’

Ask the Question: Screening for

Postpartum Mood and Anxiety
Disorders in Pediatric Primary Care
Stacy Kurtz, PsyD,a Jack Levine, MD,b and
Marcy Safyer, PhD, LCSW-R, IMH-E® (IV-C)a

Postpartum mood and anxiety disorders (PMADs) are a
significant source of toxic stress for young children and can
disrupt developing brain architecture resulting in long-lasting
deleterious effects. Thus, screening for PMADs must be consid-
ered as an essential task of a pediatric primary care provider
(PCP) and the pediatric medical home. Problems in parenting
capacity in mothers with PMADs can lead to disorders in
attachment and a range of other emotional and developmental
challenges for a young child. Therefore, all PCP office visits
with mothers should include surveillance as well as formal
screening at regular, pre-determined intervals. During surveil-
lance, identification of psychosocial, maternal, infant, and
maternal/infant risk factors is critical. There are a number of
well researched, standardized, reliable, free and valid screen-
ing tools including the Patient Health Questionnaires (PHQ-2
and PHQ-9) and the Edinburgh Postnatal Depression Scale
(EDPS). Office implementation includes availability of educational
materials, resource information, and referrals so families can get
appropriate treatment. Screening for PMADs is highly effective
and helps to identify a common, underdiagnosed disorder in
parents that without identification and appropriate treatment can
lead to significant negative outcomes for a young child.
Curr Probl Pediatr Adolesc Health Care 2017;47:241-253

hen parental challenges responsiveness, and experiences

W such as postpartum When infants and young chil- that foster cognitive growth and
mood and anxiety dis- dren do not experience positive, social and emotional develop-
orders (PMADs) are present in a ment. When infants and young
young child’s life, there can be
sensitive and responsive care- children do not experience pos-
devastating developmental con- giving they lose the opportunity itive, sensitive and responsive
sequences that impact the phys- to develop critical social, emo- caregiving they lose the opportu-
ical architecture of the child’s tional, and intellectual skills. nity to develop critical social,
brain and cause derailment emotional, and intellectual skills.
across various developmental These skills include the ability to
1,2 trust, relate to others, have a positive sense of self,
domains. From birth through age 5, brain develop-
ment is in its most rapid and crucial phase whereby a emotionally and behaviorally regulate, and develop
child should develop the foundation and capabilities on executive functioning skills and learning readiness.1
which all subsequent development forms. For healthy Consequently, the early formative years of life can be
development, young children require a secure attach- both a period of significant growth and a time of
ment to a primary caregiver, contingent emotional extreme vulnerability for young children.
Pediatric primary care providers (PCPs) are in an
optimal situation to support the healthy development of
From the aInstitute for Parenting, Adelphi University, Garden City, NY; young children, in part through the evaluation of the
and bHofstra University School of Medicine, Department of Pediatrics,
Hempstead, NY
emotional well-being of mothers, as they typically see
Correspondence to: One South Avenue, PO Box 701, Garden City, NY families earlier and more frequently than other health
11530. E-mail address: skurtz@adelphi.edu (S. Kurtz) care providers. Bright Futures recommends that new-
Curr Probl Pediatr Adolesc Health Care 2017;47:241-253 borns and infants have at least 8 health maintenance
1538-5442/$ - see front matter
& 2017 Elsevier Inc. All rights reserved. visits during the first year (48–72 h after discharge, 1
http://dx.doi.org/10.1016/j.cppeds.2017.08.002 week, 1, 2, 4, 6, 9 and 12 months).3 Asking how new

Curr Probl PediatrAdolesc Health Care, October 2017 241

 The term postpartum mood and anxiety disorders (PMADs) is a complete description
of the group of disorders that occur during and following the birth of a child. Depression can
effect up to 20% of pregnant women5. Anxiety is a common characteristic of mothers’
feelings both during and after pregnancy and is very common in postpartum depression4.
Along with “baby blues”, postpartum depressive and generalized anxiety disorders there is
also the occurrence of psychosis, obsessive-compulsive disorder and posttraumatic stress
disorder. Therefore, the term postpartum mood and anxiety disorders (PMADs) is preferred
when referring to the whole spectrum of mental health concerns.

