Peri-natal Depression Anxiety and Trauma What they are Why they dont get treated How to move forward

Brian Stafford MD MPHAssistant Professor of Psychiatry and Pediatrics UCHSC

Medical Director Postpartum Depression Intervention Program

The Kempe Center and Childrenrsquos Hospital

Colorado Perinatal Council Meeting

Denver Childrenrsquos Hospital

Tammen Hall Nov 17 2006

The Caregiving System

ldquoMothers express intense feelings of pleasure when they are able to provide protection for their children they experience heightened anger sadness anxiety and despair when they are separated from their children or when their ability to protect their children is threatened or blockedrdquo

C George and J Solomon Attachment and the Caregiving System

Handbook of Attachment p 652

My Experience in this Landscape

A case or two

Outline

Brief History Multiple Lenses

The Nature of the Problems Outcomes of Distress Predicting Problematic Outcomes Barriers to Intervention Interventions Moving Forward

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Colorado Perinatal Council Meeting

Denver Childrenrsquos Hospital

Tammen Hall Nov 17 2006

The Caregiving System

ldquoMothers express intense feelings of pleasure when they are able to provide protection for their children they experience heightened anger sadness anxiety and despair when they are separated from their children or when their ability to protect their children is threatened or blockedrdquo

C George and J Solomon Attachment and the Caregiving System

Handbook of Attachment p 652

My Experience in this Landscape

A case or two

Outline

Brief History Multiple Lenses

The Nature of the Problems Outcomes of Distress Predicting Problematic Outcomes Barriers to Intervention Interventions Moving Forward

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

The Caregiving System

ldquoMothers express intense feelings of pleasure when they are able to provide protection for their children they experience heightened anger sadness anxiety and despair when they are separated from their children or when their ability to protect their children is threatened or blockedrdquo

C George and J Solomon Attachment and the Caregiving System

Handbook of Attachment p 652

My Experience in this Landscape

A case or two

Outline

Brief History Multiple Lenses

The Nature of the Problems Outcomes of Distress Predicting Problematic Outcomes Barriers to Intervention Interventions Moving Forward

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

My Experience in this Landscape

A case or two

Outline

Brief History Multiple Lenses

The Nature of the Problems Outcomes of Distress Predicting Problematic Outcomes Barriers to Intervention Interventions Moving Forward

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Outline

Brief History Multiple Lenses

The Nature of the Problems Outcomes of Distress Predicting Problematic Outcomes Barriers to Intervention Interventions Moving Forward

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

History

Pediatric Lens Vulnerable Child Syndrome

Developmental Psychology Risk Resilience and Longitudinal Outcome

Psychiatric Lens Postpartum Depression

Maternal Outcomes Infant Outcomes Relationship Outcomes

Medical Post Traumatic Stress Infant Mental Health Treatment Strategies

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Vulnerable Child Syndrome(Green and Solnit REACTIONS TO THE THREATENED LOSS OF A CHILD A VULNERABLE CHILD SYNDROME PEDIATRIC MANAGEMENT OF THE DYING CHILD PART III Pediatrics 1964 Jul3458-66 )

Parentrsquos thought or told child wouldmight die

Anticipatory grief (Lindemann )

Parentrsquos perceive child is ldquoon tenuous loanrdquo to them

Paths to VCS Serious illness in the

child Representation of a

another figure whose loss is not resolved

Pregnancy complications and fears that she might die

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

VCS Behavioral Outcomes

Pathological Separation difficulties

Sleep problems Inability to set age-

appropriate limits Over-protectiveness

Aggression by child toward the parent

Hyperactive child in presence of the caregiver

School underachievement

Excessive health concerns frequent health care use

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Parental Perception of Child Vulnerability Contributing Factors

Low social support Parental Anxiety Cong Heart Disease Jaundice Non-illness Marital Satisfaction Prematurity

+ sickness

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Developmental Risk

Child competence is not related to current SES but the number of years the family had spent in poverty( Brooks-Gunn 1993)

