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Positive Maternal Mental Health, Parenting and Child Development

Desiree Y. Phua, Michelle Z.L. Kee, Michael J. Meaney

PII: S0006-3223(19)31778-0
DOI: https://doi.org/10.1016/j.biopsych.2019.09.028
Reference: BPS 14013

To appear in: Biological Psychiatry

Received Date: 1 May 2019

Revised Date: 17 September 2019
Accepted Date: 19 September 2019

Please cite this article as: Phua D.Y., Kee M.Z.L. & Meaney M.J., Positive Maternal Mental Health,
Parenting and Child Development, Biological Psychiatry (2019), doi: https://doi.org/10.1016/
j.biopsych.2019.09.028.

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 Positive Maternal Mental Health, Parenting and Child Development

Desiree Y. Phua1, Michelle Z. L. Kee1, Michael J. Meaney1,2,3,4

1. Singapore Institute for Clinical Sciences (SICS), A*STAR, Brenner Centre for Molecular
Medicine, Singapore 117609.
2. Department of Pediatrics, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore 117597
3. Department of Psychiatry, Douglas Mental Health University Institute, McGill
University, Montreal, Canada H4H 1R3
4. Sackler Program for Epigenetics & Psychobiology at McGill University, Montreal,
Canada H4H 1R3

Correspondence to: Michael J Meaney

Translational Neuroscience Program
Singapore Institute for Clinical Sciences
30 Medical Drive
Singapore 117609

Email: michael.meaney@mcgill.ca
Phone: +65 6407 0111

Keywords: Positive mental health; Maternal well-being; Child development; Parenting;

Oxytocin; Dopamine

Short title: Positive maternal mental health

Number of words in abstract: 163

Number of words in main text: 4023
Number of figures: 2
ABSTRACT
While maternal mental health is an important influence on child development, the existing
literature focuses primarily on negative aspects of maternal mental health, particularly symptoms
of depression, anxiety, or states of distress. We provide a review of the evidence on the potential
importance of positive mental health for both mother and child. The evidence suggests that
positive mental health is a distinct construct that associates with improved birth outcomes and
potentially with specific forms of parenting that promote both academic achievement and socio-
emotional function. We review studies that provide a plausible biological basis for the link
between positive mental health and parenting, focusing on oxytocin – dopamine interactions.
We caution that the evidence is largely preliminary and suggest directions for future research
noting the importance of identifying the operative dimensions of positive maternal mental health
in relation to specific outcomes. We suggest that the inclusion of positive maternal mental
health provides the potential for a more comprehensive understanding of parental influences on
child development.
The influence of maternal mental health on child development is such that the World Health
Organization (WHO; 1) and International Monetary Fund (2) position maternal depression as an
issue of global significance. The London School of Economics (LSE; 3) estimates the annual
costs of prenatal maternal mental health problems in the UK at 8.1 billion pounds, an
underestimate as postpartum mental health is not considered. 72% of the estimated health care
costs associate with child outcomes. Diverse measures of maternal mental health associate with
child development including stressors, daily hassles and symptoms of depression, anxiety, and
other mental disorders (e.g., 4-11). Importantly, maternal mental health is a modifiable risk
factor for problems of child development (12,13).
The focus on perinatal stress, depression or anxiety is critical but has led to a neglect of
positive mental health and well-being. The WHO defines health as “a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity” (14).
Public mental health initiatives emphasize the importance of positive mental health as a
protective influence that enhances brain health (15). We propose that the study of maternal
mental health would be enriched by considering mental health across a continuum to provide a
more comprehensive framework for studies of parental influences on child development. This
view would align the field to the Research Domain Criteria (RDoC) inclusion of positive affect
as a core domain (16).

