Among a nationally representative US sample of VLBW infants followed to preschool age, maternal depression is associated with negative perceptions of children’s abilities to share, make friends, and play independently – perceptions not corroborated by children’s teachers. Former VLBW preschool children whose mothers report depression symptomatology are approximately one third as likely to participate in typical age-appropriate child activities as those whose mothers do not. Furthermore, children whose mothers report depression symptoms at both the baseline and preschool time points are only about one-fifth as likely to participate in such activities. These associations are substantially attenuated or loose significance all together when tested among a separate population of healthy term infants.
In recent years, much attention has been given to efforts to maximize the long term developmental and social outcomes of VLBW infants. Many of these efforts, summarized in the recent IOM report Preterm Birth
, have focused on the need to develop evidence-based standards for NICU follow-up care and to organize care delivery around such standards.7
In this paper, we provide evidence that maternal depression, which is disproportionately common in mothers of VLBW infants, is associated with negative maternal perceptions of their preschool-aged children’s social abilities – and more importantly, with reported activity restriction. If activity such restriction is accepted as a negative social outcome, our results argue for efforts to address maternal depression in this population to prevent further negative sequelae among the children.
One theoretical paradigm through which our results might be viewed is the vulnerable child syndrome. Originally described in 1964 by Green and Solnit,23
the vulnerable child syndrome describes a constellation of phenomena in which a child with real or imagined illness early in life becomes the target of altered attachment by her parents, including the perception of susceptibility to illness or lack of capacity for age-appropriate behaviors.24
The vulnerable child syndrome has been previously described among children born prematurely,25,26
and some studies have invoked it to explain activity restriction among presumed-healthy children well into the school-age years.27
While our study provides no proof that the vulnerable child syndrome represents the mechanism by which maternal depression is linked to activity restriction, it may represent a useful paradigm through which to plan future family centered interventions to optimize the developmental trajectories of VLBW infants.
Our study has a number of limitations. First, depression tends to be a waxing and waning illness; therefore, documenting depressive symptoms at each of our study’s time points does not necessarily shed light on the mothers’ symptom burden between time points or address the issue of whether or not depressed mothers received treatment for their condition. Second, our measure of depressive symptoms, the CES-D, is a symptom inventory; and although it has well documented performance characteristics with cut points highly predictive of clinically significant depressive symptomatology, it does not quantify functional status – an element inherent in the definition of major depressive disorder.
Additionally, as is typical of cohort studies, the associations reported in this study are not necessarily causal, and residual confounding may exist – particularly with respect to children’s actual developmental status, which may be incompletely captured by the BSID II scale. Although many of our perception-based outcomes were cross checked with preschool teacher reports (a strength of the ECLS data), our outcomes are all based on parental self-report. Specifically, although the activities included in our assessment of activity restriction are common preschool activities, their inclusion as measures are admittedly arbitrary. Lastly, there is the inherent limitation of secondary data analysis and the need to confirm findings through targeted prospective data collection.
These limitations withstanding, our data add to the growing knowledge base on maternal depression in the context of having a child with actual or perceived special needs. Among this VLBW population, maternal depression appears to be associated with negative perceptions of preschool children’s social aptitude and concurrent activity restriction. Because of this, we argue that maternal depression be systematically addressed and further studied in this population, and that the conceptualization of follow-up services to VLBW infants be broadened to consider the wellbeing of entire families.