In Depression’s Shadow

Michelle Falli’s three children bear no outward scars of their mother’s depression. But 35-year-old Falli is a nurse as well as a mother, and she is trained to look for signs of need or trouble. Every day, she says, she searches her children’s faces for signs of the despondency, anger or hopelessness that have haunted her, on and off, for most of her life.

And sometimes, when she studies the face of her 6-year-old, Allison, Falli can’t help but imagine she sees the searing redness left by a slap she delivered almost two years ago during a particularly angry bout of depression. It is in those moments that Falli sees the injury that might be--or could have been.

Since that “rock bottom” day of the slap, Falli has undergone psychotherapy and found medication that tames her depressive symptoms and cuts through what she calls “the fog” in which she tried, for years, to parent. She’s dropped the “talk therapy” but stuck with her antidepressant. Without that, says Falli, “I would not function as a mom at all. I might not even be here. ... These pills saved my life.”

And, she hopes, the lives and well-being of her kids.

In Texas, the five drowned children of Andrea Yates have been buried for three months--victims, apparently, of a mother’s chronic depression spun out of control in the wake of childbirth. The legal proceedings that will decide Andrea Yates’ accountability for her children’s deaths are set to begin this week.

But across the nation, the cost--to children and their families--of a mother’s depression are only beginning to be tallied. Researchers and mental health professionals, however, say the evidence is already strong and growing stronger: When a mother suffers from chronic and untreated depression, her children are likely to pay a heavy price. They are the unseen victims of their mother’s misery.

A welter of recent research shows that few other factors have the potential to suppress a child’s emotional and intellectual trajectory more dramatically than a mother’s depression. In some studies, it has proved to be nearly as strong a predictor of a child’s future as family income and mother’s education--two of the most potent factors known to researchers. As a group, the children of depressed mothers have rates of depression themselves that are two to four times higher than those with healthy moms, and they have much more problematic relationships with their mothers, as well. In seemingly unrelated measures like language and other cognitive skills, their performance lags behind that of their counterparts whose mothers were free of depression. They fare more poorly in school, on average, and as adults, in work and in social situations. And they are five times more likely to fall prey to alcohol dependency.

In 30 years of clinical practice, Brentwood psychiatrist Marjorie Braude has treated a long line of children of depression, most of them seeking her help as adults. Her experience tells her three things: The damage a mother’s depression can inflict on a child can be profound; it can be remarkably lasting; and with the therapies and medications available today, it can be avoided.

“I’ve heard it over and over: ‘If only my mother had had these medications, her life--and my life--would have been different.’ It’s a statement I’ve heard many times, frequently with a tear in the eye,” Braude says.

A parent’s depression “is a very strong predictor of the outcome of a child,” says epidemiologist Myrna Weissman of Columbia University’s School of Public Health, who is one of the nation’s foremost trackers of depression and its toll. Either parent’s depression can have major impacts, Weissman says. But she says that for two reasons, the impact of mothers’ depression is more studied and better understood than the effects of paternal mental illness: First, depression in women is more widespread--the rate is twice as high as for men; and second, women are far more likely to be their children’s primary caregivers, so their emotional well-being is likely to have a direct impact on a child. As dads take on greater roles in their children’s care, many researchers say, future studies should do more to measure how fathers’ mental health affects their kids.

To understand the impact of a mother’s untreated depression over time, you might think of her disease as a wet baby blanket, issued at birth--a chilly, heavy blanket that can bind the free movement of a little one that turns to her for warmth and protection. If the depression persists, the blanket can get heavier and ever more entangling to the growing child, dampening her spirit and suppressing her emotional and intellectual growth.

But, as in a game of peek-a-boo, baby blankets are meant to come off, and therein lies the potential good news. If depressed moms and their families get help, most researchers believe, the blanket can be lifted from the child, possibly without lasting effects.

Michelle Falli is counting on it.

“I have to believe I caught it in time and that I’m a better mom for it,” Falli says, who says her mother struggled with unacknowledged depression throughout her child-rearing years. “I have to believe they will be fine. I’ll make myself nuts if I don’t.”

