[Mental Illness 2018; 10:7267] [page 27]

Infant psychomotor development in cases of maternal postpartumdepression: Observation of amother and baby unitLaure Le Treut,1,2 François Poinso,1,2Pauline Grandgeorge,1Elisabeth Jouve,3 Michel Dugnat,1Joshua Sparrow,4 Jokthan Guivarch1,21Department of Child Psychiatry, SainteMarguerite Hospital APHM; 2Faculty ofMedicine of Marseille, Aix-MarseilleUniversity; 3Department of MedicalEvaluation and Public Health, APHM,Marseille, France; 4BrazeltonTouchpoints Center, Division ofDevelopmental Medicine BostonChildren’s Hospital/Harvard MedicalSchool, Boston, MA, USA

AbstractStudies of the first year of infant psy-

chomotor development in cases of maternalpostpartum depression are lacking. Themother and baby unit (MBU) is a healthcaresystem available to infants and their moth-ers during the postpartum period in a psy-chiatric hospital, which provides supportand preserves the parent’s role in the child’sdaily care. The aim of the paper is todescribe the developmental profile ofbabies of mothers with severe postpartumdepression treated in an MBU through thedevelopmental quotients. Using the Brunet-Lézine scale, we studied six-month-oldinfants whose mothers were hospitalized.The study population consisted of 15infants. The mean global developmentalquotient score was 96.7. A developmentalquotient lower than 80 was not observed forany of the children. We found no globalpsychomotor developmental delays.Despite this, the posture subscore was thearea in which we observed the most diffi-culties. It is possible that the tonic dialoguebetween the mother and infant is disruptedby maternal depression.

IntroductionPerinatal psychiatry is a recent and

developing field of psychiatry. It focuses ontreating maternal mental disorders and pro-moting child development. Postpartumdepression is the most frequently observeddisorder during the perinatal period.1 The

mother and baby unit (MBU) is a level-three healthcare system that is available inpsychiatric hospitals in France for infantsand their mothers during the postpartumperiod. It is tasked with treating puerperaland maternal disorders, as well as relation-ship difficulties between mothers andinfants.2-4 The intervention used is based onthe continuous presence of psychiatric andpediatric nurses for the mother and child,respectively. Then, the first principle of sup-port preserves the parent’s role in the child’sdaily care. The nurses adopt a reserved atti-tude but are available and remain present atanxious times. Nonetheless, they mustaccept the mother’s request to take her placefor either a given moment or more regular-ly. The limits of their neutrality depend onthe following two factors: the child’s pro-tection (if the mother seems to be inade-quate, violent, or insufficiently reassuring)and the mother’s request for intervention.The aim of the caregivers is to provide sup-port in the development of a maternal iden-tity, exemplifying and serving as a rolemodel for the attitudes, behaviors, andmethods that the mother can imitate.2 Thus,they play a role in both prevention and earlyintervention in child development.

The indications for joint hospitalizationare initial or recurring episodes of postpar-tum psychiatric disorders, acute or chronicmaternal psychiatric pathologies, mother-baby relationship disorders, functional dis-orders and some infant developmentaldelays.2-4

The approach to treating mothers duringmother-infant hospitalizations is twofold:treatment of the psychiatric disorder andevaluation and support of the developingmother-infant interactions.2 For the infant,the institution ensures that physical andpsychiatric care is safe and consistent.5 Thisdoes not mean that the institution is replac-ing the mother but that it defers to the moth-er when she is providing the necessary careand steps in to compensate at times whenmaternal care is unavailable or when thepathological process hinders mother-infantinteractions.