FIG. PMADs terminology.4,5

mothers are feeling is not only important in assessing the
environment of the infant but is an important component
in establishing a supportive relationship with parents.
Unfortunately, only 44% of surveyed American Acad-
emy of Pediatrics (AAP) pediatricians inquired about or
screened for maternal depression in 2016; however, this
number has increased from 33% in 2004 (Fig).4
The PCP has multiple opportunities to inquire and
screen for parental mental health. The pediatric med-
ical home is the ideal model for optimal pediatric
primary care, of which an important task includes the
ability to identify postpartum mood and anxiety dis-
orders (PMADs).6,7 In a medical home, the PCP and
their team work with families to address both medical
and non-medical needs to ensure the overall health and
well-being of each child and family. The medical home
aims to routinely evaluate and screen multiple areas of
health risk for the child and parent. Central to the
practice of primary care pediatrics is asking caregivers
about their own emotions and behaviors in order to
understand the psychological issues and social deter-
minants of their health and consequently, their child’s
health.8 Incorporating questions about PMADs as part
of routine pediatric well care questions will add to
understanding of familial risk factors and is compara-
ble to asking about cigarette smoking, breastfeeding,
water temperature, care seats, and domestic violence.
Information that helps to identify concerns may impact
both immediate and long-term health outcomes.
There is growing support for screening or inquiring
about PMADs during the baby’s first year. Several
states have legislation supporting PMADs screening
although payment is not guaranteed.9 Additionally,
the Center for Medicare and Medicaid Services
(CMS),10 the AAP and its Bright Futures guide-
lines,2,11 the American College of Obstetricians
and Gynecologists (ACOG),12 and the United States
Preventative Services Task Force (USPSTF)13 all
discuss screening or inquiring about PMADs during
the baby’s first year. While the need to screen mothers
in the postpartum period has been endorsed, there are
no universally agreed upon guidelines for the timing of
screening and monitoring PMADs.
Parents with significant mood and anxiety disorders
during the postpartum period can have difficulty with
the reciprocity of parent–infant interactions, which
may negatively affect the attachment process.14 Early
identification of these disorders should lead to early
treatment, which can mitigate the detrimental effects
on infants, mothers, and their developing relationship,
as well as help to support healthy child development
and mental health over time.6,14–18
Prevalence and Symptoms of
Postpartum Mood and Anxiety
Disorders
Prevalence estimates for PMADs tend to vary widely
depending on type of disorder, diagnostic criteria,
sampling procedures, locations of populations, and
measures used to assess each disorder.19 In general,
estimates range from 8% to 25% of the population with
some low-income populations reporting rates of PMADs
in 50% of all new mothers.14,16 PMADs can have an
adverse impact on all members in a family, as parental
mental health is universally acknowledged as one of the
key determinants for healthy development in infants.19
In order to understand the impact that different perinatal
and postpartum mood and anxiety disorders have on
developing infants, it is important to be able to recognize
the differences in symptoms, presentation, and preva-
lence of each these disorders, including the variations in
the presentation in select special populations.
Depression
There is a spectrum of depressive symptoms present
in the perinatal and postpartum period. These range
from “baby blues,” minimal depressive symptoms