MATERNAL MENTAL HEALTH AND NEURODEVELOPMENTAL OUTCOMES

Maternal symptoms of depression or anxiety associate with child outcomes including brain
structure and connectivity (e.g., 17, 18-21), temperament (22), socio-emotional or behavioral
problems (e.g., 23-25), cognition and academic performance (e.g., 26-28) and the risk for
psychopathology (e.g., 4,7,23,29-31). Research in low to middle-income countries also
associates maternal depression to poor postnatal growth (32-35) and ‘physical’ health (36). By
contrast, in economically developed countries maternal depression predicts obesity (37).
The importance of maternal mental health problems for either the mother or child is not
unique to women with clinical levels of symptoms (17,38). Levels of household burden,
irritability, interpersonal conflict as well as limitations in physical function and health are as
compromised among women with high, sub-clinical levels of depressive symptoms as those with
clinical symptom levels. A similar pattern of associations is apparent for parenting (39)
including breastfeeding (40). A systematic review (17) reveals a graded relation between
maternal symptoms of depression and child outcomes, including measures of brain structure and
function, underscoring the importance of considering maternal mental health along a continuum.
Community-based studies in economically developed countries show that women with high,
sub-clinical levels of depressive symptoms combined with those revealing clinical levels (~10–
15%) represent a staggering 40% of all mothers (17). However, this seemingly continuous view
of maternal mental health remains limited since it considers maternal mental health only in terms
of symptoms of mental disorders, most commonly depression or anxiety.