Going Beyond Postpartum Depression

In the wake of the Andrea Yates case, much has been written about postpartum depression, in which the shifting tides of pregnancy hormones can send as many as one in 10 new mothers into a debilitating depressive state. Like Yates, women who have suffered bouts of depression before pregnancy are at greater risk of postpartum depression.

But painful as it can be, postpartum depression is normally short-lived: Most often, a new mother pulls out of her emotional trough as her hormones regain their balance--usually within a baby’s first six months.

To many experts, the Yates case underscores not the dangers of postpartum depression, but of “chronic maternal depression”--the gnawing beast that continues to haunt a mother long after her child outgrows babyhood.

Affecting about 13% of women of childbearing age, this mental illness is probably more widespread and far less diagnosed than postpartum depression, experts say. Maternity doctors are increasingly trained to look for signs of postpartum distress, but women suffering long-term depression are less likely to come forward or get noticed. And because their mental illness persists, affecting more children over longer periods of time, it is arguably far more damaging to the children involved than a bout of the “baby blues.”

Except in cases in which postpartum depression prompts a mother to hurt her baby, experts seem to agree that this more temporary form of the blues is unlikely to hurt a child. But sometimes, postpartum depression doesn’t yield; the loneliness, lethargy, difficulties with sleeping or eating, fear and hopelessness hang on indefinitely. When the symptoms of depression settle in for years--even if they abate for several weeks at a time--most experts would diagnose chronic depression, a mental illness that requires treatment, for a patient’s sake and her children’s.

But for all the distinctions seen between postpartum depression and its chronic cousin, both start out in the same place. With their infants, depressed mothers typically speak less “motherese,” the high-pitched trilling that draws a baby’s attention and stimulates his earliest interactions and language development. These mothers gaze less at their babies, disengage more frequently from them and are more likely to get flustered or frustrated by their demands.

“They make statements like, ‘You don’t like me,’ ‘I’m boring you,’ or ‘Maybe I should just go away,”’ says Harvard psychologist Katherine Weinberg, who has studied the interactions of thousands of mothers and infants. “It’s very sad, really. They know that things aren’t going that well.”

When all is well with both mother and child, Weinberg says, a baby’s early interactions with her mother are not so much a synchronous waltz as an “ongoing negotiation of errors” that, in time, brings parent and child into a state of mutual sensitivity and harmony. Mom, in short, learns to read her baby’s signs of distress when she draws too close, speaks too loudly or provides too much stimulation. And she backs off, quiets down or turns down the music.

But in most depressed moms, Weinberg says, the illness interferes with this disjointed dance, causing mothers to miss--or misread--their baby’s cues. Those babies, in turn, are less likely to develop smooth responses of their own, as well as the confidence to strike out and explore their surroundings boldly.

Researchers, however, point out that even a chronically depressed mother doesn’t predestine a child to a lifetime of suppressed intellect or failed relationships. Many children of depressed mothers--as many as half, estimates Harvard psychiatrist and author William Beardslee--weather their parent’s depression unscathed, achieving healthy lives and success in school.

And a national study that followed more than 1,200 mothers and their children from birth to a child’s third birthday--considered a landmark survey of child development--found that in spite of their illness, some depressed moms--particularly those with lots of family support or higher family incomes--were able to manage the kind of attentive back-and-forth necessary for their children’s healthy emotional and intellectual development.

But for all of these disclaimers, depression does assuredly shift the odds against a kid.

For the child of a mother with chronic and untreated depression, life itself is more likely to start too early: According to Dr. Rita Suri of the UCLA Mood Disorders Center, hormonal irregularities in pregnant women with depression appear to contribute to a higher-than-average rate of premature births to such mothers. The result for their children can be low birth weights and a lifetime of health complications or heightened vulnerabilities.

By the age of three months, an infant with a depressed mother will show marked behavior differences when playing with his mother or interacting with her environment. In experimental situations observed by Harvard’s Weinberg and colleagues, babies with depressed moms were likely to greet their mother’s emotional withdrawal from them with sadness or utter indifference. When a healthy mother pulled a blank face on her child--essentially feigning withdrawal--the baby was likely to cast about frantically--smiling, fussing, fidgeting--to regain his mother’s attention.

