J. Ckit4P,ychci Psychua Vol. 33. No. 3 pp 543-561 1992 0021-9630/92 $5.

00 + 0 00
Pnnicd in Grcai Bntajn. Pcrgamon Press pic
© 1992 Aisociation for Child Psychology and Psychiatry

The Impact of Postnatal Depression on

Infant Development

Lynne Murray

Abstract—A large sample of primiparous women was screened for depression after childbirth.
Those identified as depressed, women with a previous history of depression and a control
group were followed up to 18 months, when their infants were assessed on measures of
cognitive, social and behavioural development. Infants of postnatally depressed mothers
performed worse on object concept tasks, were more insecurely attached to their mothers
and showed more mild behavioural ditricultics. Postnatal depression had no effect on general
cognitive and language development, but appeared to make infants more vulnerable to
adverse effects of lower social class and male gender.

Keywords: Maternal depression, infant development, mother-infant relationship

Introduction
A large body of research has established the association between parental depression
and adverse outcome in children from nursery school age to adolescence on a wide
range of measures. These include behavioural disturbance, physical ill-health, insecure
attachments, and depressive symptoms and disorders (Billings & Moos, 1983, 1985;
Weismann et al., 1984; Radke-Yarrow, Cummings, Kuczynski & Chapman, 1985;
McKnew, Cytryn, Efron, Gershon & Bunney, 1979). However, it has been difficult
to specify the precise nature ofthe links between the adult disorder and child outcome.
One problem arises from the fact that account has not always been taken of the
heterogeneity that has existed within some of the depressed samples studied. Case
groups have included a range of depressive conditions (such as unipolar, bipolar,
admixes of anxiety states); disorders differing markedly in terms of severity have been
combined (e.g. hospitalized and community samples); and the duration ofthe child's
exposure to parental symptoms has been varied (see Miller, Birnbaum & Durbin,
1990, for a review). A more severe challenge to the interpretation of child outcome
in the context of parental depression is the difficulty in identifying accurately, by
means of retrospective enquiry, the significance of other variables that may have

Accepted manuscript received ^ July 1991

Winnicott Research Unit, Department of Psychiatry, University of Cambridge, Cambridge, U.K.

Requests for reprints to: Dr Lynne Murray, Winnicott Research Unit, Department of Psychiatry, University
of Cambridge, Fenners, Gresham Road, Cambridge CBI 2ES, U.K.

543
 L. Murray

contributed to impairments in child functioning. These include, for example, previous

difficulties in the parent-child relationship, adverse life events and difficulties that
predate the assessment of the child.
One way of addressing some of these problems is to study prospectively the
development of infants exposed to non-psychotic maternal depression. Assessments
of maternal psychiatric state and circumstances, and ofthe mother-infant relationship,
may be made prospectively, concurrently with infant assessments. Moreover, both
the recent development of screening tools to identify postnatal depression (Cox, Holden
& Sagovsky, 1987) and the prevalence of the disorder (around 10%: Cooper,
Campbell, Day, Kennedy & Bond, 1988) mean that the recruitment ofa community
sample of adequate size is unproblematic. Episodes of depression arising in the
postpartum months show the full range of clinical features, with irritability, anxiety,
poor concentration, and depressive mood and thoughts all being prominent. These
symptoms of depression typically exert a profound effect on interpersonal relations,
and it is likely that this will extend to the relationship the mother establishes with
her infant. Although the incidence of depression in the year following childbirth does
not appear to exceed that found in non-childbearing populations (Cooper et al., 1988),
a significantly raised rate of onset in the first 3 months following delivery has been
reported (Cooper, Murray & Stein, 1991). This period coincides with what Winnicott
has termed the phase of "Primary Maternal Preoccupation" (Winnicott, 1956) when
maternal psychology is ordinarily adapted to infant functioning in specific ways that
are well documented in the developmental psychology literature (e.g. Snow, 1977;
Stern, 1985). Infants in turn are preadapted to an environment of human care and
are highly sensitive to the quality of their interpersonal contacts. Indeed, if normal
maternal communication is experimentally disrupted for even brief periods, infants
as young as 6 weeks respond with distress and avoidance (Papousek & Papousek,
1975; Brazelton, Tronick, Adamson, Als & Wise, 1975; Murray & Trevarthen, 1985).
The high rate of depressive episodes occurring soon after delivery gives further cause
for concern when one considers that in most cultures the infant's primary environment
in these early months is largely constituted by the mother.
These considerations regarding the prevalence of postpartum depression, infant
sensitivity to the quality of interpersonal contacts and the fact that the infant's
environment in the early months is primarily constituted by the mother combine to
establish the question of the effects of postnatal depression on infant and child
development as one of especial clinical importance. A number of studies have assessed
the longer term impact on the child of maternal depression occurring in the postpartum
period by interviewing the mother some years later about the child's current behaviour
(Uddenberg & Englesson, 1978; Zajicek & de Salis, 1979; Ghodsian, Zajicek &
Wolkind, 1984; Wrate, Rooney, Thomas & Cox, 1985; Williams & Carmichael, 1985;
Caplan et al., 1989). This research has often been subject to methodological limitations
in sampling and assessment procedures and there have been inconsistent findings.
However, the balance of evidence suggests that, while mild levels of difficulty may
result, serious behavioural disturbance in the preschool years is not a significant
consequence of postnatal depression. On the other hand, adverse outcome in terms
of child cognitive development and the quality ofthe mother-infant relationship is
suggested by two recent studies of community samples, in which direct assessments
 Postnatal depression

