparents or domestic helper), the physician can enquire about the mother’s well-being and encourage her to visit the clinic. Further details on what to do if the screening is positive can be found in a previous Practice Integration and Lifelong Learning article on postnatal depression.(16)

Fig. 1

The Patient Health Questionnaire 2 screen for maternal depression.

Early identification of mothers with depression is important so that they can be connected to services that might mitigate the impact of the depression on the mother-child dyad. Studies of maternal depression screening in paediatric practice suggest that (a) it is feasible; (b) it yields a significant number of mothers who require intervention; and (c) intervention is effective, translating into positive child outcomes.(15) Locally, a screening and early intervention programme for postnatal depression in KKH (established since 2008) has shown improved clinical outcomes in the affected mothers’ symptoms, function and quality of life.(17)

WHAT RESOURCES ARE AVAILABLE FOR MOTHER-CHILD DYADS?

At an informal level, the family physician can encourage the mother to engage her spouse and family for support, especially senior members for their advice and experience. Enlisting the help of friends, colleagues or religious group members (educating and equipping them if necessary) can also be useful. Community support resources include Family Service Centres, counselling hotlines, community mental health services and other support programmes (Table II). KKH also offers home-based mother-infant therapy under the SURE MUMS (SUpporting Resilience and Empowering MUMS) programme.

Table II

Safety net of resources according to type of help provided.

If it appears that psychiatric attention will be beneficial, the family physician should offer to refer the mother to psychiatric services that are available in all restructured hospitals. Subspecialised services for maternal emotional and mental health are also offered at KKH and National University Hospital.

TAKE HOME MESSAGES

1. Persistent attachment difficulties in mother-child dyads, as well as maternal mental health problems, can lead to long-term consequences for the child’s mental health and development.

2. Red flags for dysfunction in mother-child dyads include reduced maternal attunement, reduced child responsiveness to the mother, and restricted child growth and development.

3. The family physician can screen for dysfunction in the mother-child dyad and maternal depression during scheduled well-child visits.

4. Early identification of maternal depression facilitates intervention and can translate into positive child outcomes.

5. Resources to support mother-child units include informal help from family and friends, community resources, and specialist psychiatric services.