By the age of 1, the child of a chronically depressed mother is more likely to show brain activity which, in an older child or an adult, would accompany sadness or irritability. By the age of 3, she is likely to speak less, to perform more poorly in a range of skills that are considered necessary for early success in school, and to be more uncooperative than a comparable child with an emotionally healthy mother. And the pattern of her brain’s activities and composition of hormones in her bloodstream will show the telltale signs of stress and sadness that adults suffering from depression exhibit.

When it comes to emotional fallout, researchers surmise that a child’s first two to three years, when critical brain functions are getting wired up and a baby’s dependence on its mother is at its zenith, is a period of special vulnerability for the child of a depressive mother. But they acknowledge they do not have the data to back up the claim.

They do have data, however, showing that little boys are more vulnerable than girls to the effects of their mother’s depression. Neurologically less mature at birth, male babies remain more dependent on their mothers than do girls for shaping their social responses and helping them regulate their emotional states, explains Harvard’s Weinberg. And girls may be better at getting the attention they need from others. So Weinberg says that when a mother’s depression disrupts her ability to provide a little boy the “emotional scaffolding” he needs, he’ll likely do a poorer job of exploring his surroundings, trying out new social skills and reining in his impulses and emotions.

But girls seem to have special vulnerabilities as well. By her teenage years, the child of a depressed mom is more likely to have weathered the marital breakup of her parents, since depressed women have a higher rate of divorce than women with no such mental illness. And for the daughters of depression, that fact leads to a surprising outcome, according to Bruce Ellis, a psychologist at the University of Canterbury, New Zealand. The female offspring of depressed women begin to enter puberty at an earlier age than the daughters of healthy mothers, Ellis found in a study that followed 87 girls from childhood and into adolescence. And in broad populations where puberty comes early, sex and childbirth are likely to come earlier as well.

Ellis and his fellow researcher, Vanderbilt University researcher Judy Garber, surmised that, from an evolutionary point of view, a girl facing early family stresses--including a mother’s depression--would naturally mature earlier, readying her for an earlier escape from the troubled family. The higher divorce rates among women with depression also play a role in inducing earlier puberty, Ellis explains, because they tend to bring stepfathers and mothers’ boyfriends into the lives and homes of young girls. Ellis and Garber found that the earlier a girl is exposed to an unrelated father-figure--such as a boyfriend or stepfather appearing in the wake of a mother’s divorce--the earlier she will enter puberty.

All of this, say those who study and work with depressives, underscores the importance of treating the disease--and those in its line of fire. It is estimated that only about a third of depression sufferers get professional help. And their children, almost without exception, are left to fend for themselves.

‘So Much Potential’ to Help Those Who Suffer

As a public health issue, says Geraldine Dawson, a psychologist from the University of Washington, this is a no-brainer: Depression is widespread--striking more than 10% of mothers with young children; its effects ripple out to many more kids. It is relatively easily detected, if a physician or social worker gets instruction in what to look for. And with a wide and ever-growing range of treatments, depression will diminish or disappear in more than 80% of patients. Considering the relative ease and impact of helping a depressive mother, targeting this population of sufferers should get high priority, Dawson adds.

“There’s so much potential to intervene,” Dawson says. “From a public-policy point of view, this is an easy one.”

Indeed, in recent years, the nation’s sweeping effort to reform welfare has made the subject of maternal depression a key policy issue for many state officials. The reason: The rate of depression among low-income mothers has been found to be two to three times as high as in the population of women as a whole. Samples of welfare-dependent moms show that nearly three in 10 suffer from chronic depression.

For states charged with moving these women off welfare and into work, and with breaking an intergenerational cycle of poverty, depressed mothers are a population that can no longer be ignored. In many states, officials report, mothers hobbled by mental health issues make up a substantial portion of those still dependent on public assistance. And state officials, says Con Hogan, a former welfare director in Vermont, have become acutely aware that these women are “one of the big barriers” to their success in driving down welfare rolls.