were made of infants and young children of mothers whose psychiatric state had been
comprehensively assessed in the postpartum period and at the time of follow-up. Cogill,
Caplan, Alexandra, Robson and Kumar (1986), in a 4-year follow-up of a postpartum
sample, found that the children of postpartum depressed mothers were significantly
delayed on a general cognitive index compared to controls. Stein et al. (1991) found
that at 19 months, mother-infant interactions were less affectively positive and less
mutually responsive in cases where the mother had suffered from depression in the
postnatal period than in non-depressed mother-infant pairs.
In order to understand the evolution of such difficulties, prospective, direct evidence
is required concerning the development ofthe mother-infant relationship and infant
functioning in the context of maternal depression. This paper reports results from
a study in which such assessments were made in the first 18 months. The principal
aim of the investigation was to compare the cognitive, social and emotional
development of infants of mothers with unipolar, non-psychotic postnatal depression
with that of infants of non-depressed mothers. In addition, the study was designed
to address two secondary issues raised in previous research regarding the process
whereby any adverse effects of maternal depression on the infant come about. This
was achieved by selecting subgroups of women with different psychiatric histories
and different postpartum mental state.
(i) It has been shown that women who have experienced depression continue to
show difficulties in family relationships even when recovered, with a persistence of
inhibited and hostile communication (Weissman & Paykel, 1974). This has recently
been confirmed for mothers recovered from postpartum depression in interactions
with their 19-month-old infants (Stein et ai, 1991). The question was therefore
addressed of whether any adverse infant outcome occurs as a function of long-term
disturbed patterns of maternal communication that are associated with vulnerability
to depression (present in those with a history of major depressive episodes, but no
depression postnatally) rather than the clinical symptoms of depression/?^.i^ (present
in those with postpartum depression, with or without a previous history).
(ii) Several investigators have noted considerable variation in the quality of relations
between depressed mothers and their infants or young children, and there have been
suggestions that, where the depression has as its focus the child or the woman's role
as mother, the mother-child relationship and child outcome in general may be more
adversely affected (Mills, Puckering, Pound & Cox, 1985; Williams «& Carmichael,
1985; Wrate et ai, 1985). This issue was addressed by considering infant outcome
according to whether maternal depression had arisen for the first time in the woman's
experience following childbirth, and was therefore likely to have early infant
care/motherhood as its principal focus; or whether the postpartum episode represented
just one ofa number of episodes in the woman's history, and was therefore less likely
to have the infant as the principal focus.
In addition, a further question when considering infant outcome is that of the
importance ofthe timing and duration ofthe maternal depressive episode, and whether
the infant is especially vulnerable to the effects of depression at certain points in
development.
Finally, it is clear that, when analysing child outcome in the context of maternal
depression, account must be taken of the impact of factors that are correlated with
 Murray

the adult disorder, such as marital discord or severe social and economic stress (Caplan
et ai, 1989; Stein et ai, 1991).