242 Curr Probl Pediatr Adolesc Health Care, October 2017

lasting a few days to a couple of weeks, to postpartum may be related to maternal sensitivity to fluctuations
major depressive episodes with or without psychosis. in various hormones, including estrogen, progesterone,
Each of these disorders and diagnoses has different thyroid, oxytocin and corticotropin following the
effects on mothers and may impact infant development delivery of a child.20,25 While some hormone fluctua-
based on the severity of mothers’ symptoms.19 tion during pregnancy and post-delivery is typical,
certain changes in hormones can lead to behavioral
“Baby Blues” symptoms, which may contribute in the development
The “baby blues” typically occur during the first few of PMADs. For example, dropping levels of estrogen
days after delivery and can include symptoms such as and progesterone have been associated with depression
crying, worrying, sadness, anxiety, irritability, and mood and a decline in progesterone can impact sleep and lead
swings. Often, symptoms characterized as the “baby
20
to the onset of insomnia.20 The serotonin system has
blues” last only a few days but at most, up to 2 weeks also been explored as it relates to the development
postpartum, with peak incidence at the 5th day post- of PMADs in women.20 Additionally, women with
partum. The “baby blues” affect between 15% and 85%
21
PMADs may experience altered neural processing,
of new mothers, and is often attributed to the amount of particularly as it relates to right amygdala region
time, energy, worry, and exhaustion that comes from activation, as researchers have found a distinct differ-
providing newborn care.20 Even though a high percent- ence in functional MRI response patterns on functional
age of women experience this condition post-delivery, MRI as compared to women with Major Depressive
symptoms are usually mild and short-term and therefore Disorder, suggesting potential phenotypic neurophy-
may affect a child less significantly that other PMADs. siological differences between PMADs and MMDs.26
This evidence may indicate that PMADs can be
Postpartum Depression considered a distinct disorder separate from MMD,
Postpartum depression has been found to affect up to which may require a different approach to intervention.
20% of women.7 More specifically, in the first 3 months Symptoms of postpartum depression have been iden-
after childbirth, approximately 14.5% of women report a tified across age, race, ethnicity, and socio-economic
new episode of depression and status; however, low socio-eco-
approximately 10–20% of moth- nomic status, single-parent
ers are believed to suffer with In the first 3 months after child- household, and unemployment
depression sometime during the birth, approximately 14.5% of have been identified as predic-
postpartum period.22 Major women report a new episode of tors of depression during the
Depressive Disorder with Peripar- depression and approximately postpartum period.27 In special
tum Onset is a recognized clinical subpopulations, prevalence of
entity, as outlined in the Diagnos- 10-20% of mothers are believed PMADs may be higher and
tic and Statistical Manual of Men- to suffer with depression some- require providers to screen
tal Disorders, Fifth Edition time during the postpartum at-risk populations more fre-
(DSM-5)23 and must be differ- period. quently. For example, the inci-
entiated from “baby blues.” dence of PMADs may be as
Symptoms include depressed mood, diminished pleas- high as 50% among lower SES populations, adoles-
ure in activities, a marked change in appetite and sleep, cents, and single mothers without adequate social
psychomotor agitation or retardation, fatigue, feelings of support.15 In one study which examined an Early Head
worthlessness or inappropriate guilt, decreased concen- Start sample, 52% of mothers with enrolled children
tration, and recurrent thoughts of death or suicide. showed signs of prenatal or postpartum depression.28
Literature suggests that approximately 50% of postpar- A number of risk factors for PMADs have been
tum depression actually begins prior to delivery.23 identified in the literature. Common maternal risk
Although the DSM-5 specifies that the symptoms of factors include depressive symptoms during or after a
postpartum depression occur during pregnancy or in the previous pregnancy, previous diagnosis of depression
4 weeks following delivery, women remain at increased or bipolar disorder, family history of depression or
risk for depression for up to 1 year after birth.24 other mental illness, stressful life event during or
In terms of endocrine effects on PMADs, some shortly after birth, medical complications during child-
studies have suggested that postpartum depression birth, mixed feelings about the pregnancy, limited