Duncan GJ Brooks-Gunn J Klebanov PK Economic deprivation and early

childhood development Child Dev 1994 Apr65(2 Spec No)296-318

Child psychopathology is related to the number of risk factors as well (Rutter 1979) Marital distressLow SES Large family Maternal Psychiatric Foster Care placement

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

Rochester Longitudinal Study (Sameroff 1998) To examine the effects of the environment on early

emotional behavior and later mental healthSameroff AJ Environmental risk factors in infancy

Pediatrics 1998 Nov102(5 Suppl E)1287-92

An investigation of the development of a group of children from the prenatal period through adolescence living in a socially heterogeneous set of family circumstances

Evaluated risk factors Childrsquos cognitive ability Socialndashemotional competence

Early childhood phase of the RLS Assessed children and their families at

Birth 4 12 30 and 48 months of age In the home and in the laboratory

During adolescence Assessment at age 13 and 18

TABLE 1 Summary of Risk VariablesRisk Variables RLS Low Risk

High Risk Mental illness

0ndash1 Psychiatric contact More than 1 contact

Anxiety 75 Least 25 Most

Parental perspectives 75 Highest 25 Lowest

Spontaneous interaction 75 Most 25 Least

Occupation Skilled Semi- or unskilled

Education High school No high school

Minority status No Yes

Family support Father present Father absent

Stressful life events 75 Fewest 25 Most

Family size 1ndash3 Children Four or more children

Additive Risk

RLS Findings

On intelligence test children with 0 environmental risks scored

30 points higher than did children with eight or nine risk factors

On average each risk factor reduced the childrsquos IQ score by 4 points

Resiliency (Werner) Kauai LS

Pediatrics 2004 Aug114(2)492 Werner EE Journeys from childhood to

midlife risk resilience and recovery

1) What are the long-term effects of adverse perinatal and early child-rearing conditions on individualsrsquo physical cognitive and psychosocial development at midlife

2) Which protective factors allow most individuals who are exposed to multiple childhood risk factors to make a successful adaptation in adulthood

The KLS has monitored the impact of a wide array of biological psychological and social risk factors

Multiracial cohort of 698 individuals who were born in 1955 on the Hawaiian island of Kauai

From the perinatal period to ages 1 2 10 18 3132 and 40 The follow-up at midlife was able to track 80 of the high-risk children

who had been exposed to chronic poverty birth complications parental psychopathology and family discord

as well as comparison groups of men and women who had not experienced significant childhood adversities

Additive Risk

RLS Findings

On intelligence test children with 0 environmental risks scored

30 points higher than did children with eight or nine risk factors

On average each risk factor reduced the childrsquos IQ score by 4 points

Resiliency (Werner) Kauai LS

Pediatrics 2004 Aug114(2)492 Werner EE Journeys from childhood to

midlife risk resilience and recovery

1) What are the long-term effects of adverse perinatal and early child-rearing conditions on individualsrsquo physical cognitive and psychosocial development at midlife

2) Which protective factors allow most individuals who are exposed to multiple childhood risk factors to make a successful adaptation in adulthood

The KLS has monitored the impact of a wide array of biological psychological and social risk factors

Multiracial cohort of 698 individuals who were born in 1955 on the Hawaiian island of Kauai

From the perinatal period to ages 1 2 10 18 3132 and 40 The follow-up at midlife was able to track 80 of the high-risk children

who had been exposed to chronic poverty birth complications parental psychopathology and family discord

as well as comparison groups of men and women who had not experienced significant childhood adversities

RLS Findings

On intelligence test children with 0 environmental risks scored

30 points higher than did children with eight or nine risk factors

On average each risk factor reduced the childrsquos IQ score by 4 points

Resiliency (Werner) Kauai LS

Pediatrics 2004 Aug114(2)492 Werner EE Journeys from childhood to

midlife risk resilience and recovery

1) What are the long-term effects of adverse perinatal and early child-rearing conditions on individualsrsquo physical cognitive and psychosocial development at midlife

2) Which protective factors allow most individuals who are exposed to multiple childhood risk factors to make a successful adaptation in adulthood

The KLS has monitored the impact of a wide array of biological psychological and social risk factors