POSITIVE MATERNAL MENTAL HEALTH

Mental health lies along a continuum with positive well-being as an independent construct (14,
41). Negative (i.e., symptoms of mental disorders) and positive mental health have distinct
antecedents, consequences, and biological correlates suggesting that they are at least partially
independent constructs, even if the relevant self-reported measures are modestly correlated (42-
45). Positive mental health reveals unique associations with stress, health, and mortality
independent of symptoms of psychopathology (46-48). People do report concurrently low or
high levels of both negative and positive mental health (42). Positive and negative mental health
reveal distinct biological signatures. Cortisol, cholesterol, waist-hip ratio, and norepinephrine
associate with measures of positive mental health less is with symptoms of depression or
anxiety. In contrast, DHEA-S and systolic blood pressure associate with negative but not
positive mental health (45). Clinical studies suggest differential effects of antidepressant
medications on positive and negative mental health (49).
The importance of positive states of mental health for the onset and progression of
multiple diseases (e.g., 50-52) suggests a potential importance for maternal health. Positive
mental health conditions show stability over time (e.g., 53-55) suggesting potential influences
across the perinatal period. Meta-analyses of intervention studies targeting positive mental
health, including RCTs, reveal sustainable effects of small to modest size (56) on a range of
health outcomes (and see 57-59). These findings imply that a comparable emphasis on positive
maternal mental health may be of potential importance for both mother and child.
Positive mental health is studied from two broad perspectives: hedonism and
eudaimonism (60-62). The hedonic perspective emphasizes positive affect or emotions and life
satisfaction (63). The eudaimonic perspective (62,64-66) includes autonomy, self-acceptance,
being meaningfully engaged and social well-being. Hedonic and eudaimonic perspectives of
positive mental health are correlated but do emerge as somewhat distinct constructs (67) that
appear to inform different aspects of optimal functioning (68). For example, resting asymmetry
activation of the frontal cortex associates with eudaimonic, but less with hedonic well-being
(69). There are also reports that hedonic and eudaimonic well-being associate with specific and
opposing transcriptional signatures (70,71) for genes associated with inflammation and antibody
production. The claim is controversial (72-74). The findings are consistent with those of
reduced levels of pro-inflammatory markers, such as CRP, associated with measures of positive
mental health, but perhaps misleading with respect the distinction between hedonic and
eudaimonic well-being and respective associations with gene expression. The Fredrickson et al
analyses were criticized, in part, because of the high inter-correlation between hedonic and
eudaimonic well-being that violates the critical assumption of independence of the predictor
variables.
The statistical controversies aside, the broad conceptualization of positive mental health
into hedonic and eudaimonic well-being bears the same weakness as traditional categorical
approaches to mental disorders. The approach fails to identify specific operative dimensions and
is thus uninformative with respect to intervention targets. There is a need for precision as
different positive emotional states may implicate different neural systems within the brain (75).
Imaging studies support this position. An activation likelihood estimation meta-analysis (76)
reveals that the emotional experience of ‘happiness’ selectively activated the rostral anterior
cingulate cortex and the superior temporal gyrus. The literature in the field of positive
psychology includes multiple examples of associations between specific dimensions of positive
mental health, such as optimism or positive affect and health outcomes (77) that could directly
inform on targets for intervention. Importantly the associations between dimensions of positive
mental health and health conditions are commonly outcome specific. A systematic review (77)
reveals that optimism is a consistent predictor of cardiovascular health, but is inconsistently
associated with other outcomes, such as cancer. Research on the protective or beneficial effects
of certain features of positive mental health should not be assumed to readily generalize to
maternal outcomes.
The largely unmet challenge is that of examining how various dimensions influence
specific maternal health outcomes and the relevant mechanistic pathways (50). Adding to the
complication, positive mental health is a subjective experience assessed through self-reports
(59). While researchers understandably favor objective measurements, the validity of subjective
well-being is confirmed by the more objective, neoclassic economic measures (78) and an
individual’s perception of psychological, physical, and social well-being is an important
determinant of health outcomes (79). Our measures of ‘negative’ mental health (i.e., symptoms
of depression or anxiety) suffer the same limitation. Studies in positive psychology have made
use of more objective measures. Davidson et al. (80) used behavioral coding to objectively
quantify positive affect, which associated with a significantly reduced risk of a cardiac event.
Recent technologies for text mining to establish emotional states and mental health could meet
this objective and serve to examine maternal mental health conditions across the peripartum
period.
Positive maternal mental health and child development. The existing evidence
suggests an influence of positive mental health on birth outcomes. Maternal optimism and self-
esteem during pregnancy associate with higher birthweight. There is also an indirect association
with gestation length by ‘buffering’ against prenatal stress (81). The positive perception of