Method
Sample
Women presenting on the postnatal wards of the Cambridge maternity hospital during the period
February 1986-February 1988 were approached and invited to participate in a study ofthe experience
of motherhood and infant development. They were included if they met the following criteria:
primiparous, aged 20-40 years, married or cohabiting, having had a 37-42-week pregnancy, intending
to be the infant's primary caretaker, and to be resident in the Cambridge city area for the subsequent
18 months. In addition, the infant was required to have had a birthweight of at least 2.5 kg, no gross
congenital abnormality, and not to have required admission to the special care baby unit. A total of
702 women fulfilled these criteria, only nine (1.3%) of whom refused to take part. Basic demographic
information, method of delivery, sex, gestation and birthweight ofthe infant were recorded for all 702
women, aJong with details of any previous psychiatric history.
At 6 weeks postpartum the mothers were sent the Edinburgh Postnatal Depression Scale (EPDS:
Cox etai, 1987). Six hundred and seventy-four (97%) returned their questionnaire, but 28 expressed
inability or unwillingness to continue in the study. Ofthe remaining 646 (92% ofthe original sannple),
all those with an EPDS score of at least 13 were interviewed at 2-3 months postpartum either by a
psychiatrist or a psychologist using the Standardized Psychiatric Interview (SPI: Goldberg, Cooper,
Eastwood, Kedward & Shepherd, 1970), to identify minor definite and major (probable and definite)
episodes of depression (according to RDC definitions: Spitzer, Endicott & Robins, 1978). Additional
items on weight loss and appetite were incorporated into the SPI to give conformity with research
diagnostic criteria (RDC). All those who had indicated previous depression at the point of postnatal
ward contact were interviewed following receipt of the EPDS. The life-time version of the Schedule
for Affective Disorders and Schizophrenia (SADS-L: Endicott & Spitzer, 1978) was used to confirm
whether there had been a major depressive episode prior to childbirth. These women were also interviewed
using the SPI, regardless of their score on the EPDS, in order to establish whether there had been a
depressive episode since delivery. In addition, in order to maximize the recruitment rate of cases of
postnatal depression, a random sample (66/85) of those with no indication of previous psychiatric history,
but with EPDS scores of 10-12, was interviewed using the SPI. Finally, after every alternate case was
identified, and then, for the last 6 months of recruitment, after every case, a potential control was selected
randomly from those who had a low EPDS score, no indication of a previous history of depression
and the same sex of infant as the case mother. These women were also interviewed with the SPI and
the SADS-L to ensure that there had been no depression prior to or since delivery.
These procedures yielded the following numbers of mothers, grouped according to the presence or
absence of depression before and after childbirth.
(i) No previous history of depression or depression since delivery (Con = 42).
(ii) No previous history of depression, but depression since delivery (PD = 40).
(iii) A previous history of major depression, but no depression since delivery (PH = 14).
(iv) A previous history of depression and depression since delivery (PHPD = 21).
All but four of these women and their infants (three in the PD group and one in the PH group)
were finally recruited into the study. In two cases unanticipated career moves prevented participation,
one was dissuaded from participating by her G.P., and one was unwilling to continue. At the point
of final recruitment, at 2-3 months postpartum, the Social Adjustment Scale (Weissman & Paykel,
1974) and a further structured interview were administered to establish information on a range of personal
and social variables. These included childhood and current family relationships, the relationship with
the partner and confidants, obstetric history, attitude to the pregnancy and infant, housing and economic
circumstances.

Follow-up assessments
Ofthe 113 mother-infant pairs who were recruited into the study, 111 were assessed when the infants
 547
Postnatal depression ^^ '

were 18 months old, one family had moved abroad, and one could not be traced. In addition to the
assessment at 18 months, a random subsample of the total population (A^= 59) was seen at 2-3 monthly
intervals throughout the 18-month period. Mothers brought their infants to the University of Cambridge
for assessment.