Multiracial cohort of 698 individuals who were born in 1955 on the Hawaiian island of Kauai

From the perinatal period to ages 1 2 10 18 3132 and 40 The follow-up at midlife was able to track 80 of the high-risk children

who had been exposed to chronic poverty birth complications parental psychopathology and family discord

as well as comparison groups of men and women who had not experienced significant childhood adversities

Resiliency (Werner) Kauai LS

Pediatrics 2004 Aug114(2)492 Werner EE Journeys from childhood to

midlife risk resilience and recovery

1) What are the long-term effects of adverse perinatal and early child-rearing conditions on individualsrsquo physical cognitive and psychosocial development at midlife

2) Which protective factors allow most individuals who are exposed to multiple childhood risk factors to make a successful adaptation in adulthood

The KLS has monitored the impact of a wide array of biological psychological and social risk factors

Multiracial cohort of 698 individuals who were born in 1955 on the Hawaiian island of Kauai

From the perinatal period to ages 1 2 10 18 3132 and 40 The follow-up at midlife was able to track 80 of the high-risk children

who had been exposed to chronic poverty birth complications parental psychopathology and family discord

as well as comparison groups of men and women who had not experienced significant childhood adversities

KLS

ldquoWith the exception of serious central nervous system damage the impact of peri-natal complications on adult adaptation diminished with time whereas the outcomes of biological risk conditions depended increasingly on the 1)quality of the child-rearing environment and 2) the emotional support provided by family

members friends teachers and adult mentorsrdquo

Poorest outcomes at age 40 were associated with prolonged exposure to parental alcoholism andor mental illnessmdashespecially for the men

KLS

Quality of the individualrsquos adaptation at age 40 correlated significantly with

Health status in the first decade of life (based on a pediatric assessment of all organ systems at age 2 and number of health problems including serious illnesses and accidents between birth and age 10)

The motherrsquos caregiving competence and the emotional support provided by the family in childhood

This study demonstrates the need for early attention to the health status of our nationrsquos childrenmdashespecially those who are exposed to poverty serious perinatal complications and parental psychopathology

The social policy implications are clear early access to good preventive and ameliorative health services and proper attention to the quality of early child care can pay ample dividends in an improved quality of life in adulthood

Other Contextual Factors

HistoricalSocialCultureFamilyInfantNeurobiology

Postpartum Depression

Definitions Postpartum Blues Postpartum Psychosis Postpartum Depression

Postpartum Baby Blues

Mild and Transient Mood Disturbance

Begins 1st Week Postpartum

Lasts from a Few Hours to a Few Days

Prevalence Up to 80 My Work 25-40

Few Negative Sequelae High EPDS Score

Symptoms 1048698 Low Mood 1048698 Mood Lability Insomnia 1048698 Anxiety Crying 1048698 Irritability

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

KLS

Quality of the individualrsquos adaptation at age 40 correlated significantly with

Health status in the first decade of life (based on a pediatric assessment of all organ systems at age 2 and number of health problems including serious illnesses and accidents between birth and age 10)

The motherrsquos caregiving competence and the emotional support provided by the family in childhood

This study demonstrates the need for early attention to the health status of our nationrsquos childrenmdashespecially those who are exposed to poverty serious perinatal complications and parental psychopathology

The social policy implications are clear early access to good preventive and ameliorative health services and proper attention to the quality of early child care can pay ample dividends in an improved quality of life in adulthood

Other Contextual Factors

HistoricalSocialCultureFamilyInfantNeurobiology

Postpartum Depression

Definitions Postpartum Blues Postpartum Psychosis Postpartum Depression

Postpartum Baby Blues

Mild and Transient Mood Disturbance

Begins 1st Week Postpartum

Lasts from a Few Hours to a Few Days

Prevalence Up to 80 My Work 25-40

Few Negative Sequelae High EPDS Score

Symptoms 1048698 Low Mood 1048698 Mood Lability Insomnia 1048698 Anxiety Crying 1048698 Irritability