prenatal stress associates with higher maternal well-being and stress management strategies (82)
that lower levels of distress (83,84). The association between maternal optimism and
birthweight is replicated in a sample of pregnant women at high-risk for adverse birth outcomes
(85). A higher level of maternal positive affect during the third trimester associates with reduced
risk of prematurity (86). The most definitive study (87) is the large Finnish (PREDO) program
with bi-weekly measures of both positive affect and symptoms of depression and anxiety. The
results reveal that positive affect is very stable over pregnancy. The PREDO results show that
an increase in maternal positive affect associates with a longer gestational length and thus a
decreased risk for prematurity. The existing reports are thus generally consistent with the
benefit of a large epidemiological study (87).
The evidence for the potential influence of positive maternal mental health on postnatal
child development is far more preliminary. One study (44) used a latent class, bi-factor analysis
of measures of antenatal maternal mental health from a longitudinal birth cohort to define both
positive and negative affective states and examine associations with specific child outcomes at
24 and 48 months. The measures included common screening tools for symptoms of depression
and anxiety across the perinatal period. This analysis yields a General Affective Symptoms
factor that integrates symptoms of depression and anxiety as well as a positive mental health
factor, the structure of which was consistent from the antenatal to early postpartum period
(Figure 1). The General Affective Symptoms factor, as expected (23), associates with measures
of socio-emotional problems (44; Figure 2). In contrast, the Positive mental health factor,
independent of the General Affective Symptoms factor, associates more strongly with unique
social outcomes, such as empathy, imitative play, as well as cognitive and communication
outcomes.
These findings require extensive replication. Moreover, the measures of maternal
mental health derive from scales designed to assess symptoms of anxiety. Replication should
involve research tools designed to assess specific dimensions of positive maternal mental health
in relation to specific child outcomes. A strength of the existing study (44) is the ability to
distinguish the correlates of a positive state with commonly used measures of symptoms of
depression and anxiety. The most informative design for future studies is one that includes
measures of ‘negative’ symptoms together with measures of specific dimensions of positive
maternal mental health.
Parenting is considered as a mediator for the association between postnatal maternal
mental health and child outcomes (39,88). Evidence for this association emerges from an
unpublished analysis of the maternal General Affective Symptoms and Positive Mental Health
factors described above, parenting styles and child outcomes. The data from 270 mother-child
dyads were collected in the context of a longitudinal birth cohort study with assessment of
maternal mental health, as described above, parental style using the Parenting Styles and
Dimensions Questionnaire (PSDQ) and a range of child outcomes at 48 months of age. The
PSDQ defines authoritarian permissive and authoritative parenting styles (89,90). Authoritative
parenting style is defined by warm and supportive parenting behaviors, while authoritarian and
permissive parenting styles are more dogmatic and indulgent, respectively. General affective
symptoms associate with authoritarian and permissive parenting. In contrast, the Positive
maternal mental health measure associates strongly with authoritative parenting, but not with
authoritarian and permissive parenting styles. The General Affective Symptoms factor
associates with socio-emotional problems. This association was mediated by both authoritarian
and permissive parenting. Maternal positive mental health predicted child performance on tests
cognition and executive function, such as numeracy, literacy, spatial working memory, and
global intelligence, and these associations are mediated by authoritative parenting. In addition to
the preliminary nature of the findings, the study is limited to only one measure of parenting and
to child outcomes at a specific age. However, these findings suggest the importance of positive
maternal mental health on specific forms of parenting (39) associated with specific child
outcomes, which, if replicated, would bear considerable importance for interventions.
Further evidence for the importance of positive maternal mental health emerges from a
study showing that maternal positive affect, assessed during mother-infant interactions, predicts
the performance of the child on tasks of executive function (91). Likewise, prenatal maternal
mindfulness associates with event-related brain potentials in the infant offspring using an
auditory oddball paradigm (92). Higher maternal mindfulness associates with higher P150
amplitudes, which reflects pre-attentional processing (e.g., 93).
These findings with normally developing children suggest that the influence of positive
maternal mental health, like that for symptoms of depression or anxiety, cuts across the
population. Of potential interest is the selective association of positive maternal mental health
with specific forms of parenting and child outcomes. What is unknown is how the dimensions
of positive mental health might influence specific forms of parenting at different periods in the
development of the offspring. Studies addressing these topics are critical if research on positive
mental health is to contribute to the development of programs to enhance child outcomes.
Nevertheless, while the topic demands far more extensive study, the existing evidence suggests
that our understanding of child development will be advanced with the consideration of the full
range of maternal emotional states, attitudes, and behaviors (also see 94).