Curr Probl PediatrAdolesc Health Care, October 2017 243

emotional and social support, and marital discord and/
or divorce.7,20,27,29 Additional psychosocial risk fac-
tors include poverty, maternal chronic illness, sub-
stance abuse, adolescent pregnancy, domestic violence,
and social isolation.20,30,31 Postpartum depression has
also been correlated with increased child abuse and
neglect, including caregiver failure to implement
injury-prevention components in the home and envi-
ronment, failure to follow through with preventive
health practices for the child, and difficulty managing
chronic health conditions in the young infant.7 Cultural
factors, such as spousal disappointment with the
gender of the baby, specifically if the baby was a girl,
have also been shown to influence developing post-
partum depression.32–34 In addition to numerous risk
factors in the mother and family, there are also infant
risk factors that have been linked to higher rates of
PMADs. These include prematurity, low birth weight,
high-risk pregnancies, congenital problems, chronic
illness and the “vulnerable child” syndrome.35 Tem-
peramental conflicts between mother and infant can
also predispose a mother to PMADs.36
There are also a number of protective factors for the
development of PMAD including strong social supports,
a partner without depression, breastfeeding, religiosity,
and spirituality.34 While choosing not to breastfeed is
not directly correlated with mood disorders, early
cessation of breastfeeding may be an indicator of
decreased motivation and lack of interest in the mater-
nal–infant bond, which are symptoms of PMADs.29
Anxiety
It is not uncommon for mothers to experience anxiety
around child rearing duties, especially for first time
mothers.37 Anxious thoughts during this time often
relate to the health and safety of the newborn (partic-
ularly for infants susceptible to illness), the responsi-
bility placed on the parent to care for and meet the
needs of the child, adjusting to a new and demanding
schedule, and effects from sleep deprivation. However,
longer lasting and more intense anxiety in the period
after delivery can be categorized as a distinct clinical
problem. Current literature on perinatal and postpartum
anxiety disorders suggests prevalence rates for prenatal
anxiety disorders between 9% and 22% and postpar-
tum anxiety disorders between 11% and 21%.38,39 The
literature suggests that approximately 50% of pregnant
and postpartum women who meet criteria for clinical
depression also have clinically significant anxiety.40
244
One study also found that high maternal anxiety in the
few days after delivery was associated with symptoms
of postpartum depression later in the first year,
suggesting the possibility that high levels of anxiety
may predispose mothers to postpartum depression.39
Postpartum Psychosis
Postpartum psychosis occurs in approximately 1–3
mothers in every 1000 deliveries, most often in the first
month after delivery, and causes severe impairment to
new mothers.7 Symptoms include paranoia, mood shifts,
hallucinations, delusions, and suicidal and/or homicidal
thoughts. Infanticide is most typically associated with
postpartum psychotic episodes, which are frequently
categorized by command hallucinations or delusions
that the infant is possessed.23 Postpartum psychosis
typically requires immediate medical attention and
usually leads to hospitalization for the mothers due to
the severity of symptoms. Risk factors for postpartum
psychosis include pre-existing bipolar I disorder, post-
partum mood episodes in prior pregnancies, a prior
history of depressive or bipolar disorder, and family
history of bipolar disorders.7,23 For subsequent deliv-
eries, the recurrence rate is as high as 30–50%.23
Special Populations
Adolescent Mothers
A number of studies suggest that the prevalence of
postpartum depression among adolescent mothers is
significantly higher than that of adults.41 Of pregnant
adolescents screened for postpartum depression,
between 28% and 59% report depressive symptoms.42
Rates of depression in adolescent mothers during the
first year postpartum have been associated with more
family conflict, fewer familial and social supports, and
low self-esteem.43,44 Additionally, the level of support
from a partner and the quality of significant relation-
ships are associated with postpartum depression in
adolescents.45
Fathers and Paternal Depression
Within the past decade, there has been increased
attention in the literature on postpartum depression in
new fathers.6,46,47 However, paternal depression in the
postpartum period is still largely understudied when
compared to maternal depression during this period
and prevalence rates are difficult to reliably estimate.
For example, fathers may not be present as often as
Curr Probl Pediatr Adolesc Health Care, October 2017
mothers at appointments in which a PMADs screening
is conducted. Literature suggests that paternal depres-
sion tends to occur in between 4% and 25% of new
fathers within the first 12 months after birth of their
child.46 Research has suggested that paternal postpar-
tum depression rates are highest between 3 and 6
46,47
months after delivery.
The rate of paternal depression is associated with a
diagnosis of postpartum depression in the partner/
mother.7 As for risk factors, there has been increasing
evidence that marital conflict and satisfaction are
linked to paternal postpartum depression.47 When in
combination with maternal depression, paternal
depression can lead to worse child outcomes, as there
48
is no healthy parent to act as a protective buffer. As
with maternal depression, paternal depression during
the postpartum period is associated with undesirable
parenting behaviors, such as unhealthy feeding and
sleeping routines, and fewer positive interactions
between parent and child, including reading, singing,
49
and playing together. Evi-
dence suggests that children
raised by fathers with paternal Infants develop expectations
postpartum depression are at an
increased risk for adverse child
about their primary caregivers they
development, including behav- from moment-to-moment inter- the quality of their attachment to
ior problems by preschool actions that start immediately their mothers.
50
age. after birth.
Neonatal Intensive Care
Another subpopulation to consider screening is
mothers who have infants in the Neonatal Intensive
Care Unit (NICU) due to prematurity or other health
complications. It is not uncommon for parents with
children in the NICU to experience high levels of
psychological distress, which is particularly true for
first time mothers.51 Levels of anxiety, depression, and
post-traumatic stress may be seen in well over 50% of
mothers of preterm infants in the NICU. 52–54
Impact of Postpartum Mood and
Anxiety Disorders
Infant Development
In order to fully appreciate the impact and need for
PMADs screening, it is important to understand key
aspects of typical infant development as it pertains to