(A) Direct infant assessments at 18 months

These were scored by trained research psychologists and a paediatrician who were blind to maternal
group. The assessments were conducted in the following order:
(1) The Bayley scales of infant mental development (Bayley, 1969). These standardized scales are composed
of items covering motor, perceptual, cognitive and social abilities, language comprehension and expression.
(2) The Reynell scales of language development (Huntley, 1985). These scales give standardized scores on
expressive language and comprehension.
(3) Security of attachment to the mother. This was assessed using the strange situation procedure devised
by Ainsworth and Wittig (1969). This procedure consists of eight 3-minute episodes, during which infants
are twice separated from, and twice united with, their mother in the context of an unfamiliar playroom.
Infant responses to the mother's departures and reunions are scored from videotapes of the sessions
using an ethological-type system which includes proximity seeking, contact maintenance, avoidance
and resistance. Infants are classified as either securely or insecurely attached to the mother (Ainsworth,
Blehar, Waters & Wall, 1978). Secure attachment is characterized by infant protest at the point ofthe
mother's departure, and proximity seeking upon her return, followed by a resumption of play. Insecure
attachment is classified in the following three ways.
(i) Avoidant: the infant shows little or no distress at the mother's departure and avoids contact at reunion.
(ii) Ambivalent/resistant: extreme distress is shown at separation, but the infant both seeks and resists
contact when the mother returns and is unable to settle.
(iii) Disorganized/disoriented: one or more ofthe following is shown—a disordering ofthe usual temporal
sequencing of behaviours, the simultaneous display of contradictory behaviour patterns, incomplete
or undirected movements and expressions, indices of confusion or apprehension.
(4) Piaget's object concept tasks (Stages V and VI). These tasks are designed to elicit infant cognitive
shemas regarding the independent existence of objects by requiring the Infant to search for objects
undergoing a series of displacements in or under one of two identical occluders. In this series opaque
plastic cups were used to hide the objects. Sessions were videotaped, and procedures for administration
and scoring followed those of Wishart and Bower (1984).

(B) Maternal interviews at 18 months

These were conducted by two psychologists and a psychiatrist, all of whom were unaware of maternal
psychiatric status at the time of assessment.
(1) Adult attachment interview (George, Kaplan & Main, 1985). This examines the mother's childhood
attachment relationships.
(2) Life events and difficulties schedule (LEDS) (Brown & Harris, 1978).
(3) Behavioural screening questionnaire (BSQ) (Richman & Graham, 1971). This questionnaire was
originally designed to identify behavioural and emotional problems in 3-year old children, but has been
modified for use with infants in their second year (Richman, 1981; Ghodsian et al., 1984). The following
areas of infant behaviour were covered: feeding difficulties (poor appetite, food refusal or food fads),
sleeping problems (frequent night waking, difficulty in settling), temper tantrums, excessive dependency
(inability to play independently, difficulty at separation), miserable mood, relationships with peers and
problems in management (lack of compliance, wilfulness). Mothers completed the questionnaire, and
then were interviewed to establish the frequency and the intensity of any behaviour problem in order
to permit a rating on a 3-point scale (none, mild or marked).
(4) Finally, maternal psychiatric status over the period since the first interviews was assessed using
the EPDS by postal administration at 6 and 12 months, and the SADS at 18 months.

(C) Subsample asses.'iments

(1) Standardized videorecordings of mother-infant and stranger-infant interactions were made from
2 months postpartum at 2-3 month intervals.
 L. Murray

(2) Stage IV of Piaget's object concept task was administered from 9 months, using the same procedures
as for the 18-month assessments.
(3) Maternal psychiatric state was assessed on the occasion of each visit, using the EPDS and SADS.