Relational challenges, even as early asthe first year, have been correlated with thedevelopment of abnormal psychology inchildren, resulting in some cases of psy-chomotor retardation and difficulties informing attachments.6,7 Few studies havefocused on evaluating the psychomotordevelopment of babies in cases wherematernal psychiatric pathology occurs dur-ing the first year. Selma Fraiberg empha-sized the need to monitor the developmentof the baby independently of professionalcaregivers, since they may underestimate

delays and signs of illness in infantsbecause of their bond with and empathytoward the troubled parent.8

In this article, we present the results ofa descriptive study of a population of six-month-old infants whose mothers were hos-pitalized for severe postpartum depressionin the MBU. Their development wasassessed using the revised Brunet-Lézinescale,9 which is the most frequently usedtool in France for the assessment of infantpsychomotor development.10 Our objectivewas to describe the developmental profileof babies of mothers with severe postpar-tum depression that were hospitalized in theMBU of the Marseille University HospitalCenter using the developmental quotients.We tested our hypothesis that infants ofdepressed mothers would present with anatypical developmental profile, eventuallyresulting in a developmental delay.

Mental Illness 2018; volume 10:7267

Correspondence: Laure Le Treut, Departmentof Child Psychiatry, Sainte MargueriteHospital, APHM, 270 Boulevard de SainteMarguerite, 13009 Marseille, France.Tel.: +33.491744767 - Fax: + 33491746242. E-mail: laure.le-treut@ap-hm.fr

Key words: Maternal postpartum depression;infant psychomotor development; revisedBrunet-Lézine Scale; mother and baby unit.

Contributions: Substantial contributions to theconception or design of this work or to theacquisition, analysis, or interpretation of thedata for this work: LLT, FP, PG, EJ, MD, JG.Drafting this work or critically revising it interms of important intellectual content: LLT,FP, PG, EJ, MD, JS, JG. Final approval of theversion to be published: LLT, FP, PG, EJ, MD,JS, JG. Agreement to be accountable for allaspects of this work in ensuring that questionsrelated to the accuracy or integrity of any partof this work are appropriately investigated andresolved: LLT, FP, PG, EJ, MD, JS, JG.

Conflict of interest: the authors declare nopotential conflict of interest.

Funding: none.

Received for publication: 15 June 2017.Revision received: 27 November 2017.Accepted for publication: 28 November 2017.

This work is licensed under a CreativeCommons Attribution-NonCommercial 4.0International License (CC BY-NC 4.0).

©Copyright L. Le Treut et al., 2018Licensee PAGEPress, ItalyMental Illness 2018; 10:7267doi:10.4081/mi.2018.7267

Materials and Methods

Plan and populationWe performed a cross-sectional,

descriptive study of the development of 6-month-old infants of mothers with depres-sion using the revised Brunet-Lézine scale.

Inclusion criteria: i) mother experiencedher first severe depressive episode duringthe postnatal period. The diagnosis wasmade according to the DSM-IV’s criteria bythe MBU’s two senior psychiatrists; ii)mother with an infant aged 6±1 months; iii)both parents’ agreement obtained for theanonymized use of their data.

Exclusion criteria: i) mothers with a dif-ferent pathology (anxiety disorders, psy-chotic disorders, borderline disorders withno associated signs of depressive episodes);ii) infant discharged before the age of sixmonths or admitted after the age of sixmonths; iii) infant with a preexisting delay.

Judgment criterion: the Brunet-Lézine scale

The revised Brunet-Lézine test is one ofthe only development scales for young chil-dren that has been calibrated using a Frenchsample. It is similar to the Bayley test.11 TheBrunet-Lézine scale is the test most oftenused in France in the field of infant develop-mental evaluation. Four major developmen-tal areas are studied: posture DQ, coordina-tion DQ, sociability DQ, and language DQ.

The global developmental quotient(global DQ) is calculated from these sub-scores. The normal global DQ value rangeis from 80 to 120, with a mean of 100. Adevelopmental delay is indicated if theglobal DQ is lower than 70. The revisedBrunet-Lézine scale provides an assessmentat a time T in the child’s development.

MeasurementA psychologist who was external to the

treatment team administered the Brunet-Lézine tests in an attempt to provide a moreobjective point of view on the impact ofrelational challenges on the baby.