BIOLOGY OF POSITIVE MATERNAL MENTAL HEALTH AND PARENTING

An obvious question concerns the biology of positive maternal mental health and mechanisms
underlying its relation to parenting, and thus child outcomes. The relevant evidence emphasizes
interactions between oxytocin (OTX) and dopamine (DA) systems corresponding to appetitive
motivational and cognitive-emotional states essential for effective parental care. Oxytocin
(OTX) has anxiolytic effects and associates with both positive affective states and pro-social
behavior, including parental behaviors (95,96). The pro-social influence of OXT is interesting in
the context of the social well-being dimension of positive mental health (e.g., 59,65).
Pharmacological studies implicate OTX signaling in the hypothalamus, amygdala and
prefrontal cortex (PFC) as mechanisms for the anxiolytic effects (95,97,98). OTX also
associates with a sense of calm characterized by increased parasympathetic tone (99) and
polymorphisms in the OTX-R gene associate with the level of positive affect (100).
Neuroimaging studies in humans implicate amygdala – PFC connectivity in the anxiolytic
effects of OTX (101-103). Intranasal OXT enhances connectivity between the amygdala – ACC
connectivity in patients with a social anxiety disorder, reversing the differences with controls
(102).
OTX is critical for the activation of maternal behavior in mammals (e.g., 81). Human
mothers with higher plasma OTX report greater maternal attachment (104). Peripartum plasma
OTX levels correlate positively with infant-directed maternal behaviors as well as with positive
affect (105). Maternal synchrony is positively correlated with maternal plasma OTX level (106).
While candidate gene studies must be interpreted with caution, there are multiple reports of
associations between single nucleotide polymorphisms (SNPs) in the OTX and OTX-R genes
and variations in both parenting and emotional well-being (107-113).
Neuroimaging studies (114) comparing patterns of activation in mothers in response to
own versus an unfamiliar infant reveal significant differential activation in the orbitofrontal
cortex (OFC) and ventral tegmental area (VTA; 115-118), regions critical for processing of
positive stimuli (126); OFC activation by infant pictures also correlates with positive affect
(119). Mothers scoring higher on observed positive parenting show a greater response to
pictures of their child in the OFC and ACC (120). OTX-R SNPs linked to maternal sensitivity
associate with both positive parenting and greater activation in the OFC and ACC to pictures of
one’s child (120).
OTX projections from hypothalamic/preoptic regions regulate dopamine neurons in the
VTA to activate maternal behavior in rodents (121-123). Neuroimaging studies with humans
likewise report increased activation in the VTA in mothers viewing pictures of their infant (114).
Mothers viewing videos of their interactions with their infants show activation of the nucleus
accumbens, the level of which is positively correlated with both maternal sensitivity and the
plasma level of OTX (106). Neuroimaging studies thus reveal activation of brain regions rich in
dopamine receptors in parental response to images of their child (114-118) and polymorphisms
dopamine signaling genes are linked to maternal sensitivity and infant-directed vocalizations
(124).
These findings are consistent with the proposed role of neuropeptide – dopamine
interactions for social behaviors (96,125) and support an association between positive affective
states and parenting. Likewise, studies in cognitive neuroscience suggest a link between positive
affect, dopamine signaling and executive functions (114,126) including cognitive flexibility,
focused attention, working memory, and empathy, which are fundamental components of human
parenting (127,128). Executive functions associate with individual differences in maternal
sensitivity (129,130). Importantly, ‘task-related’ positive affective states enhance performance
on tests of executive functions (131,132). The task in this instance is that of parenting and the
relevant affective state is that elicited by the child. Dopamine systems are proposed as a
mechanism for the association between positive affect and enhanced executive functions,
consistent with the idea that dopamine activity in the prefrontal cortex is critical for executive
functions (132,133). Polymorphisms in DRD1 and DRD2 genes predict maternal focused
attention on their infants during free-play and the duration of maternal vocalizations (124). An
association between an OTX-R polymorphism and positive parenting is mediated by executive
functions (111).
These findings suggest OTX – dopamine interactions as a neural mechanism for
maternal positive affect and couple positive affect to executive functions critical for effective
parenting. There are important caveats. The earlier description of positive mental health reveals
multiple dimensions only some of which appear linked to the neural processes described here.
The complexity of the processes linking positive mental health and human parenting will
inevitably involve multiple biological systems. These concerns notwithstanding, there is a
plausible biological mechanism linking positive maternal mental health to neural processes
essential for effective parenting.