Analysis of data
This paper presents infant outcome at 18 months, as well as the data on performance on the cognitive
task at 9 months.
At the time ofthe 18-nionth assessments it was found that a few mothers recruited into the control
and the PH groups (those without any history of depression up to 3 months postpartum, and those
with episodes occurring only prior to childbirth) had experienced episodes of depression in the 4-18
months following delivery (four and three mothers, respectively). Since the principal concern was to
investigate the impact on infant development of depression arising in the early postnatal months, data
for these women and their infants were omitted from the analyses of infant outcome.
In order to address the specific issues concerning the impact of maternal functioning the following
comparisons were made, using /-tests, chi-square tests and Fisher's exact tests, as appropriate.
(a) The impact of postnatal depression: comparisons between infants whose mothers had neither previous
nor postpartum depression (i.e. the Con group, N = 38) and those whose mothers had suffered from
depression in the first 3 months since delivery (i.e. PD and PHPD groups, A^= 56).
(b) The impact of a style of interpersonal contact associated with depression (rather than depressive symptoms):
comparisons between infants whose mothers had neither previous nor postnatal depression (Con group,
A'^= 38) and those whose mothers had had a previous but not a postnatal depression (PH group, N= 10).
(c) The impact of depression where motherhood and early infant care is the focus, versus depression where these
issues are not the focus: comparisons between infants whose mothers had had no previous depression but
had had a postpartum depression (PD group, A'^= 35) and those whose mothers had had both a previous
and a postpartum depression (PHPD group, A^=21).
In addition to the above specific comparisons, tests were conducted for overall differences between
the four maternal groups. The effects ofthe following variables were also exeimined: maternal depression
concurrent with the 18-month assessment (this applied to only 10 mothers), maternal education (classified
as either below the A level stage or else up to and beyond this point), maternal employment at the
18-month assessment (classified as either less than 20 hours per week or else equal to or more), social
class, paternal psychiatric history, marital friction (assessed using the SAS) and infant gender. The
effects ofthe duration of postnatal depression were examined in regression analyses, treating the duration
of postnatal depression in months as a linear variable. The effects of severity of depression were assessed
where main effects of maternal group were identified by comparing the outcome of infants whose mothers
had suffered from minor depressive episodes with that of infants whose mothers had experienced major
depression (probable or definite).
Finally, all two-way interactions were tested, and multiple regression was used to examine further
the effects found in univariate analyses.

Results
Characteristics of the sample
The initial population from which the final study sample was drawn (A'^= 702) had
a mean age of 28 years (SD = 4.3). Their social class was defined according to the
Registrar General's (1980) classification ofthe partner's occupation, and for purposes
of data analysis the sample was divided into two groups: I, II, III non-manual and
students (60%); III manual, IV, V, forces and unemployed (40%). Fifty-four per
cent had vaginal deliveries without forceps, 26% were delivered by forceps and 19%
by Caesarean section.

Maternal depression
(a) Prevalence. The prevalence of depression in this Cambridge sample at 2 months
 Postnatal depression

postpartum was estimated to be 11.1% (Carothers & Murray, 1990). Of those

confirmed as depressed at the 2-3-month interview, 26 had experienced a minor,
and 35 a major definite episode; the severity of depression did not distinguish those
women with first onset occurring after childbirth (PD group) from those with previous
as well as postnatal episodes (PHPD group).
(b) Symptoms. The symptom profiles derived from the SPI for the four maternal
groups at the point of recruitment are shown in Table 1. There were no significant
differences in the pattern of symptoms between the two postpartum depressed groups,
apart from the findings that women with first onsets of depression following childbirth
(PD group) showed more symptoms of concentration impairment and less fatigue
than those with previous as well as postpartum episodes (PHPD group). Women with
a prior history, but no postnatal depression (PH group), showed more anxiety and
phobic symptoms than the control women.

Table 1. Symptoms
Maternal group
Con PD PH PHPD
(yV=42) (A^=37) (.N= 13) (^=21)
Clinical symptoms % % % %
Somatic 2.4 48.6 2:i.i 42.8
Bodily function 0.0 16.2 7.7 9.5
Fatigue 2.4 48.6 23.1 76.1
Sleep disturbance 4.8 51.3 0.0 33.3
Irritability 23.8 97.3 30.8 100.0
Concentration 46.0 94.6 61.5 66.6
Depression 0.0 100.0 0.0 100.0
Depressive thoughts 0.0 83.7 0.0 90.5
Anxiety 0.0 62.1 23.1 57.1
Phobias 0.0 18.9 23.1 9.5
Obsessions and compulsions 2.4 32.4 00 28.6

