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7/29/2019 Reducing Maternal Depresion
1/28
Project thriveiss B N. 2
Reducing Maternal Depressionand Its Impact on Young Children
Toward a Responsive Early Childhood Policy Framework
jan Knz n Szann tb n Kay jnsn
janay 2008
7/29/2019 Reducing Maternal Depresion
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rdn Mana Dpssn and is impa n Yn cdn:tad a rspns eay cdd Py Famk
by jan Knz, Szann tb, and Kay jnsn
ts ss b s NccPs nnn mmmn nsn a y -nm d ns
s sks sd, and a pymaks a ass y bs sa a
ps a s pb ss n ms , smas ay. i s basd n a mn nnd
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dns ay dpmn and s adnss. t b s bn ny pbsd by P
thrive, NccP ss as a s Mana and cd ha Ba-ndd
Sa eay cdd cmpns Sysms (eccS) sysms pam and Paays eay S
Sss, NccPs n-n p p pymaks, pam admnsas and pans ad-
dss bas a n ay dn amn ap yn -nm dn.
AuthorS
jan Knz, edD, s d a NccP and cna Pss Ppan and Famy ha a
cmba unsys Maman S Pb ha. S as nbd many mpan sds
n pb ps an pm ay dpmn -nm dn and b spp
ams, paay s a ms nab.
Kay jnsn, MPh, Med, s a nsan NccP and d P thrive, nks ps
d a, ay ann, and amy spp. S as bad xps n many aas mana
and d a and as d nms sds mana and d a and ay dd py,
fnan, and nas sss.
Szann tb, MPh, s sa anays P thrive.
AcKNowleDgMeNtS
NccP s dpy a papans a NccP mn sad nss, ans and
das s ny (S Appndx), ky nmans sad pams and xpn
s, jan cp mmns, and Maasa isaas s anayss, Community Care
Networks for Low-Income Communities and Communities of Color, dd and nspd s k. w
a as spay a Pys Sbbs-wynn, ss P thrive k
Mana and cd ha Ba.
cpy 2008 by Nana cn cdn n Py
The National Center or Children in Poverty (NCCP) is the nations leading
public policy center dedicated to promoting the economic security, health, and
well-being o Americas low-income amilies and children. Founded in 1989
as a division o the Mailman School o Public Health at Columbia University,
NCCP is a nonpartisan, public interest research organization.
7/29/2019 Reducing Maternal Depresion
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 1
Project thrive iSSue BrieF 2
Reducing Maternal Depression and Its Impact on Young Children:Toward a Responsive Early Childhood Policy Framework
jan Knz n Szann tb n Kay jnsn janay 2008
Introduction
Maternal depression is a signicant risk actor aecting
the well-being and school readiness o young children.
Low-income mothers o young children experience par-
ticularly high levels o depression, oten in combination
with other risk actors. This policy brie provides an
overview o why it is so important to address maternal
depression as a central part o the eort to ensure that
ALL young children enter school ready to succeed. It
highlights:
n what research says about the impact o maternal de-
pression on young children, particularly inants andtoddlers, and how prevalent maternal depression is;
n examples o community and programmatic strategies
to reduce maternal depression and prevent negative
cognitive, social emotional and behavioral impacts
on young children;
n key barriers to ocusing more attention to maternal
depression in policies to promote healthy early child
development and school readiness;
n state eorts to address policy barriers and crat more
appropriate policy responses; and
n recommendations or national, state and local poli-
cymakers.
Dollars invested in moms are dollars that really pay off.
D. Fank Pnam, Pss Pdas and Psyay,
unsy cnnna. 20061
Framing the Challenge
Depression is increasingly recognized as major world-
wide public health issue. It has a negative impact on
all aspects o an individuals lie work and amily
and can even lead to suicide. Typically, depression
is discussed as an adult problem aecting women or
men, and increasingly, it is recognized as a signicant
problem or children.2 But ar too rarely is depression,
particularly maternal depression, considered through a
lens that ocuses on how it aects parenting and child
outcomes, particularly or young children; how oten
it occurs in combination with other parental risks, likepost-traumatic stress disorder; and what kinds o strate-
gies can prevent negative consequences or parents, or
their parenting and or their young children.
Defning Depression through a Parenting Lens
in nx pann, dpssn an b dfnd
as:
n a mbnan sympms a n
aby k, sp, a, ny and parent(as
s) and a as a asps k and amy;
n an nss a qny sas ay n , a may
a a ba mpnn and a pds sb-
sana dsaby n nnn ( s dfnd
as Ma Dpss Dsd dpss sympms);3
n a mmn b nsb paay a s ad-
ss ads a pans, and dn,
paay ms and yn dn;
n a ndn a spnds pnn and amn.4
7/29/2019 Reducing Maternal Depresion
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2 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
1) Maternal depression is widespread, particularly
among low-income women with young children.
Maternal depression is widespread across class and race,
and has been linked to genetic composition, situational
risk actors and circumstances, and environmental gene
interaction.6 Disproportionately, it impacts low-income
parents, whose depression is embedded in their lie
circumstances, poverty, lack o social supports and
networks, substance abuse, intimate partner violence,childhood abuse, and stress linked to a lie o hardship,
and too oten, no hope. (See box.) Research has shown
correlations between race and ethnicity and depression,
but the exact nature o the interaction is unclear. Ari-
can American women have very high rates o depres-
sion; rates among Latino women vary rom high to very
low, although rates in Latina adolescents are uniormly
high.14 But research also suggests that poverty is a more
powerul predictor. For poor women, rates o depres-
sion are high regardless ofethnicity. One study showedequal rates o depression among Arican American and
European American low-income women, and a study o
TANF recipients did not nd a dierence in prevalencebetween ethnic groups.15 In eect, poverty trumps race
as a actor in maternal depression.16
2) Maternal depression, alone, or in combination
with other risks can pose serious, but typically un-
recognized barriers to healthy early development
and school readiness, particularly or low-income
young children.
Maternal depression threatens two core parental unc-
tions: ostering healthy relationships and carrying outthe management unctions o parenting. The result,
long tracked in child development research, has been
linked to demonstrable reductions in young childrens
behavioral, cognitive, and social and emotional unc-
tioning. The impact o depression varies by its timing
(maternal depression during inancy has a bigger impact
on a childs development than later exposure), its sever-
ity, and the length o time it persists.17
Negative effects can start before birthThe negative eects o maternal depression on childrens
health and development can start during pregnancy.18
While the biological mechanisms are not clearly under-
stood, research on untreated prenatal depression nds
links to poor birth outcomes, including low birth-
weight, prematurity, and obstetric complications.19 The
biological eects can continue; research has ound that
maternal depression in inancy predicts a childs likeli-
hood o increased cortisol levels at preschool age, which
Prevalence Data on Maternal Depression
n Appxmay 12 pn a mn xpn
dpssn n a n ya.7
n F -nm mn, smad pan
dbs a as 25 pn.8
Estimatedratesofdepressionamongpregnantand
pspam and pann mn n na an
m 5 25 pn.9
Low-incomemothersofyoungchildren,pregnant
and pann ns p dpss sympms n
40 60 pn an.
o a ms (52%) n a sdy 17
eay had Sa pams pd dpss
sympms.10
An sdy nd a an aa 40 p-
n yn ms a mmny pda
a ns snd ps dpss
sympms (s spf as and m 33%
59%).11
Sds mn papan n sa a-
-k pams nda a dpssn and
ad s dpss sympms an
m 35-58 pn.12
Note: Sm sds p na dpssn as, s p dpss
sympms. Sm sas b a mp dpss sympms an b
nna qan ma dpss dsd as y pd sma nna
pan and mpamns.13
If Mama aint happy, no one is happy.
Papan n a s p -nm mn .
D. Maasa isaas, ex D, NAMBhA. 20045
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 3
in turn has been linked with internalizing problems
such as anxiety, social wariness and withdrawal.21
Maternal depression can impair critical early
relationshipsRecent neuroscience is clear that the primary ingredi-
ent or healthy early brain development is the quality o
the earliest relationships rom a babys primary caregiver
(which can be either parent, o course, but most oten
is the mother, especially or low-income children).Maternal depression can interere with the early bond-
ing and attachment process between mother and baby.
Maternal depression has also been linked with nega-
tive relationships in early childhood, and with reduced
language ability, which is key to early school success.22
Three year old children whose mothers were depressed
in their inancy perorm more poorly on cognitive and
behavioral tasks.23 Mothers who are depressed lack the
energy to carry out consistent routines, to read to their
children, or simply, most importantly, to have un with
them, singing, playing, and cuddling them.24 Childreno mothers with major depression are known to be at
risk or behavior problems, and are also at high risk or
depression or other mood disorders in later childhood
and adolescence.25
Maternal depression can impair parental safety
and health managementThe impact o depression in mothers has also been
linked with health and saety concerns. Depressed
mothers are less likely to breasteed, and when they do
breasteed, they do so or shorter periods o time thannon-depressed mothers.26 Mothers who are depressed
are less likely to ollow the back-to-sleep guidelines
or prevention o SIDS or to engage in age appropri-
ate saety practices, such as car seats and socket cov-
ers.27 Depression also aects the health services use and
preventive practices or their children. For example,
depressed parents are also less likely to ollow preventive
health advice and may have diculty managing chronic
health conditions such as asthma or disabilities in their
young children.28
The cumulative impact of depression in combina-
tion with other parental risks to healthy parenting
is even greater.