Statistical methodsThe statistical analysis was primarily

descriptive. The qualitative variables aredescribed by the numbers and percentagesof the patients within each group. The quan-titative variables (DQ and subscores) arereported as means, standard deviations andmedians. The 95% confidence intervals(95%CI) were calculated. Next, pairwisecomparisons of the DQ scores were testedusing paired t-tests, then the P-values werecorrected using the Bonferroni adjustment.

Ethics CommitteeThe protocol was submitted to the

University of Aix-Marseilles’s EthicsCommittee, which granted its approval.

Results

Description of the study population The study population consisted of 14

dyads and 15 infants (one dyad included aset of twins) successively treated in themother and baby unit of the Saint-Marguerite University Hospital Center inMarseille between 2014 and 2016.

The main diagnosis of the mothers wassevere postpartum depression. Three of the14 mothers had borderline personality dis-order, and one had a depressive episode inthe context of bipolar disorder. There were15 infants comprised of ten boys and fivegirls. The mean age of the babies was sixmonths and 8 days. The main characteristicsof the population are presented in Table 1.

Description of the DevelopmentalQuotients of the children

The mean global DevelopmentalQuotients (DQ) score was 96.7 (95%CI:93.4-99.9), the median was 96.8 and therange was 108 to 87. Two children had aglobal DQ score under 90, but no child hada score under 80.

Regarding the DQ subscores, the meanposture DQ score was 92.3 (median 93.7;95%CI: 87.2-97.4); the mean coordinationDQ score was 98.2 (median 98.6; 95%CI:93.5–102.9); the mean language DQ scorewas 102.7 (median 100.5; 95%CI: 97.8-107.5); and the mean sociability DQ scorewas 95.5 (median 97; 95%CI: 93.4-99.9).The main developmental scale results aredisplayed in Table 2 and Figure 1.

Comparisons of the DevelopmentalQuotients scores

Pairwise comparisons of the DQ scoresshowed differences between:- Posture DQ and global DQ (P=0.013)- Posture DQ and coordination DQ

(P=0.035)- Posture DQ and language DQ

(P=0.005)- Language DQ and global DQ (P=0.016)- Language DQ and sociability DQ

(P=0.011)After the Bonferroni adjustment, we

found a difference between the Posture DQand the language DQ (P=0.05).

Discussion and ConclusionsThe main result of our study was the

absence of developmental delays among theinfants in our population. This is a signifi-cant result, as shown by the 95%CI, whichdoes not include values lower than 80. Onlytwo children fell in the average-low zone,with a global DQ score of 88. These resultsare consistent with the observations of Piteoet al., who studied the development of 18-month-old infants whose mothers sufferedfrom postpartum depression. They foundthat maternal depression during the first 6months of the postpartum period was notassociated with cognitive, language ormotor development in infants 18 months ofage.12 We found a developmental profilecharacterized by higher values in the lan-guage DQ score and lower values in theposture DQ score. After adjustment, theseresults were significant.

Although it was not pathological, theposture category was the index wherein weobserved the most difficulties in the popula-tion of children studied. Two children wereactually in the borderline zone (score of 70-80). Four other children had results in theaverage-low zone (score of 80-90),

Brief Report

Table 1. Population characteristics.

Variables N. %

Child’s sex Boy 10 66.7

Girl 5 33.3Mother’s diagnosis Postpartum depression 10 71.4 Postpartum depression + borderline personality disorder 3 21.4 Postpartum depression + bipolar disorder 1 7.14

Other parameters Mother’s age, mean 34 years and 8 months Child’s age, mean 6 months and 8 days

[page 28] [Mental Illness 2018; 10:7267]

[Mental Illness 2018; 10:7267] [page 29]

accounting for 26.6% of the population. Atotal of six children, or 40%, had low scoresin this index.

These children of depressive mothersdid not, therefore, present any impaireddevelopment in the first months of life, butsome of them seemed fragile in terms of theposture category.