emotion regulation, brain development and mother–
infant attachment. Infants develop expectations about
Curr Probl PediatrAdolesc Health Care, October 2017
their primary caregivers from moment-to-moment
interactions that start immediately after birth.55 By
8–12 weeks of age, an infant can clearly distinguish his
mother from others through visual cues and senses and
by 4–6 months infants come to clearly prefer a primary
caregiver, most often the mother, to others. Around
6 months of age, infants develop a preferred attach-
ment with more active attempts to seek and achieve
proximity to a primary caregiver by locomotion and
signaling. During this period, infants develop clear
expectations of their mother in their relationship. They
come to expect that mothers will soothe and regulate
them when upset. Infants remember how their mother
has interacted with them in previous interactions and
anticipate how she will interact with them in the future.
As a result, at approximately 1 year, infants develop an
internal representation of their mother; a cognitive map
of their relationship which helps infants anticipate how
their mothers will behave and what feelings, plans or
motives might impact their interactions.55–57 The kind
and quality of the experiences
infants have with their mothers
ultimately impacts how well
develop the capacity to
cope, regulate themselves, and
Mothers with PMADs tend to
display lower levels of maternal
sensitivity and can exhibit
responses that are neglecting, rejecting, intrusive, fright-
ening, unpredictable or inconsistent. In this type of
aversive caregiving environment infants develop defen-
sive adaptations both psychologically and biologically
in order to cope.56,58 These maladaptive patterns may
lead to difficulties with regulation, arousal, and attach-
ment quality. Impaired mother–infant interactions that
occur in the first year of life without intervention can
impact infants’ development for the rest of their lives.59
Attachment Theory
An infant’s attachment system helps to support
survival through increasing the likelihood of protection
of the infant in response to perceived threat or stress.60
The fundamental premise of attachment theory is that
infants with mothers who are available and responsive
to the infants’ needs establish a sense of security. The
infant knows that the caregiver is dependable, which
creates a “secure base” from which the child can
245
explore the world and a “safe haven” to return to when organize, function, and respond to the patterns of
in need of comfort and soothing. Unfortunately, this is relational expectations.70 The first few years of a
not true of all infants, particularly infants of mothers young child’s life is a critical period for the evolving
with PMADs.61 Attachment patterns develop as the attachment relationship and a sensitive period for
result of repeated interactions that infants have with significant neurological development and brain capa-
their caregivers. Attachment theory recognizes the bilities.71,72 From a neuropsychological perspective,
following 4 types of attachment quality: secure, extremely rapid brain development in the first few
ambivalent, avoidant, and disorganized/disoriented.59 months of life yields the establishment of “experience-
Current thought posits that the symptoms of born” neural pathways that provide the foundation for
depressed mothers, such as helplessness, sadness, the acquisition of specific abilities. This experience,
irritability, hostility, volatility, anxiety, and excessive when filled with positive social interaction with a
concern for their child impede their ability to interact sensitive and attentive primary caregiver, prepares the
with their infants in a sensitive, responsive, and attuned brain to function optimally in a healthy environ-
manner. Compared to women without depression in ment.73–75
randomized controlled studies, depressed mothers’ When a young child’s stress response system is
interactions were less responsive and consistent; more activated in an environment with an attentive primary
hostile and critical; both intru- caregiver’s support the physio-
sive and disengaged; and less logical effects from the stress
competent overall. 62
Infants Infants and toddlers of can return to baseline fairly
were found to be at particular depressed mothers were at sig- quickly; resulting in a well-
risk for developing disorganized nificantly higher risk for avoi- functioning stress response sys-
attachment quality if their moth- tem.2 Learning to cope with
ers used spanking as a form of dant and disorganized stress is key for healthy devel-
discipline,63 had more severe attachment and a range of poor opment; however, if a child has
and chronic depression,64 a outcomes in early childhood inadequate protective relation-
comorbid personality disorder such as internalizing and exter- ships, the stress response is
or a history of unresolved grief, severe and long-lasting. A
loss or trauma during their own
nalizing behavior problems child’s stress response system
childhood.65 Mothers that particularly in boys, impaired becomes permanently set on
exhibited disinterest, with- cognitive development, and “high alert” quickly shifting into
drawal and/or were non-verbal psychopathology. defensive mode with very little
when providing caregiving dur- provocation, reacting strongly
ing daily routines were more even when not needed or shut-
likely to have a disorganized infant than control ting down completely.73 The result is often hyper-
mothers.66 Infants and toddlers of depressed mothers arousal in certain areas of the brain which can result in
were at significantly higher risk for avoidant and hyperactivity, sleep and working memory disturban-
disorganized attachment67 and a range of poor out- ces, difficulty labeling affect and the inability to
comes in early childhood such as internalizing and develop coping mechanisms.76 These negative early
externalizing behavior problems particularly in relational experiences cause toxic stress and impact
boys,68 impaired cognitive development, and neural processes at every level of development includ-
psychopathology.69 ing the neuro-circuitry and physical architecture of the
brain with long-lasting consequences for cognitive,
Ecobiodevelopmental Framework and Toxic language, socio-emotional development, mental health,
and school readiness.1
Stress
Toxic stress is strong, frequent, and/or prolonged
The development of the quality of infant attachment activation of the body’s stress response system in the
and the development of brain architecture are inextri- absence of stable adult support.2 The neglect and
cably linked. Neurobiologists explain attachment deprivation often seen as the result of PMADs can be
security as a reflection of the brain’s adaptation and easier to ignore than overt maltreatment yet can still
development of neural pathways or “wiring” that severely compromise infant development. Neglect can