Depression in women oten co-exists with otherparental adversities and lie stressors, particularly
in low-income communities. These actors include,
along with the hardships associated with not having
enough money, substance abuse, domestic violence,
and prior trauma. A recent analysis o a birth cohort
rom 1998-2000 that ollowed children rom inancy
up to age 3 years in 18 cities provides important data.
On the positive side, hal o the mothers in the sample
had no risks. But o the hal who did, one-third o
those had more than one risk,* and as the number o
risks increased, so too did the likelihood o behavioralproblems related to aggression, anxiety and depression
and inattention and hyperactivity in the children.29 At
age three, o young children o parents who experienced
no risk actors, 7 percent were aggressive, 9 percent
anxious and depressed, and 7 percent hyperactive. The
comparable gures or young children whose moms ex-
perienced three risk actors were 19 percent, 27 percent
and 19 percent. The study also ound that maternal
depression and anxiety is associated with a stronger risk
o child behavior problems than our other risks tracked
(smoking, binge drinking, emotional domestic violenceand physical domestic violence).30
If those treating domestic violence dont screen for depression and
those treating for depression dont recognize post-traumatic stress disorder
or social anxiety or if neither recognizes the impact on children,
effective services and important resources are minimized.
D. Maasa isaas, ex D, NAMBhA. 200420
__________
* Risks measured included major depressive episode (14%); generalized anxiety disorder (3.6%); smoking (28%); binge drinking or illicit druguse (5%); emotional domestic violence (21%); and physical domestic violence (9%).
7/29/2019 Reducing Maternal Depresion
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4 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
3) Depression in other caregivers can also impact
the early development o young children.
FathersOverall, depression in athers is estimated at 6 percent,31
with community sample prevalence rates ranging rom
1.2 to 25 percent.32 Eighteen percent o athers in Early
Head Start report depressive symptoms.33 In the 18-city
study highlighted above, athers had lower rates o
major depression and anxiety disorder, but higher rates
o substance abuse (including smoking, binge drinking
and illicit drug use). In amilies where both parents are
depressed, the eects on children are compounded. It
is also noteworthy that some studies show that depres-
sion in athers is strongly related to maternal depression:
rates o paternal depression are higher when mothers
suer rom post partum depression, ranging rom 24
to 50 percent.
34
Further, non-depressed athers oer aprotective eect on children o depressed mothers.35
GrandparentsWhile there is little research on depression in grandpar-
ents raising children, even the scant data that we have
suggest that as states expand strategies to address ma-
ternal depression, they should take a amily and indeed
intergenerational perspective. Over a quarter o Head
Start grandparents who are primary caregivers were
mildly depressed (26.8%) and another quarter were ei-
ther moderately depressed (9.8%) or severely depressed(17.2%); in eect, hal o the sample.36 Thus these
rates are comparable to those o mothers. A study by
Chapin Hall Center or Children o grandparents who
are the ull-time caregivers o their grandchildren ound
that over a third (36.8%) scored above the CES-D (a
depression screening tool) cuto or depression, and an
additional group reported occasional or past depression.
The higher CES-D scores were signicantly associated
to parental incarceration; grandchildren with emotional
behavior issues; and grandparents perceptions o their
own physical health and well-being.37
Other caregiversNot surprisingly, since many who provide child care
and work in early learning programs are themselves
low-income women, emerging research also highlights
the impact o depression on other caregivers and on the
child care system in general. (See box.)
4) Much is known about how to treat depression
in women but too oten women, especially low-
income women, do not get appropriate help.
Depression is in general, a highly treatable disease. It
is responsive to combinations o traditional cognitive
and interpersonal treatment strategies, to medication,
and to creating peer-to-peer support groups.42 Studies
examining the ecacy o standardized treatment orlow-income populations, particularly with respect to the
use o cognitive-behavioral therapies suggest that core
treatment strategies need to be adapted, or example,
with more emphasis on engagement strategies, or using
phone, rather than ace-to-ace interventions.43 But even
with adaptations, there is another limitation o tradi-
tional treatment or parents.
Most interventions or depression address only the
adult; they do not address the adult as a parent, and
they do not actively include strategies to prevent or
repair damage to the early parent-child relationship,
which, as we know rom early brain science, is critical to
healthy early development.44 Further, there is very little
research that tests the ecacy o strategies that address
maternal depression in low-income women with mul-
tiple risks. In act, women with multiple risks are oten
excluded rom research. But even when treatment strat-
egies are linguistically and culturally appropriate and
Depression in child care providers exacerbates problems
in early childhood programs and is related to the high
levels o expulsion rom child care.
n rsa ss a as n -nm and
nn-sbsdzd a ns m ky s
m dpssn an aa ma u.S. ppa-
n.38
n cd a n ds and as dps-
sn sympms m ky a ps-
sn an s dpssn, adn a ss
xpnd k, mpndn pbm.39
n A sdy 1,217 nn-ama as nd a-
s dpssd ss sns, m
dan, and nad ss qny
dn an s n dpssd, pa-
ay as n amy d-a sns and
as ss dan.40
n in a sdy yn dn bn xpd m d
a ns, dpssd as m ky
xp dn an nn-dpssd as.41
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 5
research-inormed, oten there are too ew appropriately
trained providers, particularly providers o color.46
Even more signicant is that many low-income women
lack access to health insurance in general, or mental
health insurance in particular, creating an additional
set o hurdles or them. Medicaid does allow the states
to cover parents o eligible children, but in most states,
eligibility levels are very low. (See box.)
Focus groups with low-income women rom multiple
ethnic groups also make it clear that oten the women
are reluctant to seek treatment because o how they per-
ceive depression, and what acknowledging the need or
treatment might mean or them and their amily.47
For example, many women think how they eel is just
the way it is; that depression comes with the reality
o their lie situations. Secondly, they are very leery o
the stigma involved in admitting they have a prob-
lem. There is great distrust o mental health agencies,
including community mental health centers. And, most
important o all, women are earul o what admitting
to depression will mean or their children. Many are
reluctant to take medications because they ear what the
side eects will do to their parenting (such as not being
able to get their children ready or school). Others ear
that i they are not seen as good parents, child welare
will come and take their children away. On the other
hand, researchers have successully adapted traditional
treatments to be more responsive to women by address-
ing trauma, using outreach and strengthening the ocus
on educational and support approaches.48
The gap between the availability of good treatment for parents and the
utilization of treatment is enormouswhat we tolerate for depression,
we would not tolerate for diabetes.
D. wam Bads, Aadm ca, Dpamn Psyay,
cdn's hspa Bsn. 200645
Parental Access to Mental Health Services through
Medicaid49
Sas mak s ab pana by s
ass Mdad/SchiP, mans y an, n
y, a ass mna a ss.
F pnan man,
n 16 sas s by s a 200 pn m
da py ($20,650 a amy
n 2007), mand, bn 133 pn
and 200 pn py .
F kn pans,
n 5 sas s by s a 200 pn
da py ; 14 sas s by s a
ss an 50 pn da py .
n 35 sas s by a b 100 pn
py ; 14 m a b 50 pn
py .
F nnkn pans,
n 35 sas s by s a ss an 100 pn
da py ; 30 m a 50 pn
ss an py .
N: S as 50 sa pfs ay dd p s: .
7/29/2019 Reducing Maternal Depresion
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6 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
What Can Help Parents With or
At Risk o Depression and Their
Young Children?
Parental depression can pose a serious risk to young
children, but it is not a sentence either or a mom or
or her young children. Promoting early identicationand screening and, or low-income women, adapting
and making traditional treatments more accessible will
help. Both research and reports rom the eld suggest
that educating parents about the eects o their depres-
sion on their children may also encourage mothers to
seek treatment. Some practitioners have ound that
presenting maternal depression treatment as a git or
your child to be highly eective to mothers who may
otherwise be resistant to treatment.55 Other important
strategies are also emerging that center around oering
amily-ocused services in settings that parents trust,such as doctors oces or early childhood programs.
A amily approach to treatment or all women with
young children, but particularly or low-income wom-
en, in settings that they trust represents an opportunity
or interventions that can help both young children and
their parents.56 It is, in other words a two-er. Treat-
ment or the mom becomes prevention or early inter-
vention or the child (and or the parent-child relation-
ship). Early childhood programs can also provide such
supportive experiences or parents that they may alsoprevent depression or reduce the need or more ormal
treatment in some amilies.