It is possible that the tonic dialoguedescribed by Wallon and Ajurriaguerra isdisrupted by maternal depression, both onan emotional level and through maternalpsychomotor anomalies.13,14

Tonic dialogue is one of the ways tohelp the baby with tonic regulation, whichoccurs by metabolizing body tension that isaccumulated in reaction to sensory stimuliand giving it meaning. For Bullinger,15

tonic dialogue meets a vital communicationneed for the baby. Babies are sensitive totonic and rhythmic variations of the armsthat hold them. Tonic variations in mothersaffect tonic variations in babies.16

Psychomotor anomalies are some of themost fundamental features of depression.They manifest themselves as disturbancesin speech, facial expression, fine motorbehavior, gross motor activity andideation.17 In postpartum depression, psy-chomotor symptoms are more frequent thanin non-postpartum depression.18 Whentonus, rhythm, facial mimics and prosody inthe mother are not congruent, the baby can-not understand the mother’s emotions.16 Inpostpartum depression, there is a lasting

impact of the mother’s tonus, rhythm, andfacial mimics, which disturbs tonic dialogueand could impact tonus in the baby. Thiseffect could explain the moderate drop inthe posture DQ scores.

The DQs in this study were tested early.The mothers also received psychiatric carethat attenuated the severity of the depres-sive symptoms and, therefore, any potentialeffects on the child’s development.Furthermore, the infants who received earlytreatment in the mother and child unit hadthe advantage of having childcare nurses

with them. It is possible that this treatment,which focused on interactions and on pro-moting interpersonal communication,boosted early socialization. We would,therefore, suggest that the treatment had apositive effect on infant development.Indeed, childcare nursing could allow thedevelopment of nonverbal communicationand of maternal positive feelings regardingparenting. These items are the two mostimportant factors of resilience that wereidentified in a prospective cohort study ofchildren who were exposed to depressive

Brief Report

Table 2. Developmental Quotients scores on the revised Brunet Lézine scale.

Case Sex Age (months) Posture DQ Coordination DQ Language DQ Sociability DQ Global DQ

S1 M 6 96 103 108 108 102S2 M 6 98 98 114 98 100

S3 M 6 102 99 90 99 99S4 M 6 91 88 115 96 94

S5 M 6 104 106 100 100 103S6 M 6 95 100 100 84 96

S7 M 6 101 114 114 98 108S8 M 7 85 106 109 96 98

S9 F 6 73 93 108 100 88S10 M 7 89 106 100 92 97

S11 F 6 99 103 99 99 102S12 F 6 98 90 98 82 92

S13 F 6 89 83 100 100 93S14 F 7 75 93 84 93 87

S15 M 6 90 91 101 87 91Mean 6 m8d 92.3 98.2 102.7 95.5 96.7

Median 93.7 98.6 100.5 97.0 96.8SD 9.2 8.4 8.8 6.9 5.9

L95%CI 87.2 93.5 97.8 91.6 93.4U95%CI 97.4 102.9 107.5 99.3 99.9

Figure 1. Mean subscores and global scores of the infants on the revised Brunet-Lézinescale.

[page 30] [Mental Illness 2018; 10:7267]

symptoms post-natally.19.A future compara-tive study using a control group of depres-sive mothers who were treated without spe-cific childcare would allow us to confirmthis hypothesis.

The main limitation of this study wasthe population size due to the small size ofour unit.

The DQ subscores of the differentdevelopmental areas should also be inter-preted with caution because they are basedon a small number of items, and the behav-ior of very young children is labile andremains difficult to assess, even for sea-soned psychologists.

The scores taken when the babies weresix months old could serve as a baseline; itmight be interesting to add longitudinaltimepoints to the study and to performretests over time in order to investigate ifthe infant profiles are maintained, if dropsin the DQ scores appear, and/or the scorescorrelate with maternal symptom progres-sion.

Despite the rather reassuring appear-ance of our results, we would like to drawattention to the advantages of a more objec-tive metric than the daily observation of ababy’s behavior. This assessment is part ofa systematic evaluation and is useful inlearning a baby’s strengths and weaknesses;it can also sometimes identify developmen-tal warning signs.