246 Curr Probl Pediatr Adolesc Health Care, October 2017

be defined as “the persistent absence of responsive for Mental Health in Pediatric Primary Care recom-
care”73 and impacts infant development in critical mends screening at 2, 6, and 12 months90 and the
ways. Infants who experience neglect in the context SDBP Workgroup suggests screening within the first
of their relationships with depressed mothers have too 2 weeks, at 2 months, 6 months and at 1 year.91
few “serve-and-return” experiences, which are neces- Some state legislation and guidance also suggests
sary for the development of a healthy and secure timing for screening (i.e., how often screening will be
attachment. Serve and return paid for). However, it is rec-
interactions shape brain architec- ommended that providers fol-
ture. When an infant makes When an infant makes sounds, low medical recommendations
sounds, smiles, or cries, and their smiles, or cries, and their parent rather than legislative ones.
parent responds with appropriate responds with appropriate eye Based on a review of all guide-
eye contact, verbalizations, or lines, we recommend PMADs
rocking, neural connections in
contact, verbalizations, or rock- screening be completed at pre-
the infant’s brain are developing ing, neural connections in the determined well visits includ-
and being strengthened. The73
infant’s brain are developing ing 2 weeks, 2 months,
absence of supportive interaction and being strengthened. 6 months and 12 months with
activates the infant’s stress hor- additional screens at 1 month
mone system, likely resulting in and 4 months if desired.
lifelong physiological consequences. Severe neglect The Patient Health Questionnaire (PHQ-9)77–79,92
has been associated with decreased hippocampal and the Edinburgh Postnatal Depression Scale
volume and reduced pre-frontal cortex size as well as (EPDS)14,31,35,91–93 are free and easy-to-administer
abnormal activities in areas of the brain associated with screening tools. They are validated, reliable, stand-
emotion regulation, attention, and ardized, and translated into a
IQ. In addition, there can be number of languages. The
increased fearfulness and a PMADs screening should be PHQ-994 can be downloaded
reduced sense of safety and pro- completed at predetermined from www.phqscreeners.com
2
tection. Toxic stress can be cir- and is based on DSM-IV cri-
cumvented if we ensure that visits of 1, 2, 4 and 6 months teria for depression. Scores of
relational environments in which with additional screens at 2 5–9 indicate mild depression
infants develop are nurturing, sta- weeks and 12 months if desired. and scores of 10 or greater are
ble, and engaging and attention is significant for moderate or
paid to the impact that PMADs severe depression, which
have on the mother–infant relationship and infant require further evaluation and treatment. Of impor-
development. tance, the final question regarding suicidal ideation
requires immediate intervention. The tool does not
include questions regarding anxiety and screens for
Timing and Tools for PMADs depression only. In a primary care setting, a PHQ-9
Screening score greater than or equal to 10 has a sensitivity of 88%
and a specificity of 88% for major depression.95 The
There are few concrete recommendations for the PHQ-296 is a simple and reliable screen for depression
timing of screening. The natural history of PMADs only. It consists of the first 2 questions of the PHQ-9:
gives some guidance with major depression peaking at During the past month, have you often been bothered by
6 weeks and minor depressive symptoms at 2–3 months (1) little interest or pleasure in doing things, and (2)
and 6 months.7,36 Symptoms of “baby blues” usually feeling down, depressed or hopeless. Any “yes” response
resolve by 2 weeks so earlier screening may over is considered positive and requires additional evaluation
identify. Additionally, symptoms of PMADs can be and treatment. If there is a positive response the PHQ-9
24
delayed and evident for up to 1 year or longer. The may be administered to further evaluate the extent of
AAP clinical report suggests screening at 1, 2, 4 and depression. If only the PHQ-2 is given and it is positive,
6 months7 while Bright Futures recommends assess- the screener must ask about suicidal thoughts or
ments at 1, 2, and 6 months.31 The DC Collaborative attempts. Additionally, the PHQ-2 questions are included