Below we highlight examples o emerging eorts across
the country to address depression in the context o par-
enting young children. In general, these eorts involve
three types o strategies:
n screening and ollow-up or women, typically in
ob/gyn or pediatric practices;
n targeted interventions to reduce maternal depressionand improve early parentingin early childhood pro-
grams such as home-visiting and Early Head Start
Programs; and
n promoting awareness about the impact o maternal
depression and what to do about it or the general
public, low-income communities, and early child-
hood and health practitioners.
Themes rom Focus Groups with Low-Income Women50
n Many -nm mn and mn a
dfy nzn dpssn, bas y s
sympms as naay n ns a a pa
y-day .
n unmy, mn a dn; nz
mpa dpssn n m; and a a s-n dn, a aady xpnd ss
mman, d a .
n Ms mn nd and a spp m-
n , and a ay spp m s n
y .
n tsn ansps pds ndsand
day and a as s ky mn
n n amn.
n cnns ab s mdans as a-
mn n pmay a a and mna
a sns a a dn amn.
N: isaas basd s anayss n daa m spaa ss s ps
-nm mn .
Low-income Women, Access to and Use o Traditional
Treatment
n esmas a a 80 pn a a-
mn dpssn a pd. esmas ab a
pna s nd p an m a
57 pn a 20 pn, n n-
n nm.51
n l-nm mn and mn nssny
a ss ass , a ss ky sk a-
mn.
A sdy mn n pb asssan nd
43 50 pn tANF pns ad xp-
nd dpssn m an s pds
m n as ya,* y ny 11 13 pn
n amn dpssn.52
A sdy mpan ass amn amn
mn, Aan Aman mn, and lan
mn nd a s pd mda
s dpss sympms, 58 pn
mn pd a mna a s, m-pad 36 pn Aan Aman mn
and 11 pn lan mn.53
l nm mn a as m ky b n
d mdans an nn-p mn.54
__________
* wn bkn dn by a, as s amn 40+ a p,
57 60 pn pn dpssn n as ya, and as s n
18-24 a p, 35 38 pn pn dpssn n as ya. ras
ay by sa, b an n ab pna pns.
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 7
Screening and Follow-up
Early detection leading to treatment can be important
in reducing the impact o depression on women and
young children. One strategy that states and communi-
ties are implementing is to identiy, through the use o
standardized screening instruments, women who are
experiencing depression who are pregnant or parenting
young children. Screening is being done in a variety o
settings including pediatricians oces, womens health
clinics, and obstetrics/gynecology practices. When the
screening is implemented in pediatric practices, it is
oten part o a child-ocused eort to increase develop-
mental screening.
The American College o Obstetricians and Gynecolo-
gists (ACOG) recommends psychosocial screening o
pregnant women at least once per trimester (or three
times during prenatal care), using a simple two question
screen and urther screening i the preliminary screenindicates possible depression.58 Others support the use
o standardized, validated tools. But there is research
showing that even asking parents questions about how
they are eeling and what they are acing makes it pos-
sible to discuss otherwise seemingly o-limits issues.
Although there has been concern that amilies would
nd screening intrusive, some evidence suggests that
most seem to welcome it.59
Experience also suggests that screening should be readily
available in settings where mothers are, should be easyor both the provider and the client, and should involve
building the inrastructure to support ollow-up. The
screeners must be trained, and a reerral/ollow-up sys-
tem should be in place beore screening is implemented
so that those doing the screening know how to respond
and where they can turn i a problem is identied.
Screening or Maternal Depression in Action
n In North Carolina, a project unded by The Com-
monwealth Fund supported through its ABCD I
project (described below) piloted a project to increase
ormaldevelopmental screening and surveillance or
Medicaid-eligible children receivingEarly Periodic
Screening, Diagnosis, and Treatment (EPSDT)
servicesin pediatric and amily practices. Beginning
in one county in 2000, the project assisted pediatric
practices in implementing an ecient, practical pro-
cess or young childrenor screening, promotedearly
identication and reerral, and acilitated the prac-
ticesability to link to early intervention and other
A focus on maternal depression as a family intervention can support
strengthening families, attachment to work and employment, and
greater assurance that young children will enter school ready to learn.
D. Maasa isaas, ex D, NAMBhA57
Tools or Screening
n t ms mmn adad snn s sd
d mana dpssn a Edinburgh Postnatal
Depression Scale (EPDS), Postpartum Depression
Screen (PPDS), Beck Depression Inventory-II
(BDI-II), and Center or Epidemiological Studies-
Depression Scale (CES-D). A a m sns
dnyn ma dpss dsd, b an a-
ay dny mn dpss dsds as .60*
n Acog mmnds a smp qsn sn
a pnan mn (1. o pas ks, a
y dn, dpssd, pss? 2. o
pas ks, a y ns pa-
s n dn ns?), snn s
mn s anss nda pssb dpssn.61
n Sds nd a a -qsn pap-basd
sn, d by a b dsssn m
by a pdaan, as b asb and n
dnyn mn ndd -ps as.
on sds xamnd dn bn
a ba n and a pap m, and pap
sn as nd b a m .
62
__________
* Sm sa sss a d ypa ans n nma pnany and
pspam y, na dpssn snn s may s as as
pss, ndan a pspam-spf dpssn snn s may b
m . (hdn, jn; cx, jn. 2003.Perinatal Mental Health: A Guide to
the Edinburgh Postnatal Depression Scale (EPDS). lndn: rcPsy Pbans.)
7/29/2019 Reducing Maternal Depresion
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8 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
community services. Once the approach took hold,
the designers began to embed maternal screening
into the project. The approach is now used statewide
in North Carolina and has spurred similar initiatives
elsewhere.63 It has also been the catalyst or a state-
wide policy change in North Carolinas Medicaid
program that is discussed below.
n In Chicago, spurred by the deaths o several women
who were suering rom maternal depression, the
UIC Perinatal Mental Health Projectwas ounded
to enhance the health care system's early recognition
and treatment o perinatal depression. The project
has trained over 3,000 providers in specic tools to
aid screening assessment and treatment. Technical
assistance on implementation o these procedures is
available or clinics and providers. A key component
o the intervention is telephone-based consulta-
tion or the primary care providers to ensure theyhave access to additional inormation and guidance
when necessary. In addition, a medications chart was
developed and widely disseminated to assist primary
care providers in treating perinatal depression. This
work is unded in part by a HRSA-MCHB Perinatal
Depression Grant. With support rom the Michael
Reese Health Trust and Healthcare and Family
Services, UIC is also working on two alternative
approaches to treatment o perinatal depression or
HFS-enrolled providers and women. A stepped
care model provides training and tools to primarycare providers to assess, treat and reer women
with perinatal depression. A sel-care tool provides
women with suggestions or dealing with cognitive
behavioral issues and help them emerge rom perina-
tal depression.64
n The MOMobile program, based in eight sites in
southeastern Pennsylvania, under the auspices o the
Maternity Care Coalition, sends community health
workers around neighborhoods to support pregnant
women, new parents, and amilies with inants.
The advocates link amilies with services and sup-ports, provide parenting education, provide service
reerrals, and distribute baby supplies and ood in
emergency situations. Through a Pew Charitable
Trusts grant, MCCs social workers and community
health workers have begun screening newly regis-
tered clients at all eight sites or perinatal depression
using EPDS, totaling about 1,500 women each year
(previously, clients at some o the eight programs
were screened). The overall program has served over
50,000 amilies since its ounding in 1989.65
Targeted Interventions in Early ChildhoodPrograms to Address Depression*
A potentially powerul, but still underutilized strategy
is to embed explicit interventions designed to prevent,
or reduce depression and its harmul impacts on young
children into early childhood programs, especially
home-visiting and Early Head Start programs. In these
programs addressing maternal depression is an invest-
ment in improved outcomes or the children. Typically,
the interventions involve a ocus on improved parent-
child relationships and parenting practices. But it is
important to underscore that amily-ocused interven-
tions are not mental health as usual, where the adult
is treated, and sometimes the child is either treated or
screened, but they are not treated together.
Home-visiting programs, whether they are stand-alone,
or a component o Early Head Start or through eder-
ally unded Healthy Start programs, are available in
many communities across this country and represent an
important, but underutilized opportunity to prevent andaddress maternal depression and its consequences or
young children.
Research on Early Head Start, which is a nationwide,
comprehensive amily support and child development
program that seeks to enhance all aspects o develop-
ment or inants and toddlers at the poverty level, has
paid special attention to maternal depression. An initial
study ound that depressed parents participating in Ear-
ly Head Start were more likely than the control group
to improve their parenting practices and have childrenwho were less aggressive or negative when interacting
with peers; had more positive parent-child interactions;
were less likely to receive harsh discipline strategies; and
overall, were more engaged and attentive.66 The ollow-
up study, two years ater the program, shows ewer__________
* There are also powerul individual therapeutic strategies that engage parents and children. The dyadic therapy model teaches a mother how to read,interpret, and respond to her inants cues, and assists the mother in dealing with her emotions and needs related to motherhood. The model improvesattachment, increases both maternal and child sensitivity, and reduces incidence o abuse and neglect, and is eective even when the mother is de-pressed. (Parent-Child Mental Health Interventions, Zero to Three Fact Sheet. Zero to Three, National Center or Inants, Toddlers, and Families.)