(c) Course and duration. Figure 1 presents data for the women who were identified
as depressed at 2-3 months, and shows the duration in months of episodes with onset
occurring in the 2-month period since delivery. Data for those with first onset after
childbirth (PD group) and those with previous episodes (PHPD group) are shown
separately. Some women had more than one episode in the 18-month postpartum
period. Although there were not significantly more separate episodes in women from
the PHPD group than in women from the PD group, for the group with a previous
history of depression the duration ofthe first postnatal episode was significantly longer,
and the number of months in which there was an episode significantly greater (see
Table 2). The mean number of years since the most recent previous episode for those
with previous as well as postnatal depressions was 4.1 (PHPD group), and for those
with only previous episodes 2.9 (PH group).
(d) Associated variables. None of the variables recorded at the initial postnatal ward
contact, taken singly, predicted depression postnataJly, although a previous psychiatric
550 L. Murray

50 n
@ PD Group (N = 35)

D PHPD Group (N = 21)

•1(1 -

o
30-

20-

Q_

1-2 3-4
1
5-6 7 - 8 9 - 1 0 1 1 1 2 13-14 15-16 17-18

Months Postpartum
Fig. 1. Duration ofthe first continuous episode.

Table 2. Course and duration

Number of months depressed
in 1st episode in full 18 months
< 3 months > 3 months < 3 months > 3 months
Maternal group A^ (%) A^ (%) A^ (%) A^ (%)
PD (A^ = 35) 25 (71.4) 10 (28 .6) 20 (57 • 1 ) 15 (42. 9)
PHPD (. 21) 8 (38.1) 13 (61 • 9 ) 5 (23 .8) 16 (76. 2)
X" = 6.03, P< 0.02 5.90, p< 0.02

history did so when taken in conjunction with EPDS score. However, multiple logistic
regression analysis suggested that a number of personal and social factors recorded
at the time ofthe interviews conducted at 2-3 months postpartum, taken together,
predicted postnatal depression. These were: an unplanned pregnancy, obstetric
complications in pregnancy, anxiety in pregnancy, a poor marital relationship, poor
social relationships, and dissatisfaction with housing area.

Infant cognitive development at 9 months

Stage IV object concept task (see Table 3). Analysis of infant outcome on the AAB
task in the object concept series showed a significant overall effect of maternal group
(X^ = 8.63, d f = 3 , /j<0.04). This appeared to be due mainly to the poor
performance of infants whose mothers had their first onset of depression after childbirth
(PD group) where only two ofthe 15 infants passed. When the specific sets of paired
group comparisons were made it was found that this group was significantly more
likely to fail than infants whose mothers had suffered from previous as well as postnatal
depression (PHPD group) (Fisher's exact test, p < 0.04). Infants of mothers who had
experienced a major depression postpartum were more likely to fail than infants whose
mothers had suffered from a minor episode (Fisher's exact test, p < 0.03), but this
effect of severity did not interact with maternal group. No differences were found
between infants of mothers with a previous history (PH group) and controls.
 Postnatal depression

There was a marginally significant effect of maternal education on infant outcome:

infants whose mothers had qualified at the A level stage and beyond were less likely
to succeed (X' = 4.14, df= 1, ^ < 0.05) (see Table 3). Multiple logistic regression
analysis showed that both maternal group and education made independent
contributions to infant outcome. There was no evidence that the direction of effect
of maternal education differed between the maternal groups.
Finally, there was a tendency for marital friction to be associated with failure on
stage IV of the object concept, but this did not reach statistical significance
(X^ = 2.89, df= 1, p<0.09).

Table 3. Object concept tasks

Severity of
Maternal group depression Maternal Education
Con PD PH PHPD Minor Major No A levels A levels
(i) Stage IV. 9 months
Pass 10 2 4 8 7 3 15 9
Fail 7 13 3 6 4 15 10 19