Curr Probl PediatrAdolesc Health Care, October 2017 247

in the Survey of Well-Being of Young Children
(SWYC), a screening instrument that assesses a broad
range of issues, including maternal depression, other
family risk factors, and child development and behav-
ior.86 Some practices may favor the use of this composite
tool to screen for PMADs as well as other domains.
The EPDS97 is an excellent tool developed specifi-
cally to screen for postpartum depression and also asks
about anxiety. The EPDS has been used cross-cultur-
ally, and has been translated into 23 languages,
although all translations have not been validated. It
can be obtained from http://www.fresno.ucsf.edu/pedia
trics/downloads/edinburghscale.pdf.
Scores of 5–9 indicate borderline depression and
scores of 10 or more require intervention. Any positive
response to question 10, regarding suicidal ideation,
requires immediate intervention. Research in a primary
care setting found the best cutoff point for screening
postpartum depression to be greater than 10, with
82.6% sensitivity and 65.4% specificity.98 The abbre-
viated EPDS-399 has been found to be an effective
screen. It consists of questions 3–5 of the EPDS, with
scores of 3 or greater being considered positive and
requiring treatment. There are some suggestions to use
lower cutoffs on the EPDS to identify adolescent
mothers who may have PMAD.42 Analogous to the
TABLE. Risk factors to address during survellience of PMADs
Psychosocial risk factors
• Poverty
• Maternal chronic illness
• History of depression, anxiety, mood disorder,
substance abuse
• Adolescent pregnancy
• Social isolation
Maternal behavior (observed or expressed by mother, father, grandparents)
• Depressed affect
• Changes in sleep behavior
• Lack of enjoyment and/or avoidance of usual activities
• Withdrawal from family and friends
• Neglect of newborn or other children
• Questions reflecting self-doubt
• Inaccurate expectations of behavior and/or development
• Punitive child rearing attitudes or discipline
• Irritable/disruptive in office or frequent visits
248
inclusion of the PHQ-2 in the SWYC, the EPDS can be
found as part of the SWYC-MA, a modified version of
the SWYC that incorporates the full EPDS to screen for
PMADs.100
Surveillance of PMADs
In addition to formal screening, surveillance is one of
the ways to recognize and monitor delays or other
concerns. Surveillance is flexible and done at multiple
visits and implies skilled observation performed during
the provision of healthcare.46 Surveillance as it applies
to PMADs includes assessment of psychosocial fac-
tors, parental history, infant history, infant behavior,
growth and development, caregiver/infant interaction,
and parental behavior.80–83
Monitoring and inquiring about psychosocial risk
factors (Table) can be done in a number of ways
including the pediatric intake form from Bright
Futures,3 parental ACEs screening,85 and the SWYC.86
Asking directly about maternal and paternal family
history is necessary because, there is a strong genetic
component to mood and anxiety disorders.30,31,35,84
These types of questions may open the door to more
detailed and meaningful discussions and create a more
Infant risk factors
• Prematurity
• Congenital problems
• “Vulnerable child” syndrome
• Difficult temperament
Infant behavior
• Decreased activity
• Increased crying
• Poor feeding
• Failure to thrive
• Sleeping problems
Relational risk factors
• Misses or misunderstands cues
• Escalating rather than calming effect on
infant’s distress
• Negative attributions
• Poking and grabbing child to get attention
• Limited sensitive and/or responsive interactions
• Decreased attunement
Curr Probl Pediatr Adolesc Health Care, October 2017
collaborative relationship between the PCP and the
families for whom they care, which can even begin at
the prenatal visit. The Table summarizes the risk
factors that should be evaluated when assessing
maternal mental health. Of note, cultural competence
and sensitivity is essential in addressing this issue. In
terms of infant behavioral concerns and development,
pediatricians can assess these domains using the Baby
Symptom checklist. This tool is used in the SWYC for
its infant behavior screening component.86
Maternal and Infant Behavioral Indicators of
PMADs
Maternal behavior can be indicative of PMADs. Most
PCPs have encountered highly anxious, possibly dis-
ruptive, mothers who schedule frequent office visits or
who appear depressed with flat affect and/or complain
of difficulty caring for their infant. The more classic
signs of depression35 may be described by a mother or
observed and reported by other family member, such
as fathers, grandparents or other children. Other
possible behaviors may include neglect of newborn
or other children, self-doubt, severe anxiety, inaccu-
rate expectations of child behavior and/or develop-
ment, punitive child rearing attitudes or discipline,
disruptive behavior, and difficulty following recom-
mended child rearing practices such as back to sleep,
and standard child safety practices.18,35,87,88
Infant behavior is another important clue to maternal
mental health.16 Problems in the infant–caregiver
dyadic relationship can result in increased crying
(possibly mistaken for colic), poor feeding behaviors
and possible failure to thrive, problems with sleep
routines, and increased likelihood of injuries. Addi-
tionally, mothers who are depressed are likely to
discontinue breastfeeding.89 The discussion of breast-
feeding with mothers with depressive symptoms needs
to be approached sensitively and without judgment or
pressure of unrealistic expectations.