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 9
depression symptoms among women who participated
in Early Head Start than in the control group.69 A
combination o child actors such as improved cogni-
tion, vocabulary at ages two and three; and improved
child engagement at age three; and amily actors, such
as improved parenting skills, reduced parenting distress,
seems to account or the reduction in depression.68
Augmenting Early Childhood Programs69
n Family Connections in Head Start: Taking
Prevention Seriously
In Boston, the Family Connections project is a
strength-based prevention model that is being imple-
mented across six Head Start and Early Head Start
sites. The core elements o the program are to:
build competence and resilience in HS/EHS sta
in order to strengthen sta s ability to engagearound issues o depression and adversity;
provide hope, to enhance parent engagement and
parenting skills;
strengthen meaningul teacher-child interactions
related to emotional expression and adversity; and
better identiy and plan or needed services or
children and amilies in emotional distress.
Family Connections (which is part o a major pre-
ventive intervention study) is based on lessons rom
several intervention models including an empiricallytested amily-ocused intervention developed or to
help older, middle class children and parents cope
with depression.70
Reports by Head Start parents, teachers, and director
showed that it is easible to deliver training sessions
linked to consultation and to develop and sustain par-
ent and teacher activities. Most strikingly, sta turn-
over and sick days decreased markedly in more than
one center in response to the program. Sta also report
increase in skills. Positive change in teacher attitudes
and practices relating to mental health and related
adversities were evident in all centers. Findings varied
by center, based on site organization and readiness.71
n Every Child Succeeds (Cincinnati): Addressing
Depression Directly
Recognizing that the challenges o helping depressed
moms cuts across dierent home-visiting models,
Every Child Succeeds has developed and approach
that embeds cognitive behavioral therapy into three
dierent home visiting models. Pilot results show
that the two-generational approach resulted in
signicant decreases in parental depression and im-
proved language and cognitive unctioning in inants
and toddlers.72 ECS therapists provide an adapted
orm o cognitive behavior therapy to mothers in
their homes, working to treat depression and preventrelapses, as well as maximize the eectiveness o the
home visiting program. The programs success rates
are comparative to antidepressants or typical cogni-
tive behavior therapy.73The early results show thato the 29 percent o mothers who enter ECS with
clinically signicant levels o depression, hal are no
longer depressed ater nine months in the program.74
A randomized control trial is now in progress that
will also track child outcomes.
Every Child Succeeds is a collaborative regionalprogram that has three ounding partners: Cincin-
nati Childrens Hospital Medical Center, Cincinnati-
Hamilton County Community Action Agency/Head
Start, and the United Way o Greater Cincinnati.
Funding comes rom a public-private partnership
that includes Medicaid, state and county unding,
United Way o Greater Cincinnati agencies, corpo-
rate and individual sponsorships.
Two other strategies refecting practice and experiential
wisdom should also be noted: peer-to-peer support/recovery groups or depressed women in low-income
communities, and expanding access to mental health
consultants in both early childhood programs (includ-
ing home-visiting programs) and health care settings,
such as pediatric practices.
Peer-to-peer support groups, requently called Sister
Circles, have been shown to reduce depression in black
and Latino women.75 The groups provide support and
social networks, and they may particularly appeal to
women who ear the stigma o traditional mental healthservices.76 Most groups do not ocus on young children;
however, we did identiy one program that ocuses on
parents with inants and toddlers.
n In New York City, the Caribbean Womens Health
Association organizes the Community Moms Pro-
gram, a program or immigrant women who are
pregnant and parenting children, birth to age two.
The program provides health education workshops,
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10 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
support services, home visiting, and screening and
reerrals or maternal depression.77 Active, older com-
munity members were recruited to provide direct ser-
vices, such as home visiting and community engage-
ment. The Health Workers build strong connections
with mothers to both build social support networks
and to provide education about maternal depression
at the one-on-one and community level. Because
the Health Workers come rom the communities
in which they work, they are uniquely equipped tounderstand the roles o racism, cultural gender roles,
and stress o the daily lives o the women.78
Linking mental health consultants to home-visiting
programs is another approach to strengthening the ca-
pacity to respond to amilies with depression and other
risks. The consultants role is to help the home-visitors
identiy and respond eectively to relationship based
problems, including depression, to help home-visitors
decide i reerrals are needed and in some programs, to
work directly with the amily alongside the home-visi-tor. Below is an example o embedding a mental health
consultant in the Nurse Family Partnership Program.
n Louisiana Nurse-Family Partnership Program:
Adding Mental Health Consultants
The Louisiana Nurse-Family Partnership Program
augmented the standard nurse intervention with
extra training and with mental health proession-
als in order to deal with the increased inant and
maternal mental health risks they knew to be pres-
ent in the Louisiana population, including maternaldepression. In a preliminary trial, the nurses and the
mental health consultants received intensive training
in inant mental health issues and child development
and then worked together in an extremely high-risk
population, with one consultant per site nursing team
(typically eight nurses and one nurse supervisor or
160 amilies). While the study was small, it indicated
that incorporating mental health consultants into
the home visiting program strengthened the team
approach o the Nurse-Family Partnership, increased
the skills o both the nurses and the clinicians to deal
with maternal and inant mental health issues, and
allowed the consultants to reach a greater number o
amilies than would otherwise be possible.79
These on-the-ground examples suggest that core com-
ponents o successul eorts to address maternal and
other risks in early childhood settings:n link services and supports or parents and children,
through ormal and inormal strategies;
n provide training and support to home visitors, teach-
ers and child care providers to help amilies and to
get support or their own depression;
n help parents address specic parenting challenges
related to depression and other adversities;
n ensure that children in higher-risk amilies have ac-
cess to high-quality child development programs like
Early Head Start to reinorce social and emotionalskills and early learning opportunities; and
n provide clinical treatment when it is needed in set-
tings amilies trust.
Policymakers should focus serious attention on maternal depression
as part of the larger efforts across the country to improve healthy
developmental and school-readiness outcomes in young children.
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 11
Building the Policy Framework
State Eorts
The lesson rom research is clear: adult depression is
not only bad or adults, it is bad or children, especially
young children. Yet crating a coherent policy responsebeyond demonstration programs is very dicult. A
basic issue is that most low-income women, as noted
above, lack access to health insurance, o i they have
it, coverage or mental health. Policy mechanisms to
pay or screening and ollow-up are limited. Even more
challenging is sustaining amily-ocused interventions in
the context o early childhood programs such as home-
visiting and Early Head Start. In act, most o the initia-
tives highlighted above are either oundation unded, or
time-limited research and demonstration programs. Few
states have the capacity, nor are there ederal incentives,to take research-inormed practices to scale. At the same
time, states are trying to respond.
Using ABCD as a Catalyst
The major strategy that is emerging across the country,
largely as theresult o an on-going project developed
by the Commonwealth Funds Assuring Better Child
Health and Development (ABCD) program, is screen-
ing or maternal depression, either in context o pedi-
atric practice or prenatal care. The ABCD program,administered by the National Academy or State Health
Policy (NASHP) is designed to assist states in improv-
ing the delivery o early child development services
or low-income children and their amilies. The rst
ABCD consortium (ABCD I) was created in 2000 and
provided grants to our states (NC, UT, VT, WA) to
develop or expand service delivery and nancing strate-
gies aimed at enhancing healthy child development or
low-income children and their amilies.
The ABCD II Initiative, launched in 2003, is designedto assist states in building the capacity o Medicaid
programs to deliver care that supports childrens healthy
mental development. The initiative is unding work
in ve states (CA, IL, IA, MN, UT).80 An additional
20 states currently receive support through the ABCD
Screening Academy. Some o the ABCD II sites have
integrated maternal depression screening and pediatric
social-emotional screening into primary care. Below we
highlight policy activities related to, or including mater-
nal depression in two states.
n North Carolina, the North Carolina ABCD I ini-
tiative. The North Carolina eort to promote paren-
tal screening or depression is part o a larger eort
to promote and pay or developmental screening or
all young children. Ater the project to test strategiesto increase screening in pediatric oces was success-
ully replicated in nine counties (see earlier descrip-
tion), it was expanded to cover the state, backed by
ormal changes in the state Medicaid policy in 2004.
The policy requires that practices to use a ormal,
standardized developmentalscreening tool at 6, 12,
18, or 24 months and 3, 4, and 5 yearso age, and
as o 2006, more than 70 percent o children were
being screened at well-child visits, compared to an
average o only 15.3 percent prior to implementa-
tion.81
Parents are screened or depression by theirchildrens primary care providers. North Carolina
has also provided or parental access to treatment.