(ii) Stage V, 18 months

Pass 21 12 3 7
Fail 17 23 7 14

Infant cognitive and language development at \8 months

(i) Object Concept tasks; stage F (see Table 3). The performance of infants in both
groups whose mothers had suffered from depression in the postnatal months (PD
plus PHPD groups) was significantly poorer than that of infants whose mothers had
never been depressed (Con group) (x^ = 4.22, df= 1, / J < 0 . 0 4 ) . Outcome was not
more adverse for infants whose mothers had experienced a previous history of
depression (PH group). Unlike the results for the 9-month task, there was no difference
between the performance of infants of mothers with first onset after childbirth (PD
group) and those of mothers with previous as well as postnatal episodes (PHPD group).
This change in the pattern of results between 9 and 18 months was not accounted
for by the 9-month subsample (A'^=53) being unrepresentative ofthe total infant
population tested (N = 104).
Overall it was the case that those infants who had succeeded at 9 months on Stage
IV were more likely to succeed on Stage V at 18 months (x^ = 6.42, d f = l ,
p < 0.02), but the pass rate for infants of mothers with both previous and postnatal
depressions (PHPD group) dropped across the two assessments, whereas the
performance of infants in the other three groups remained consistent.
No other variable tested was significantly related to infant outcome, although there
was a tendency for girls to be more successful than boys (X^ = 3.83, df = 1, /> < 0.06);
and, as in the stage IV object concept task at 9 months, infants tended to perform
less well where there was marital friction in the family (x^ = 2.72, df= \, p<0.\).
 L. Murray

None of the factors investigated was significantly related to performance on the

stage VI task, where pass rates were very low (10.6%).
(ll) Bayley mental development scales (see Table 4). Univariate analyses showed social
class alone to be significandy related to infant performance on the Bayley scales. Infants
of parents in the upper-middle and middle class occupations performed, overall, better
than those of working class parents (^ = 2.52, p < 0 . 0 2 ) . In addition, as with
performance on the object concept stage V task, there was a tendency for girls to
perform better than boys {t = 1.93, p < 0.06). There were no overall effects of maternal
psychiatric status on Bayley scores. However, when each maternal group was examined
separately, it was found that there was a significant adverse impact of lower social
class only in the group of infants whose mothers experienced a first onset of depression
after childbirth (PD group) (/ = 3.27, p < 0.003).

Table 4. Bayley scales of infant development: social class and

maternal group
Social class
I, II, III III manual,
non-manual IV, V
Maternal group A^ Mean' A^ Mean Significance

Con (A^=38) 25 115 13 115

PD (7^=35) 24 117 11 99
PH (N= 10) 2 114 8 105
PHPD {N=2\) 11 113 10 110

Mean 115 107

SD 14.9 16.4
scores on mental development index scales.
*p<0.05; **p<O.Q\.

(iii) Reynell scales. The pattern of results for language comprehension was similar
to that obtained with the Bayley scales. There was no overall effect of maternal group
on infant language comprehension, but, as shown in Table 5, higher parental social
class was related to better outcome (t = 2.71, p < 0.009), and girls scored significantly
better than boys (/ = 3.74, p < 0.0004). The effects of class and gender each remained
significant when the other variable was added to the regression equation first.
As with the Bayley scales, the effects of variables identified from univariate analysis
as exerting a significant impact on outcome did not apply evenly across maternal
groups. As can be seen from Table 5, social class interacted with maternal group
[i^3) = 3.74, p < 0.02], and subsequent examination ofthe data showed that the impact
of social class was only significant in the group of infants whose mothers had
experienced their first onset of depression following childbirth (PD group) (/ = 4.89,
p<0.0001).
Differences in infant outcome according to gender were significant only in infants
whose mothers had experienced postnatal depression (PD and PHPD groups) (/ = 2.56,
p < 0.02 and t = 2.38, p < 0.03, respectively). The effects here are less clear than with
 Postnatal depression 553

the results on the Bayley scales, since within the upper and middle social class category,
and within the group of girls, mean scores are distributed according to maternal group
in a way that is counter to the hypothesis that depression may exert an adverse impact
on language comprehension.

Table 5. Reynell scales of language comprehension: social class, infant gender and maternal group

Social class^ Gender

I, II, III III manual.
non-manual IV, V Cirls Boys
Maternal group* MSS^^ MSS Significance A^ MSS N MSS Significance

Con 0.11 -0.09 18 0.25 20 -0.15

PD 0.69 -0.62 19 0.63 16 -0.14
PH 0.85 -0.12 4 0.10 6 -0.02
PHPD 0.14 0.34 10 0.85 11 -0.33

Mean 0.36 -0.14 0.50 -0.17

SD 1.01 0.81 0.79 1.00

•^Sample sizes as for Table 4.