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Other Contextual Factors

HistoricalSocialCultureFamilyInfantNeurobiology

Postpartum Depression

Definitions Postpartum Blues Postpartum Psychosis Postpartum Depression

Postpartum Baby Blues

Mild and Transient Mood Disturbance

Begins 1st Week Postpartum

Lasts from a Few Hours to a Few Days

Prevalence Up to 80 My Work 25-40

Few Negative Sequelae High EPDS Score

Symptoms 1048698 Low Mood 1048698 Mood Lability Insomnia 1048698 Anxiety Crying 1048698 Irritability

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Postpartum Depression

Definitions Postpartum Blues Postpartum Psychosis Postpartum Depression

Postpartum Baby Blues

Mild and Transient Mood Disturbance

Begins 1st Week Postpartum

Lasts from a Few Hours to a Few Days

Prevalence Up to 80 My Work 25-40

Few Negative Sequelae High EPDS Score

Symptoms 1048698 Low Mood 1048698 Mood Lability Insomnia 1048698 Anxiety Crying 1048698 Irritability

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Postpartum Baby Blues

Mild and Transient Mood Disturbance

Begins 1st Week Postpartum

Lasts from a Few Hours to a Few Days

Prevalence Up to 80 My Work 25-40

Few Negative Sequelae High EPDS Score

Symptoms 1048698 Low Mood 1048698 Mood Lability Insomnia 1048698 Anxiety Crying 1048698 Irritability

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Baby Blues Case

Melinda 20 yo Hispanic female Baby hospitalized for jaundice Anxious Didnrsquot sleep for 4 days Wants to go home Irritable with nurses neonatal staff Not yet prepared at home

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Postpartum Psychosis

1048698 Unipolar or Bipolar Affective Disorder

Schizophrenia

Primiparity Cesarean Delivery Previous Psychosis Previous

Postpartum Psychosis

Family History of Psychosis

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

PPP

Immediate treatmenthospitalization Usually Begins Within 90 Days

Postpartum Length is Quite Variable Prevalence 1500 to 11000 Sequelae Future Postpartum Psychosis A Yates et al

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Post partum depression

1048698 Not as mild or transient as the blues 1048698 Not as severely disorienting as

psychosis Range of severity

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

PPD symptoms (DSM-IV-TR)

1) Depressed Mood 2) Diminished

pleasure

================= 3) Change in

appetite 4) Change in sleep 5) Psychomotor

agitationretardation

6) Fatigue 7) Worthlessness or

guilt 8) Poor

concentration 9) Recurrent

thoughts of death SI plan attempt

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Prevalence of PPD

18 average of numerous studies

Higher in lower SES and other high-risk groups Up to 25

Nationally

Colorado

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Front Range Counties (Colorado Vital Statistics 2003)

County Live Births 2004 Estimated Depressed (12)

Adams 7483 900

Boulder 3548 420

Denver 10438 1300

Jefferson 6251 750

Colorado 68000 8160

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

PRAMS DATA

Variable Premature Not premature

Depression=Not depressed at all 3672 4535

Depression=A little depressed 3435 3668

Depression=Moderately depressed 1554 1206

Depression=Very depressed 747 362

Depression=Very depressed and had to get help

592 230

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Risk Factors for PPD (Beck and OrsquoHara)

Social Support Prenatal depression Life Stress Marital relationship Depression History Child Care Stress

Unplanned Unwanted

Self-Esteem Prenatal anxiety Infant Temperament Unexpected change

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

A Motherrsquos Fault Line

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

PPD Etiology

Hormonal Stress Loss Role transition Support Expectation Own receipt of care

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Consequences of Perinatal Depression 1048698 Maternal

Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord

Child Consequences Cognitive delay Speech delay Disruptive behavior Less frequent HSV More Urgent Care

ER Ineffective

Anticipatory Guidance

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Other consequences

Relationship Consequences Less sensitive caregiving Insecure attachments Trauma and the Caregiving System