And they are not always easy to help. In an experimental welfare initiative studied in 1997, poor teenage mothers were targeted for a package of programs intended to ready their kids for school and ready the young women for jobs. By the end, however, those participants who were depressed reported much higher stress levels than those who were not depressed, and their children suffered the consequences, according to a later analysis of the program’s impact. Citing this finding, the nation’s premiere congregation of child development experts, writing for the National Research Council and Institute of Medicine, concluded last year that for such mothers, treating their depression may simply have to come first.

So when it comes to protecting kids from a parent’s depression, what works?

At a minimum, researchers say, mom must get help, and a combination of “talk therapy” and antidepressant drugs is widely believed to be the most successful treatment. If her depression abates or even becomes intermittent, “there’s a hopeful message” in the research numbers, says Martha Cox of University of North Carolina. In the national sample of kids they have followed for almost a decade, a federally funded research team recently found that the children of mothers who reported “intermittent” depression look more like kids with healthy parents; it was those with chronic depression that fared the worst.

But Harvard’s Beardslee has sought to go beyond that source, emotionally inoculating a child against a parent’s depression.

For more than two decades, Beardslee has studied the children of depressed parents, seeking to distill the secrets of the resilient ones who dodged the odds against them. The resulting program at Boston Children’s Hospital treats kids between ages 8 and 15 and their families, and more than 100 families have passed through it since it began in 1985. Its formula: not only to get direct treatment for the afflicted parent, but to teach their children the key ingredients to coping.

In nearly all of the resilient kids, Beardslee observed deep commitments to friends and family and a drive not only to help out at home, but also to develop networks outside, at school or in a broader community. And all of these kids understood they were not responsible for their parent’s disease.

“They knew what they could and couldn’t do about it, and they took actions consistent with that,” said Beardslee, author of a forthcoming book titled “Out of the Darkened Room: Protecting the Child, Strengthening the Family When a Parent is Depressed.”

Many, however, believe that intervention could start even earlier. They point to a child’s first two to three years as a key opportunity to correct a relationship between mother and child that may start bad and either never get back on track or get worse.

“The infant is the forgotten patient here and really needs to be put back into the equation,” Harvard’s Weinberg says. “If you don’t address that relationship [between infant and mother], you don’t change the communication.”

And when it comes to reducing the impacts of a mother’s depression, money does help, researchers acknowledge. Not only do more affluent mothers tend to have the resources and education to get help, they tend to have fewer of the “multiple stresses”--depression mixed with substance abuse, domestic violence or household transience--that tend to send the affected family into a tailspin.

Finally, while treating a parent’s depression is key, experts say acknowledging it openly within families is an essential way to help protect kids from the risks it brings. When a depressed mother levels with her children about her disease, she is better able to cope and they are less likely to conclude, in the way that only kids can, that mom’s bouts of sadness are somehow their fault.

Michelle Falli knows that acknowledging her family history of depression has helped her plot a different course for her children than the one she took as a child. Stigma and stubbornness, Falli believes, prevented her mother from acknowledging her own chronic depression, with the result that Falli and her siblings “never got the hugs, the kisses, the ‘we’re so proud of you”’ praise that keeps kids thriving. By contrast, when she’s sad, she says so and makes sure to explain it’s her illness--not their actions--that have got her down, Falli says. And sad or not, she says, she lavishes her children with the hugs and kisses and praise she missed out on as a child.

“I’ve overcompensated in the other direction,” she says today. “I figure ... what’s the worse that can happen?”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

What Is a Depressive Disorder?

A depressive disorder is an illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months or years. Appropriate treatment, however, can help most people who suffer from depression.

Signs of depression:

* Persistent sad, anxious or “empty” mood.

* Feelings of hopelessness, pessimism.

* Feelings of guilt, worthlessness, helplessness.

* Loss of interest or pleasure in activities that were once enjoyed, including sex.

* Decreased energy, fatigue, being “slowed down.”

* Difficulty concentrating, remembering, making decisions.

* Insomnia, early-morning awakening or oversleeping.

* Appetite and/or weight loss or overeating and weight gain.

* Thoughts of death or suicide; suicide attempts.

* Restlessness, irritability.

* Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain.

Not everyone who is depressed experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals.

*

Source: National Institute of Mental Health (www.nimh.nih.gov/publicat/depressionmenu.cfm).