INTERVENTIONS TARGETING POSITIVE MATERNAL MENTAL HEALTH

Associations between psychological well-being and health outcomes derive largely from
observational studies. Intervention studies targeting specific dimensions of positive mental
health are required to establish causal directions. Meta-analyses of interventions studies using
psychotherapeutic approaches to target mothers with postpartum depression generally yield
small effects on parenting and child outcomes (134-136). Combining such treatments with
programs designed to target positive mental health might prove more impactful. Meta-analyses
of positive psychology interventions, including RCTs, reveal positive outcomes on well-being
and depression (56,137). The critical issue is whether such approaches are effective over the
perinatal period and affect maternal behaviors in relation to the infant?
Interventions targeting the positive mental health of pregnant women are emerging, the
most common of which is mindfulness training (138). Reviews on mindfulness-based
interventions for prenatal mental health show mixed results in decreasing mental health
problems among pregnant women (138,139). A meta-analysis (135) reveals the inconsistent
findings; mindfulness interventions for pregnant women show smaller effects than with non-
pregnant populations (135). Intervention effects should thus not be assumed to necessarily
generalize to peripartum women. Interventions will need to be tailored to the specific cognitive-
emotional demands of pregnancy and child-rearing, which underscores the importance of a more
comprehensive understanding of the multiple dimensions to maternal mental health.
Postnatal interventions often focus on parenting to improve mother and child outcomes.
The Triple-P Parenting program (140) is a multi-level parenting intervention program designed,
in part, to improve maternal positive mental health, notably self-efficacy, positive affect and
optimism (141). A meta-analysis of 116 studies on the Triple-P program reveals medium short-
term and small long-term effects on social, emotional and behavioral development (142).
However, Triple-P programs are extensive and include parenting skills. What is unknown is
whether effects on positive maternal mental health are critical for the observed effects on
parenting or child outcomes. It is also important to appreciate that existing intervention studies
target maternal mental health over the postpartum period. There is now considerable evidence
for the importance of prenatal maternal mental health on a range of child outcomes (4-11,22,26)
including the later risk for psychopathology (143).
 The discussion of interventions targeting positive maternal mental, parenting and child
outcomes must be placed in an ecological context. There are, unfortunately, hostile conditions
under which more anxious phenotypes that enhance awareness of threat are highly adaptive. A
comparative analysis (144) of studies in multiple species reveals that the adaptive value of
variable forms of parental care and offspring outcomes is context-specific. This consideration
speaks to a societal imperative to provide the support for communities and families that
enhances parental mental health and parenting that enhance academic performance and diminish
the risk for psychopathology in a manner that is adaptive at the level of the individual and their
circumstance.

FUTURE DIRECTIONS
Although preliminary, the existing studies of positive maternal mental health taken together with
the health science literature in positive psychology suggest the importance of this topic.
Relevant studies are observational and would be strengthened considerably through a
hypothesis-driven integration with the biological sciences. An example is the association
between positive mental health with birth outcomes. A strength of these studies is that of
measures of specific dimensions of positive mental health in relation to specific outcomes.
Research in biological psychiatry and obstetrics suggest a fruitful research direction. Positive
mental health during pregnancy associates with decreased maternal levels of cortisol (145) that
may protect the fetus during periods of maternal distress. Prematurity associates with pro-
inflammatory signaling while increased glucocorticoid activity is linked to low birth weight (6).
These systems are also candidate mediators of the association between maternal distress and
neurodevelopmental outcomes (6,146,147). Positive affect is inversely associated with both
CRP and IL-6 levels (148). Evidence linking specific dimensions of positive maternal mental
health to specific endocrine or inflammatory inter-uterine signals known to underly birth
outcomes would strengthen the evidence for an association of positive mental health with fetal
development and support the rationale for prenatal interventions.
The empirical support for the relevance of positive maternal mental health on parenting
and child outcomes is preliminary. Nevertheless, the possibility that specific dimensions of
positive mental health selectively associate with specific forms or parenting and child outcomes
is of considerable potential importance. The limited impact and sustainability of existing
interventions targeting maternal depression suggest that a more comprehensive approach to
maternal mental health is important to consider. There is evidence for neurobiological
mechanisms that might link positive affective states to neural processes essential for forms of
parenting that enhance cognitive and social development in the offspring. These preliminary
studies suggest positive maternal mental health associates with specific forms of parenting and
specific child outcomes, possibly distinct from negative mental health states (i.e., symptoms of
depression and anxiety). Executive functions linked to parenting might be particularly sensitive
to positive mental health and form the basis for testable hypotheses to identify relevant neural
processes linking positive maternal mental health to specific forms of parenting with mediational
analyses to examine child outcomes. These approaches would strengthen support for the topic
of positive maternal health and identify intervention targets.
There is a pressing need for reliable measures of independent dimensions of positive
mental health and pro-nurturant behaviors, and their biological substrates, across the perinatal
period. A similar argument applies to the study of negative states of maternal mental health
where measures of depression, anxiety, and distress are often considered under a common rubric
of maternal ‘stress’ without acknowledging that these states differ in underlying biological
mechanisms (6). Studies of prenatal maternal anxiety are a useful example of more specific
measures that identified pregnancy-related anxiety as a particularly important source of maternal
distress in relation to child outcomes (149). The development of a research tool to specifically
assess pregnancy-related anxiety, as opposed to more general anxiety states, enhanced our
understanding of the relevant maternal condition and informed intervention accordingly. The
study of positive maternal mental health will benefit from a similar level of precision.