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Attachment and Caregiving

Attachment Secure Avoidant Resistant Disorganized

Caregiving Flexible Distant Close Disabled

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Disabled Caregiving

Unresolved Loss Grief Diagnosis Trauma Depression

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Comorbidity

Anxiety Worry canrsquot control Fatigued Poor concentration Irritability Sleep Muscle tension

OCD Obsessions Compulsions

Panic Attacks

Acute Stress Disorder and

Post Traumatic Stress Disorder

Substance Abuse

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Medical Traumatic Stress

Informing lens

Ongoing possible trauma

Threatened delivery and consequences NICU environment Complication

IVH NEC Long-term consequences CP other

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Acute Stress Disorder (DSM-IV-TR) A) Trauma exposure

1) Confronted 2) Fear

helplessness horror

B) Dissociation Numbing Daze De-realization De-personalization Amnesia

C) Re-experiencing D) Avoidance of

reminders E) Increased anxiety

and arousal F) Impairment in

Functioning

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Importance of Acute Stress Disorder

Unable to process information

Difficulty sleeping

Edginess

Predictor of PTSD

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

PTSD (DSM-IV)

A) Trauma exposure 1) confronted 2) Fear helplessness horror

B) Re-experiencing Distressing recollections Dreams Flashbacks Distress at cues Physiological reactivity to

cues

C) Avoidance of stimuli Thoughts and feelings Activities places people Inability to recall aspects Decreased

interestparticipation Detachment Restricted affect Foreshortened sense of

future

D) Symptoms of arousal Insomnia Irritability Concentrating Hypervigilance Startle

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Caregiver PTSD

Of parents completing follow-up ndash 3 months later - (21) met symptom criteria for PTSD

PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU Unexpected admission Parents degree of worry that the child might die The occurrence of another hospital admission or other

traumatic event subsequent to the first admission

Neither ASD nor PTSD responses were associated with objective measures of a childs severity of illness

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

NICU

ASD symptoms assessed in the NICU

Unexpected admission

Parents degree of worry that the child might die

The occurrence of another hospital admission or other traumatic event subsequent to the first admission NEC ICH etc

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Screening

EPDS 10 item Likert 1213 CES-D 20 question BDI-II 15 question PPDS 25 question

Acute Stress Disorder Scale (ASDS)

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Assessment

Empathic Education Safety Screening Assessment of Other

Pathology All women are

different

Subjective experience is the key

Assessment as Intervention

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Treatment of PPD and Its Co-morbidities Biological

Medication Antidepressants Anti-anxiety

Sleep Massage Exercise Sunlight

Alternative Narrative Journaling Meditation Art Music

Social Family Friends Church Nurse Visitors

Psychological Psychotherapies

Cognitive Behavioral Group Individual Family EMDR

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Psychopharmacology

Antidepressants Breast Milk SSRIs Time to Work

Anti-anxietySomnolents Klonopin

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Psychotherapies

Cognitive Behavioral Therapy

Inter Personal Therapy

Mother Infant Therapy Group

Limitations Cost Logistics Training Doesnrsquot address

trauma specifically

No change in relationship with infant

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Who gets treated

Mental Health Centers

Nurse Home Visiting Kaiser study

28 of women received medication for depression or anxiety in 1 yr past delivery

In Colorado

Mostly mid and high SES with support and resources Individual

Psychotherapy Psychotropics Group

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Barriers

Lack of Awareness

Lack of Formal Screening

Lack of Resources

Lack of Training

Public Awareness Professional Training Satellite Support

Groups Mandatory Screening Linking IMH and MH Conference

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

KEMPE PPDIP

Psychiatric Evaluation

MITGGroup Therapy Infant Motherrsquos Group Dyadic

Open Groups Conference

Professionals Families

Strategic Initiative Public Awareness Screening

Primary Care Public Health

Improved Education Improved mental

health services 1-800 Community Network Linking MMH to IMH

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Neonatal

Nursery Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication Connection to Local

Resources

NICU Mandatory

Screening and Education

Consultation Availability of

Support Availability of

Medication On-site therapy

Who gets whatStep ndashwise approach

Collaboration

Thank You

Who gets whatStep ndashwise approach

Collaboration

Thank You

Collaboration

Thank You