They have expanded coverage to reimburse or up to
26 mental health visits or covered children. Parents
can be seen under their childs Medicaid benets or
the rst six visits, and providers can include PCPs,
LCSWs, and psychologists. The project has worked
to co-locate mental health providers within primary
care practices, which both makes it easier or ami-
lies to access care and reduces stigma by delivering
services within locations and communities whereparents are already comortable.82
n Great Start Minnesota, the Minnesota ABCD II ini-
tiative, integrates mental health screening into pedi-
atric care. The clinic systems co-locate mental health
proessionals into pediatric clinics. While the ocus is
on childrens mental health, parents are screened or
mental health issues during the prenatal and perinatal
periods, and or postpartum depression. In addition,
the project assisted with passing the 2005 Postpartum
Depression Education legislation in 2005, which
requires physicians, traditional midwives, and otherlicensed health care proessionals providing prenatal
care to have inormation about postpartum depres-
sion (PPD) available, and hospitals to hand out writ-
ten inormation about postpartum depression to new
parents as they leave the hospital ater birth.83 The
legislation also requires the Minnesota Department
o Health to work with a broad array o health care
providers, consumers, mental health advocates, and
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12 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
amilies to develop materials and inormation about
postpartum depression.
The eorts just described generally involve multiple
stakeholders coming together to gure out how to
use existing resources in ways that will maximize their
impact or mothers with depression and their young
children. In particular, they are embedding screen-ing or treatment across settings (in ob/gyn as well as
pediatric practices) and they are nding ways to extend
parental eligibility through Medicaid. However, the
recent regulations proposed by the Center or Medicare
and Medicaid Studies pose serious threats to many o
these strategies.
Enacting State Legislation
At least one state, New Jersey, has enacted legislation
requiring screening or depression and strengthening
the capacity to respond to the identied need.
n New Jerseyenacted the Postpartum Depression
Lawin April, 2006, that requires physicians, nurse
midwives, and other licensed health care proession-
als to screen new mothers and to educate pregnant
women and their amilies about post partum depres-
sion.84 New Jersey has long been at the oreront o
postpartum depression action and legislation, due
in part to the advocacy work o Mary Jo Codey, the
wie o the ormer governor Richard Codey, and thiswas the rst law in the country to require health care
providers to screen all women who have recently
given birth, and to educate women and amilies.
The bill provides $4.5 million or a comprehensive
program, including the establishment o a statewide
perinatal mental health reerral network. New Jersey
is also the original developer o the Speak Up When
Youre Down campaign, which is now used in Wash-
ington State. (See box.)
Using the State Early Childhood ComprehensiveSystems (ECCS) grants to leverage change
In a number o states the ECCS coordinators and the
ECCS grant itsel have been the catalyst or ocused,
cross-system attention to maternal depression and
how it impacts the broader early childhood goals.
For example:
n As part oIowas ECCS activities, Maternal Depres-
sion Screening: Train the Trainer workshops are
oered in partnership with the Iowa departments o
Public Health, Human Rights, Management, Educa-
tion, Human Services, Prevent Child Abuse Iowa,
Head Start Collaboration Oce, and the University
o Iowas Depression and Clinical Research Center.
As o the end o scal year 2007, 34 trainers were
trained atthe Maternal Depression Screening: Trainthe Trainer workshops, and these trainers held 15 lo-
cal trainings or providers in Iowa. Preliminary results
rom two demonstration sites indicate a 70 percent
increase in rates o screening or maternal depres-
sion.87
n Rhode Islands ECCS project includes supporting
screening in child care and primary care settings, and
increasing the capacity o service providers to addressparent and amily behavioral health issues, through
treatment and reerral as objectives. Watch Me Grow
RI trains participating pediatric and amily prac-
tices to screen parents using the Early Childhood
Screening Assessment, which has our questions that
directly screen or maternal depression. Providers are
also trained in how and where to reer parents who
screen positive or depression.88
Speak Up When Youre Down in Washington State
Washington State nds a pb aanss ampan
da mn and ams ab sympms
and amn pspam dpssn. t Speak Up
When Youre Down ampan, fs dpd by N
jsy, s d by wasnn cn Pnn
cd Abs and N, an pan anza-
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sns, and pssna anzans n wasnn
Sa. t ampan, sad n 2005
hrSA ans, pds dana maas and
ns a am n ms sn m ps pam
dpssn.85 t pam ad n ndn a ya
b as ndd by a n m n bd (
a ampn n sa sa) $250,000
m yas, san jy 1, 2007. t p-
ams n as nd xpandn ampan
f anas (ens, Spans, vnams, rssan,
and Sma); nsn a maas a ay
mpn; and an a pb s annnmn
ampan sn, pn, and ad. t campanas pand unsy wasnn S
Nsn spp a wb-basd pd ann a
as dpd by S n a an.86
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 13
n In Connecticut, the ECCS Director also acilitates
the Statewide Perinatal Depression Screening Work-
group. The Department o Public Health convened
a Perinatal Depression Screening: Implications or
Consumers and Providers summit in May 2006,
and has launched a perinatal depression screening
public awareness campaign. A pilot perinatal depres-
sion screening project has been started in two com-munity health clinics, and eorts are underway to
institutionalize perinatal screening in DPH unded
perinatal case management programs.
Putting It All Together
Over the past several years, Illinois has ocused major
energy on improving and linking its eorts on behal o
young children. Illinois has a strong state policy rame-
work that includes legislation that calls or preschool or
all young children and includes a set-aside or inants
and toddlers. In addition, the state has a strong leader-
ship group, built on solid relationships among advocates
and state ocials, that has made a special eort to ocus
on the importance o promoting healthy early relation-
ships. Illinois success is based on public/private part-
nerships, strong advocacy, and state agencies working
together to assure the service delivery system meets the
needs o young children.
The ocus on maternal depression builds on earlier
work to promote healthy social and emotional develop-
ment in young children, or example, by expanding ac-
cess to early childhood mental health consultation and
the Childrens Mental Health Partnership. The partner-
ship brings together a broad-based strategy to address
the mental health and social/emotional development
o children and adolescents, including young children.
Recognizing the importance o maternal depression and
particularly its impact on inants and toddlers, Illinois
has taken a number o steps across multiple agencies
and communities to develop a putting it all togetherstrategy. Largely driven through public-private collabo-
rations, the work has grown out o the states Birth-to-
Five early childhood systems development initiative,
convened by Illinois Ounce o Prevention Fund and
through state agency work to address the health needs
o young children. The eort can be linked to the states
ECCS grant work and the governors initiatives to im-
prove health outcomes o children and assure they are
ready to learn.
Eorts to assure the healthy mental development o
young children are many:
n In July 2006, Governor Blagojevich implemented
All Kids, which provides uninsured children accessto comprehensive health care with a rich benet
package (similar to that under Medicaid EPSDT).
In December 2007, FamilyCare eligibility (aord-
able coverage or parents and caretaker relatives) was
raised to 400 percent o the poverty level, thereby
assuring health benets or many more Illinoisans.
To assure that beneciaries have access to care
and a medical home, the Illinois Department o
Healthcare and Family Services (HFS), the single
state agency responsible or the administration o
Title XIX and Title XXI o the Social Security Act,
FamilyCare, and the All Kids program, imple-
mented a mandatory statewide Primary Care Case
Management (PCCM) program, with a strongquality assurance process that includes ongoing
tracking and monitoring. Feedback to providers on
key indicators and ongoing provider training are
among the strategies incorporated in the program.
HFS contract with its Managed Care Organiza-
tions (MCO) was strengthened to specically
require objective developmental screening o
young children and perinatal depression screening,
reerral and treatment, with ongoing monitoring
and tracking. Enrollment in an MCO is voluntary
and available in seven counties, including Cook
County.
n Public Act 93-0536 (305 ILCS 5/5-5.23) was passed
with the goal o improving birth outcomes or over
80,000 babies whose births are covered each year by
HFS. The law requires HFS to develop a plan to im-
prove birth outcomes. Addressing perinatal depres-
sion is among the strategies outlined in the plan.89
n Illinois participated in the ABCD II project with
support rom The Commonwealth Fund, the Na-
tional Academy or State Health Policy, the MichaelReese Health Trust, The Chicago Community Trust,
the Centers or Medicare & Medicaid Services, The
Ounce o Prevention Fund, provider organizations
(Illinois Chapter o the American Academy o Pe-
diatrics and the Academy o Family Physicians) and
many other partners.
n Public Act 095-0469, Perinatal Mental Health
Disorders Prevention and Treatment Act, eective
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14 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
January 1, 2008, was enacted to increase awareness
and to promote early detection and treatment o
perinatal depression.90 This act requires that:
Women and their amilies be educated about peri-
natal mental health disorders in the prenatal and
hospital (labor/delivery) settings.
Women be invited to complete a questionnaire toassess whether they suer rom perinatal mental
health disorders in the prenatal, postnatal and
pediatric care settings.