Implementation of a PMADs
Screening Program
Implementation of office screening and surveillance
is dependent on the individual characteristics of the
primary care environment. The PCP needs to prepare
for identification, referral and follow-up before imple-
menting a screening program in the practice. Treatment
Curr Probl PediatrAdolesc Health Care, October 2017
for PMADs can be found in most communities, how-
ever there are gaps in the quality and quantity of service
providers. Treatment options can vary but need to
address the developing relationship between the
mother–infant dyad as well as maternal mental health
and potential psychiatric intervention. Therefore, it is
important for PCPs to have referral information on hand.
One concerning aspect of PMADs screening is the
ability for immediate referral for mothers who are
suicidal or thinking of harming their infants. In most
cases, activation of local emergency services or noti-
fication of child welfare agencies is the most effective
way to get needed and immediate services. Mild
depression and “baby blues” can often be addressed
in the office with reassurance, demystification and
patient education.7 When positive screens are obtained,
discussions regarding breastfeeding, finding ways to
obtain more rest, getting assistance from family,
friends and community organizations in caring for
the home and family are all important aspects of the
visit, which may require more time than scheduled. In
addition, frequent follow-up visits and phone calls are
often required. Specifics of treatment are addressed in
the article by Umylny et al.101 elsewhere in this issue.
While there are certain challenges such as time
limitation, payment, preparation of staff, and office flow,
it is possible for every PCP to screen for PMADs.
Initiating changes in any setting is best done in small
steps.102 Plan-Do-Study-Act (PDSA) cycles are often
used to make small changes and then evaluate their
results.103 For example, in a multi-physician group, one
of the providers may begin screening for PMADs at the
2 month visit for their patients only. After a few months
they can identify potential problems and make small
changes to improve the process until it was performed
satisfactorily and could be expanded to the entire practice.
The Commonwealth Fund suggests 3 aspects to
practice preparation: engagement, practice approach,
and development of office systems.104 Engagement
could include finding a practice champion who is the
leader in the new screening initiative and who would
begin motivating and educating office staff to under-
stand the importance of screening for PMADs. Practice
approach to screening would involve choosing an
appropriate screening tool, deciding on when to screen,
and developing referrals and resources for mothers
with positive screens. Changes in office systems would
include who will distribute, administer and score the
screens; how screening and surveillance will be
monitored to make sure that it is happening; and
249
introduction of any changes needed in the office
environment. In addition to follow-up with the PCP,
sensitive and timely referrals and resources are critical
and should be translated or available in multiple
languages if needed. If possible, one trained staff
member should be assigned to assist families in
obtaining resources and following up to see that
appointments are kept and resources are helpful. Phone
numbers for emergency response and child welfare
should be easily available in case of suicide concerns
or safety issues.
There are a number of perceived roadblocks to
screening including liability and confidentiality. Other
common concerns involve payment for PMADs
screening, which should be a discrete billable
service assigned to the infant visit, as indicated by
many states. Health risk assessments for infants have
always included assessments of their environment
(e.g., water temperature), parental/caregiver behaviors
(e.g., cigarette smoking) and parental medical
factors (e.g., mental health, physical health, and
breastfeeding). For this reason, a new CPT code
96161, Administration of caregiver-focused health risk
assessment instrument (e.g., depression inventory) for
the benefit of the patient, with scoring and documen-
tation, per standardized instrument is now being
used.105 This is used with a modifier with the E/M
codes for the well visit. The new code is replacing the
older code 99420, Administration and interpretation of
health risk assessment instrument (e.g., health hazard
appraisal). This approach is supported by Medicaid7
but individual states may still require billing under the
mother’s identification number.8
Screening for PMADs can be a highly rewarding
experience. Asking questions about how the mother is
feeling, what her mood is like, and whether she is
sleeping or anxious, are critical to establishing open
communication about maternal mental health. There are
also tremendous practice and personal advantages to
screening for PMADs including establishing more mean-
ingful relationships with families, identification of chal-
lenging patients and reduction in either the excessive
frequency of their visits or their non-compliance, reducing
provider burn-out, developing a better understanding of the
factors that influence health and health decisions, and
developing a better reputation in the community and with
other medical professionals. PCPs are in an optimal
position to identify PMADs and potentially change the
course of infants’ development by helping to improve the
mental health of their caretakers.
250
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