This study is the first step before largerprospective and controlled studies. Inanother study, we would like to compareinfants and mothers in a controlled settingwithout a mother and baby unit to study theprecise impact of the unit. For these studies,it will be necessary to increase the size ofour population through the participation ofother mother and baby units.

References 1. Glangeaud-Freudenthal NMC, Sutter

AL, Thieulin AC, et al. Inpatient moth-er-and-child postpartum psychiatriccare: factors associated with improve-ment in maternal mental health. EurPsychiatry J Assoc Eur Psychiatr 2011;26:215-23.

2. Poinso F, Gay MP, Glangeaud-Freudenthal NMC, Rufo M. Care in amother-baby psychiatric unit: analysisof separation at discharge. ArchWomens Ment Health 2002;5:49-58.

3. Cazas O, Glangeaud-FreudenthalNMC. The History of Mother-BabyUnits (MBUs) in France and Belgiumand of the French version of the Marcéchecklist. Arch Women’s Ment Health2004;7:53-8.

4. Glangeaud-Freudenthal NMC, Sutter-Dallay AL, Thieulin AC, et al.Predictors of infant foster care in casesof maternal psychiatric disorders. SocPsychiatry Psychiatr Epidemiol2013;48:553-61.

5. Winnicott DW. De la pediatrie a la psy-chanalyse. Paris: Payot; 2008.

6. Murray L, Arteche A, Fearon P, et al.The effects of maternal postnataldepression and child sex on academicperformance at age 16 years: a develop-mental approach. J Child PsycholPsychiatry 2010;51:1150-9.

7. Cornish AM, McMahon CA, UngererJA, et al. Postnatal depression andinfant cognitive and motor developmentin the second postnatal year: The impactof depression chronicity and infant gen-der. Infant Behav Dev 2005;28:407-17.

8. Fraiberg L, Fraiberg S. Clinical studiesin infant mental health: the first year oflife. New York: Basic books; 1980.

9. Brunet O, Lézine I, Josse D. Brunet-Lézine révisé: échelle de développe-

ment psychomoteur de la premièreenfance: BLR. Editions et applicationspsychologiques. 1997.

10. Fily A, Pierrat V, Delporte V, Breart G,et al Factors associated with neurode-velopmental outcome at 2 years aftervery preterm birth: the population-based Nord-Pas-de-Calais EPIPAGEcohort. Pediatrics 2006;117:357–66.

11. Bayley N. Bayley scales of infantdevelopment: manual. PsychologicalCorporation. 1993.

12. Piteo AM, Yelland LN, Makrides M.Does maternal depression predict devel-opmental outcome in 18month oldinfants? Early Hum Dev 2012;88:651–5.

13. Wallon H. Les origines du caracterechez l’enfant: les preludes du sentimentde personnalite. 2015.

14. Ajuriaguerra J de. Manuel de psychia-trie de l’enfant. 2. ed. Paris: Masson;1974. 1089 p.

15. Bullinger A. Le developpement sensori-moteur de l’enfant et ses avatars: Unparcours de recherche. RamonvilleSaint-Agne: Eres; 2004.

16. Bachollet M-S, Marcelli D. Le dialoguetonico-émotionnel et ses développe-ments. Enfances Psy 2011:14-9.

17. Bennabi D, Vandel P, Papaxanthis C, etal. Psychomotor Retardation inDepression: A Systematic Review ofDiagnostic, Pathophysiologic, andTherapeutic Implications. BioMed ResInt 2013;2013:158746.

18. Bernstein IH, Rush AJ, Yonkers K, et al.Symptom features of postpartumdepression: are they distinct? DepressAnxiety 2008;25:20-6.

19. Savage-McGlynn E, Redshaw M,Heron J, et al. Mechanisms ofResilience in Children of Mothers WhoSelf-Report with Depressive Symptomsin the First Postnatal Year. PLOS One2015;10:e0142898.

Brief Report