Under the authority o Public Act 93-0536, and
through a collaborative eort involving public-private
partnerships, including the states human services agen-
cies, the Conerence o Women Legislators, the Univer-
sity o Illinois at Chicago Womens Mental Health Pro-
gram, and private oundations, Illinois has developed a
comprehensive perinatal depression initiative.
n Screening or perinatal depression using an approved
instrument is a reimbursable service to HFS-enrolled
providers, including community mental health
centers, or screening HFS-enrolled women. Screen-
ing is reimbursed both prenatally and up to one year
ater delivery.
n The Perinatal Mental Health Consultation Service
operated by the University o Illinois at Chicago
(UIC) is available to HFS-enrolled providers or
consultation on perinatal depression. The consul-tation service is toll-ree, provides consultation to
physicians by psychiatrists, and provides inormation
about medications.
n A 24-hour crisis hotline operated by Evanston
Northwestern Healthcare (ENH) Postpartum De-
pression Program is available to women experiencing
perinatal depression. The hotline is staed by trained
mental health proessionals. Callers receive psycho-
social assessment by phone and are reerred to local
mental health providers.
n Reerral and treatment resources are available state-
wide or reerral o women who call the hotline.
n Provider education and training on the healthy
development o young children, which includes ad-
dressing perinatal depression, is available rom the
Enhancing Developmentally Oriented Primary Care
(EDOPC) program operated by Advocate Health-
care, the Illinois Chapter o the American Academy
o Pediatrics and the Illinois Academy o Family
Physicians (web-based training), and the Mental
Health Consultation Service.
n A major initiative was undertaken with the Chicago
Department o Public Health to screen pregnant
women or depression.
n The Illinois Department o Human Services has
provided State Title V Maternal and Child HealthServices Block Grant unding to support the states
perinatal depression initiative and promotes perina-
tal depression screening and developmental screen-
ing o young children in the public health sector.
n HFS provides support o provider training on peri-
natal depression, telephone consultation and reerral
coordination or its participants with support rom
private oundations and ederal matching unds.
Perhaps most signicantly, cross-agency, public-private
collaboration has led to system-wide change at the s-
cal, policy, and practice levels.
n HFS provides reimbursement or screening perinatal
program participants and/or their inants who are
enrolled in the program.
n The state has created the expectation through
EPSDT that objective developmental screening will
occur, at a minimum, annually rom birth to age 3.
n Illinois has made it a priority to ocus on promoting
healthy social and emotional development in young
children, including addressing mental health needs o
their mothers to improve healthy early relationships.
n Inants and toddlers with a mother with a mental
health illness diagnosis (including depression) are
automatically eligible or the Early Intervention
program.
n Screening and identication o mothers experienc-
ing depression have increased in the HFS-enrolled
population.
n An eort to cross-walk and implement DC-0-3 is
under way.
n HFS began providing reimbursement or adult
preventive care services eective July 1, 2007. In
conjunction with this, an annual preconception visit
will also be allowed. The coverage o routine preven-
tive services and preconception/interconception care
or women allows greater opportunity or screening
or perinatal depression.
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 15
To make these eorts work, there is close and requent
communication among a core group o leaders, which
promotes leveraging o dollars toward achieving a com-
mon vision.
Federal Eorts
To date there has been a limited explicit ederal response
to maternal depression. At the agency level, over the past
three years, in response to a Congressional appropriation,
MCHB-HRSA has given 16 states one-year grants to
promote awareness o and address perinatal depression.
n In Fiscal Years 2004 and 2005, 10 State MCH
programs (AK, CT, DC, IL, IN, MD, MA, NE, NY,
VA) received money to launch multilingual public
education programs to promote mental wellness ormothers and amilies, and to increase public aware-
ness and understanding o maternal depression to
reduce stigma and encourage treatment. The initia-
tive also required states to decrease barriers to care
or low-income amilies.
n In 2006, the program awarded grants to six states (IL,
IA, LA, KY, MA, PA) to provide comprehensive, co-
ordinated services or maternal depression and other
mental health problems during pregnancy and at least
through the rst year ater pregnancy. In this program,
maternal mental health services must be combined with
services or inant mental health within a service system
model that ocuses care on the mother-inant pair.93
While the rst round o grants have been useul, states
do not seem to be able to sustain the public awareness
strategies.
Pending Federal Legislation as o Winter 2007
n t Melanie Blocker-Stokes Postpartum Depression
Research and Care Act as passd by hs n
ob 15, 2007. Spnsd by Bbby rs (il),
and spnsd by 130 rpsnas, hr
20 nd sa, snn, amn, and d-
an ms pspam dpssn and
psyss, fsa yas 2008-2010. t b, fs
ndd n 2001, as passd by a 382
3. i as bn sn Sna.
n Moms Opportunity to Access Health, Education,
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(MOTHERS Act), as ndd by Sna rb
Mnndz (Nj) and spnsd by Babaa Bx
(cA), Sd Bn (oh), csp Ddd (ct),
rad Dbn (D-il), Fank lanb (Nj), Baak
obama (il), Bnad Sands (vt), oympa j. Sn
(Me), and Sdn ws (ri). ts sa-
n d asss a a pds da-
n, dnfan, and amn, and ns a
n ms and ams a dad ab
pspam dpssn, snd sympms, and
pdd ssna ss.91 i as as
nasd sa a Nana inss ha
n pspam dpssn amns and dans
s. t b as ndd n jn 2006, as
ndd n May 2007, and as bn d
Sna cmm n ha, edan, lab,
& Pnsns. in ak passn Man
Bk-Sks Pspam Dpssn rsa and
ca A, pspam dpssn adas a bn
anzn nsn spp, ndn a nana
day an a snas and b ab a. 92
n Ps hs san passd n 2000, House
Resolution 163, xpssn sns hs
rpsnas sp pspam dps-
sn nad and mmndd mana
dpssn snn, pd dan, and pb
aanss, b dd n manda any ans.
Update: in Nmb 2007, hs and Sna bs
mbnd and namd as The Melanie Blocker
Stokes MOTHERS Act. As Fbay, 2008, A s
Sna cmm n ha, edan, lab,
and Pnsns, aan mak p and psnan
Sna dn nx sa sssn.
Innovative Coverage or Depression Screening
hFS-nd pds pd pmay a s-
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an appd snn nsmn (ednb Psnaa
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ca eaan Mna Dsds Pan ha
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snns an b pmd as many ms as ns-
say, p n ya a b. Bas pna
na mpas mana dpssn n dn,
snn s d as a sk assssmn and an
b mpd dn pnaa and pspam ss, as
as dn nan -d and psd ss. D-
n pspam pd, pds b nd m-
ans a, s s d by hFS. F sn-
ns a ak pa dn a -d psd s,
hFS mbs nans a. en-
n ra cns, Fday Qafd ha cns,
and ra ha cns d n mbsmn
snn bas y a pad by nn a, s a ss p s. on a man s d-
ansd dpssn, hFS mbs and-
pssans pamaa amn mn
d nd s mda pams.
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16 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
There have also been eorts to introduce legislation to
promote public awareness and a more coherent set o
services or pre-natal depression. However, none has
been successul. (See box.) Nor has there been any exec-
utive order or Congressional mandate to bring together
health, mental health and child development agencies
to maximize the impact o scattered research projects.
Recommendations
Addressing and targeting resources to maternal depression
as a barrier to early healthy development and early school
success is complex undertaking that will require the in-
volvement o programs, community leaders, state policy-
makers and legislators and amilies and researchers at local
and state levels, as well as some national leadership. At the
same time it is clear rom this report that approaches are
emerging, both at the practice level and the policy level.To move this agenda orward, below is a set o strategic
actions or those at the local, state and ederal levels.
At the local level, communities can:
n conduct a community scan to assess local capacity
or screening and ollowing-up or pregnant women
and parents o babies and young children and to
identiy how existing resources are used;
n engage local unders, including community ounda-
tions, to develop a strategic plan and implementa-
tion steps to help local early childhood programs test
and/or replicate evidence-based, eective amily-
ocused practices to address maternal depression and
its impact on young children (See Appendix or con-
tacts or approaches mentioned in this issue brie.);
n assess and strengthen community capacity to ad-
dress depression in athers as well as mothers, and in
others who care or young children on a daily basis,
whether in amilies or in child care settings;
n engage leaders o low-income communities in de-
signing and evaluating public awareness campaignsand culturally and linguistically responsive outreach
and program strategies;
n document disparities and implement strategies to
track and improve access to culturally and linguisti-
cally responsive instructions; and
n combine public and private dollars to support early
childhood mental health consultants to work with
home-visitors and other caregivers.