CONCLUSION
While the existing evidence for the importance of positive maternal mental health should be
considered as preliminary, the findings argue for the inclusion of positive mental health
dimensions in studies of the influence of maternal mental health on child growth and
development. There is a pressing need to advance beyond epidemiological observation to
identify the specific pathways by which maternal mental health influences child development.
The challenge is to identify specific dimensions of maternal mental health, positive or negative,
with the biological systems that underlie specific neurodevelopmental outcomes in the offspring.
These studies are critical in developing the foundation for evidence-based interventions targeting
maternal mental health. We suggest that the inclusion of positive maternal mental health into the
study of maternal influences on child development would provide a more comprehensive
approach with the prospects of developing more effective interventions.
FINANCIAL DISCLOSURES
Dr. Meaney’s research on maternal mental health has been, in part, supported by funding from
an A*STAR – Industry (Johnson & Johnson) research grant. The authors report no other
disclosures. Drs. Phua and Kee report no biomedical financial interests or potential conflicts of
interest.

ACKNOWLEDGMENTS
The research of the authors is supported by a Translational Clinical Research grant from the
National Medical Research Council of Singapore and a grant from the Hope for Depression
Research Foundation (MJM).
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 Figures captions

Legend
cluster 1 (orange)
22: I feel nervous and restless.
24: I wish I could be as happy as others seem to be.
25: I feel like a failure.
28: I feel that difficulties are piling up so that I cannot overcome them.
29: I worry too much over something that doesn’t matter.
31: I have disturbing thoughts.
32: I lack self-confidence.
35: I feel inadequate.
37: Some unimportant thought runs through my mind and bothers me.
38: I take disappointments so keenly that I can’t put them out of my mind.
40: I get in a state of tension/turmoil as I think over my recent concerns &
interests.

cluster 2 (blue)
21: I feel pleasant.
23: I feel satisfied with myself.
26: I feel rested.
27: I feel calm, cool, and collected.
30: I am happy.
33: I feel secure.
34: I make decisions easily.
36: I am content.
39: I am a steady person.

Figure 1. A symptom network of the State Trait Anxiety Inventory trait items from mothers
three months postpartum. The clusters represent latent factors derived from exploratory graph
analysis. Green lines depict positive polychoric correlations between the symptoms while red
lines depict negative correlation. The thickness of the lines represents the strength of the
correlations. The two-factors structure and the relative lack of strong negative correlations
between the positive (blue cluster) and negative (orange cluster) items suggest the independence
of negative (i.e., anxiety) and positive mental health constructs.
Figure 2. Simplified heatmap from (44) illustrating significant correlations between maternal
mental health latent factors (only general, positive mood and positive self are presented here)
and child outcomes measured by the Infant Toddler Social Emotional Assessment. General
refers to General Affective Symptoms factor score that included both depressive and anxiety
symptoms. What is of interest is the general pattern of findings: Negative mental health as
indicated by the general affective symptoms factor score was positively correlated with
negative child outcomes (e.g., impulsiveness, aggression, anxiety), while positive maternal
mental health was associated with positive outcomes (e.g., competence, empathy).