At the state level, public ofcials and advocates
can:
n use ECCS grants to help health care providers and
systems implement a developmental multi-genera-
tional amily health/mental health perspective, in-
cluding attention to prenatal depression and related
risks as part o implementing the medical/dentalhome vision;
n dedicate a sta person to coordinating interagency
screening, prevention and treatment eorts to ad-
dress depression through a amily lens, paralleling
positions that have been created or to coordinate
cross-agency activities around womens health or
HIV/AIDS;
n develop a cross-agency strategic action plan to
reduce maternal depression and its impact on young
children that identies what each system will do
separately and together, such as:
build on medical home initiatives and perinatal
screening initiatives, making sure there is appro-
priate ollow-up treatment;
support cross-training eorts or primary care pro-
viders in health and early care and learning settings;
expand early childhood mental health strategies to
include attention to depression in sta and amilies;
provide support to expand access to screening and
ollow-up treatment or pregnant and parentingmothers through both health practices and early
childhood programs;
train and identiy mental health consultants with
documented expertise in dealing with depression
through a amily lens to work with pediatricians,
early care and learning programs and womens
health agencies; and
embed attention to depression beyondhealth andearly childhood systems and programs (especially
TANF, marriage initiatives, WIC, child welare, etc.)
in developing program initiatives, regulations, etc.
n Maximize the use o Medicaid to prevent and treat
depression and related risk actors in the context o
promoting healthy early child development, such as:
use Medicaid waivers (or i that is prohibited,
state unds) to extend health insurance coverage
to mothers with young children at least to the
eligibility levels that the children are covered or
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 17
the rst two years ollowing birth or use the childs
access to Medicaid to cover parents;
promote public awareness campaigns and educa-
tional materials that show the links between early
school success and addressing maternal depression.
At the ederal level ederal ofcials, includingCongress can:
n ensure that Medicaid acilitates, rather than impedes,
states ability to pay or depression reduction and
prevention strategies that are designed to improve
outcomes or young children;
n provide incentives to the states to cover parents o
young children through Medicaid up to 200 percent
o the poverty level to ensure access to treatment or
depression as well as health conditions that impair
parenting;
n create a ederal interagency work group, either
through legislation or executive order, including
health, mental health and childrens agencies that
can develop a strategic action plan, and potentially
pool unds to support state eorts to design compre-
hensive approaches to prevent and reduce parental
depression and improve outcomes in young children;
n embed attention to depression beyondhealth andearly childhood systems and programs (especially
TANF, marriage initiatives, child welare, etc.) in
developing program initiatives, regulations, etc.; and
n develop a strategic NIH research agenda that
includes support to develop and test a range o in-
terventions to address maternal depression, promote
more eective parenting strategies and improve
outcomes or young children, particularly or low-
income women experiencing depression along with
other risk actors.
Conclusion
This issue brie calls or policymakers to include much
more serious attention to maternal depression as part o
the larger eorts across the country to improve healthy
developmental and school-readiness outcomes in young
children.
The argument is simple: particularly or low-income
children, maternal depression is a known barrier to
ensuring that young children experience the kinds o
relationships that will acilitate their success in the
early school years. Investing in treatment and support
or one generation will promote healthy development
and school readiness or the next. Addressing maternal
depression through a parenting and early childhood lens
is in eect a two-er: it can help parents, but impor-
tantly, it will also pay o or their children, both in
the short term and in the longer term. There are tough
barriers, particularly scal barriers, to creating amily-
ocused interventions. It requires a ramework shit that
provides public incentives or a amily-ocused, namely
multi-generational, culturally responsive, approach that
brings together resources rom multiple public systems.
There is also a critical role as a catalyst and seeder o
initiatives or private philanthropy.
The real message rom this brie is clear. While there
is much more to be known, we already have enoughevidence about eective approaches to address a damag-
ing condition that ripples throughout a amily and a
community, with lielong implications or everyone it
touches. We simply cannot aord not to respond with
resources and commitment.
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18 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py
Endnotes
1. Putnam, Frank. Reducing Maternal Depression and Its Impact onYoung Children: Building a Policy Framework. Policy Roundtable.June 22, 2006. New York NY: National Center or Children inPoverty.
2. Ibid.
3. Gaynes, B. N.; Gavin, N.; Meltzer-Brody, S.; Lohr, K. N.;Swinson, T.; Gartlehner, G.; Brody, S.; Miller, W. C. 2005. PerinatalDepression: Prevalence, Screening Accuracy, and Screening Outcomes.Rockville, MD: Prepared by the RTI-University o North CarolinaEvidence-based Practice Center, under Contract No. 290-02-0016.
Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National
Alliance o Multiethnic Behavioral Health Associations (NAMBHA).
Roca, Catherine. National Institute o Mental Health. 2007.Personal communication.
4. Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National
Alliance o Multiethnic Behavioral Health Associations (NAMBHA).
5. Ibid.
6. Ibid.
7. Ibid.
8. Lanzi, R. G.; Pascoe, J. M.; Keltner, B.; Ramey, S. L. 1999.Correlates o Maternal Depressive Symptoms in a National HeadStart Program Sample.Archive of Pediatric Adolescent Medicine153(8): 801-807.
Miranda, Jeanne; Green, Bonnie L. 1999. The Need or MentalHealth Services Research Focusing on Poor Young Women. The
Journal of Mental Health Policy and Economics2(2): 73-80.
Onunaku, Ngozi. 2005. Improving Maternal and Infant MentalHealth: Focus on Maternal Depression. National Center or Inantand Early Childhood Health Policy at UCLA.
Riley, A. W.; Broitman, M. 2003. The Effects of Maternal Depressionon the School Readiness of Low-Income Children. Baltimore, MD:Report or the Annie E. Casey Foundation, Johns HopkinsBloomberg School o Public Health.
Sieert, K.; Bowman, P. J.; Hefin, C. M.; Danziger, S.; Williams,D. R. 2000. Social and Environmental Predictors o MaternalDepression in Current and Recent Welare Recipients.American
Journal of Orthopsychiatry70(4): 510-522.
9. Gaynes, B. N.; Gavin, N.; Meltzer-Brody, S.; Lohr, K. N.;Swinson, T.; Gartlehner, G.; Brody, S.; Miller, W. C. 2005. PerinatalDepression: Prevalence, Screening Accuracy, and Screening Outcomes.
Rockville, MD: Prepared by the RTI-University o North CarolinaEvidence-based Practice Center, under Contract No. 290-02-0016.
10. Research to Practice: Depression in the Lives of Early Head StartFamilies. April 2006. Administration or Children and Families,U.S. Department o Health and Human Services.
11. Kahn, Robert S.; Wise, Paul H.; Finkelstein, Jonathan A.;Bernstein, Henry H.; Lowe, Janice A.; Homer, Charles J. 1999.The Scope o Unmet Maternal Health Needs in Pediatric Settings.Pediatrics103(3): 576-581.
12. Sieert, K.; Bowman, P. J.; Hefin, C. M.; Danziger, S.;Williams, D. R. 2000. Social and Environmental Predictors oMaternal Depression in Current and Recent Welare Recipients.
American Journal of Orthopsychiatry70(4): 510-522.
13. Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National
Alliance o Multiethnic Behavioral Health Associations (NAMBHA).
14. Isaacs, Maresa R. 2006.Maternal Depression: The Silent Epidemicin Poor Communities. Baltimore: MD: Annie E. Casey Foundation.
15. Belle, Deborah; Doucet, Joanne. 2003. Poverty, Inequality, andDiscrimination as Sources o Depression Among U.S. Women.Psychology of Women Quarterly27(2): 101-113.
Hoboll, Stevan E.; Ritter, Christian; Lavin, Justin; Hulsizer,Michael R.; Cameron, Rebecca P. 1995. Depression Prevalence andIncidence Among Inner-City Pregnant and Postpartum Women.
Journal of Consulting and Clinical Psychology63(3): 445-453.
Richardson, Phil. 2002. Depression and Other Mental Health BarriersAmong Welfare Recipients Results from Three States. Reston, VA:Maximus.
16. Hoboll, Stevan E.; Ritter, Christian; Lavin, Justin; Hulsizer,Michael R.; Cameron, Rebecca P. 1995. Depression Prevalence andIncidence Among Inner-City Pregnant and Postpartum Women.
Journal of Consulting and Clinical Psychology63(3): 445-453.
17. Essex, Marilyn J.; Klein, Marjorie H.; Miech, Richard;Smider, Nancy A. 2001. Timing o Initial Exposure to MaternalMajor Depression and Childrens Mental Health Symptoms inKindergarten. British Journal of Psychiatry179(2): 151-156.
Hammen, Constance; Brennan, Patricia A. 2003. Severity,Chronicity, and Timing o Maternal Depression and Risk or
Adolescent Ospring Diagnoses in a Community Sample.Archivesof General Psychiatry60(3): 253-258.
18. For more detailed syntheses o research see Bonari, Lori; Pinto,Natasha; Ahn, Eric; Einarson, Adrienne; Steiner, Meir; Koren,Gideon. 2004. Perinatal Risks o Untreated Depression DuringPregnancy. Canadian Journal of Psychiatry49(11): 726-735.
19. Neggers, Yasmin; Goldenberg, Robert; Cliver, Suzanne; Hauth,John. 2006. The Relationship between Psychosocial Prole, HealthPractices, and Pregnancy Outcomes.Acta Obstetrica et GynecologicaScandinavica85(3): 277-285.
20. Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National
Alliance o Multiethnic Behavioral Health Associations (NAMBHA).
21. Ashman, Sharon B.; Dawson, Geraldine; Panagiotides, Heracles;Yamada, Emily; Wilkinson, Charles W. 2002. Stress HormoneLevels o Children o Depressed Mothers. Development andPsychopathology14(2): 333-349.
Essex, Marilyn J.; Klein, Marjorie H.; Cho, Eunsuk; Kalin, Ned H.2002. Maternal Stress Beginning in Inancy May Sensitize Children
to Later Stress Exposure: Eects on Cortisol and Behavior. BiologicalPsychiatry52(8): 776-784.
22. Huang, Larke N.; Freed, Rachel. 2006. The Spiraling Effects ofMaternal Depression on Mothers, Children, Families and Communities.Issue Brie #2. Annie E. Casey Foundation.
Lyons-Ruth, K.; Connell, D. B.; Grunebaum, H. U.; Botein, S.1990. Inants at Social Risk: Maternal Depression and FamilySupport Services as Mediators o Inant Development and Securityo Attachment. Child Development61(1): 85-98.
23. NICHD Early Child Care Research Network. 1999. Chronicityo Maternal Depressive Symptoms, Maternal Sensitivity, and ChildFunctioning at 36 Months. Developmental Psychology35(5): 1297-1310.
7/29/2019 Reducing Maternal Depresion
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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 19
24. Huang, Larke N.; Freed, Rachel. 2006. The Spiraling Effects ofMaternal Depression on Mothers, Children, Families and Communities.Issue Brie #2. Annie E. Casey Foundation.
Paulson, James F.; Dauber, Sarah; Leierman, Jenn A. 2006. Individualand Combined Eects o Postpartum Depression in Mothers andFathers on Parenting Behavior. Pediatrics118(2): 659-668.
25. Beardslee, W. R.; Bemporad, J.; Keller, M. B.; Klerman, G. L.1983. Children o Parents with Major Aective Disorder: A Review.
American Journal of Psychiatry140(7): 825-832.
Essex, Marilyn J.; Klein, Marjorie H.; Miech, Richard; Smider,Nancy A. 2001. Timing o Initial Exposure to MaternalMajor Depression and Childrens Mental Health Symptoms inKindergarten. British Journal of Psychiatry179(2): 151-156.
26. Henderson, Jennier J.; Evans, Sharon F.; Straton, Judith A.Y.;Priest, Susan R.; Hagan, Ronald. 2003. Impact o PostnatalDepression on Breasteeding Duration. Birth 30(3): 175-180.
Paulson, James F.; Dauber, Sarah; Leierman, Jenn A. 2006. Individualand Combined Eects o Postpartum Depression in Mothers andFathers on Parenting Behavior. Pediatrics118(2): 659-668.
27. Chung, Esther K.; McCollum, Kelly F.; Elo, Irma T.; Lee, HelenJ.; Culhane, Jennier F. 2004. Maternal Depressive Symptoms andInant Health Practices among Low-Income Women. Pediatrics
113(6): 523-529.Kavanaugh, Megan; Halterman, Jill S.; Montes, Guillermo; Epstein,Mike; Hightower, A. Dirk; Weitzman, Michael. 2006. MaternalDepressive Symptoms Are Adversely Associated with PreventionPractices and Parenting Behaviors or Preschool Children.
Ambulatory Pediatrics6(1): 32-37.
McLennan, John D.; Kotelchuck, Milton. 2000. Parental PreventionPractices or Young Children in the Context o Maternal Depression.Pediatrics105(5): 1090-1095.
Paulson, James F.; Dauber, Sarah; Leierman, Jenn A. 2006. Individualand Combined Eects o Postpartum Depression in Mothers andFathers on Parenting Behavior. Pediatrics118(2): 659-668.
28. Huang, Larke N.; Freed, Rachel. 2006. The Spiraling Effects ofMaternal Depression on Mothers, Children, Families and Communities.Issue Brie #2. Annie E. Casey Foundation.
Kavanaugh, Megan; Halterman, Jill S.; Montes, Guillermo; Epstein,Mike; Hightower, A. Dirk; Weitzman, Michael. 2006. MaternalDepressive Symptoms Are Adversely Associated with PreventionPractices and Parenting Behaviors or Preschool Children.
Ambulatory Pediatrics6(1):32-37.
Sills, Marion R.; Shetterly, Susan; Xu, Stanley; Magid, David;Kempe, Allison. 2007. Association between Parental Depression andChildrens Health Care Use. Pediatrics119(4): 829-836.
29. Whitaker, Robert C.; Orzol, Sean M.; Kahn, Robert S. 2006.Maternal Mental Health, Substance Use, and Domestic Violencein the Year ater Delivery and Subsequent Behavior Problems inChildren at Age 3 Years.Archives of General Psychiatry63(5): 551-560.
30. Ibid.31. Isaacs, Maresa R. 2006.Maternal Depression: The Silent Epidemicin Poor Communities. Baltimore, MD: Annie E. Casey Foundation.
32. Goodman, Janice H. 2004. Paternal Postpartum Depression, ItsRelationship to Maternal Postpartum Depression, and Implicationsor Family Health.Journal of Advanced Nursing45(1): 26-35.
33. Research to Practice: Depression in the Lives of Early Head StartFamilies. April 2006. Administration or Children and Families,U.S. Department o Health and Human Services.
34. Goodman, Janice H. 2004. Paternal Postpartum Depression, ItsRelationship to Maternal Postpartum Depression, and Implications
or Family Health.Journal of Advanced Nursing45(1): 26-35.
35. Kahn, Robert S.; Brandt, Dominique; Whitaker, Robert C.2004. Combined Eect o Mothers and Fathers Mental HealthSymptoms on Childrens Behavioral and Emotional Well-Being.
Archives of Pediatric & Adolescent Medicine158(8): 721-729.
Paulson, James F.; Dauber, Sarah; Leierman, Jenn A. 2006. Individualand Combined Eects o Postpartum Depression in Mothers andFathers on Parenting Behavior. Pediatrics118(2): 659-668.
Ramchandani, Paul; Stein, Alan; Evans, Jonathan; OConnor,Thomas G. 2005. Paternal Depression in the Postnatal Periodand Child Development: A Prospective Population Study. Lancet365(9478): 2201-2205.
36. OBrien, R. W.; DElio, M. A.; Vaden-Kiernan, M.; Magee,C.; Younoszai, T.; Keane, M. J.; Connell, D. C.; Hailey, L. 2002.
A Descriptive Study of Head Start Families: Faces Technical Report I.Washington, DC: U.S. Administration on Children, Youth, andFamilies. Department o Health and Human Services.
37. Smithgall, Cheryl; Mason, Sally; Michels, Lisa; Licalsi,Christina; Goerge, Robert. 2006. Caring for Their ChildrensChildren: Assessing the Mental Health Needs and Service Experiences ofGrandparent Caregiver Families. Chapin Hall Center or Children atthe University o Chicago.
38. Whitebook, Marcy; Phillips, Deborah; Bellm, Dan; Crowell,Nancy; Almaraz, Mirella; Jo, Joon Yong. 2004. Two Years in EarlyCare and Education: A Community Portrait of Quality and WorkforceStability. Center or the Study o Child Care Employment,University o Caliornia at Berkeley.
39. Ibid.
40. Hamre, Bridget K.; Pianta, Robert C. 2004. Sel-ReportedDepression in Nonamilial Caregivers: Prevalence and Associations
with Caregiver Behavior in Child-Care Settings. Early ChildhoodResearch Quarterly19(2): 297-318.
41. Gilliam, Walter S.; Shabar, Golan. 2006. Preschool and ChildCare Expulsion and Suspension: Rates and Predictors in One State.Infants & Young Children: An Interdisciplinary Journal of Special CarePractices19(3): 228-245.
42. Miranda, Jeanne; Chung, Joyce Y.; Green, Bonnie L.; Krupnick,Janice; Siddique, Juned; Revicki, Dennis A.; Belin, Tom. 2003.Treating Depression in Predominantly Low-Income Young Minority
Women: A Randomized Controlled Trial.JAMA 290(1): 57-65.
Perry, Deborah F. 2006. What Works in Preventing and TreatingMaternal Depression in Low-Income Communities of Color. Issue Brie#3. Annie E. Casey Foundation.
43. Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National
Alliance o Multiethnic Behavioral Health Associations (NAMBHA).
44. Knitzer, Jane. 2000. Promoting Resilience: Helping Young Children
and Parents Affected by Substance Abuse, Domestic Violence, andDepression in the Context of Welfare Reform. New York, NY: NationalCenter or Children in Poverty, Mailman School o Public Health,Columbia University.
45. Beardslee, William R. Reducing Maternal Depression and ItsImpact