''MSS = Mean standard score.
* / ) < 0 . 0 5 ; • • ^ < 0 . 0 1 ; ***p<

With regard to expressive language (see Table 6) there was, as with comprehension,
no overall effect of maternal group on infant outcome. Cirls performed better than
boys {t = 2.08, p < 0.04), and there was a tendency for infants of parents in the higher
social classes to perform better ( / = 1 . 5 2 , ^ < 0 . 1 ) . A significant interaction obtained
between social class and maternal group [^(3) = 3.03, p < 0.008]. As with outcome
on the Bayley and the Reynell comprehension scales, examination of each maternal
group showed that the effect of social class was only significant in the group of infants
whose mothers had experienced first onset of depression following delivery (PD group,
t = 3.29, p < 0.003). In addition, there was a trend for gender and maternal group
to interact [F{3) = 2.50, p < 0.07]. Boys whose mothers had first onsets of depression
following childbirth (PD group), performed poorly compared to girls (/ = 2.69,
p < 0.02), but this also applied in the group with previous but not postnatal episodes
(PH group) (t = 8.15, p < 0.0001). The same complication applied to the interpretation
of these results as to those for language comprehension, with outcome, at least in
girls and in infants of parents in the higher social classes, vaiying according to maternal
group in a fashion counter to the hypothesis of adverse effects of maternal depression.
No other variable was related to infant performance on this measure.

Attachment to (he mother at 18 months

For the purposes of statistical analyses, infant attachment to the mother was classified
as either secure or insecure. Table 7 shows the more detailed categorization of
insecurity, along with numbers of securely attached infants, according to maternal
group and gender. There was a significant overall effect of maternal group on infant
554 L. Murray

Table 6. Reynell scales of language expression: gender, social class and maternal group
Social class'* Gender^
I, II, III III manual,
Maternal group non-manual IV, V Significance Girls Boys Significance
Con -0.04 0.03 -0.23 0.18
PD 0.48 -0.58 *•• 0.53 -0.31 *•
PH -0.75 -0.23 0.23 -0.70 •«**
PHPD 0.07 0.29 0.51 -0.13

Mean 0.16 -0.12 0.24 -0.13 «•

SD 0.99 0.79 0.90 0.91
"Sample sizes as for Table 4.
'^Sample sizes as for Table 5.
•p<0.10; * > < 0 . 0 5 ; •••/7< 0.001.

attachment classification (x^ = 15.4, df= 3, /?< 0.002). Infants whose mothers had
been depressed in the postnatal period (PD and PHPD groups combined) were
significantly more likely to be insecurely attached to their mothers at 18 months than
infants of non-depressed mothers (Con group) (x^ = 13.7, df= 1, p< 0.0003). There
was no difference in outcome between infants whose mothers had experienced their
first episode of depression following childbirth (PD group) and those who had previous
as well as postpartum depression (PHPD group). Here, as was also the case for the
Bayley scales of mental development and for language development, the duration
and severity ofthe depression made no difference to outcome, and current maternal
depression at 18 months was also unrelated. Women who had previous but not
postpartum depression (PH group) were not significantly more likely to have infants
who were insecure than women with no history of depression (Con group), although
there was a trend in this direction (Fisher's exact test, p<O.OS).
Marital friction was found from univariate analysis to be associated with insecurity
of attachment (x^ = 9.59, df = 3, p<Q.OO2). However, in a multiple logistic
regression, in which secure/insecure attachment was taken as the binary dependent
variable, when maternal group was included in the regression equation first, marital
friction was no longer significant. When marital friction was included in the analysis
first, on the other hand, maternal group still made a contribution to infant outcome
(p = 0.05).
Infant gender was related to attachment classification, girls being less likely to be
insecure than boys (x^ = 6.55, df = 3, p < 0.02) (see Table 7). The effect of infant
gender and maternal group each remained significant when the other was included
in the regression analysis first, as was true of infant gender and marital friction. In
addition, maternal group contributed significantly to outcome when both marital
friction and gender were included in the regression analysis first, while marital friction
was not significant when maternal group and gender were included first. These results
indicate that a satisfactory model for predicting outcome is one that includes just
maternal group and infant gender. The observed numbers and those predicted by
the model are shown in Table 8. The model predicts that, compared with the control
group infants, the odds of insecurity are 5.4 times greater in the group whose mothers
 Postnatal depression 555

had their first onset of depression following childbirth (PD group), 5.1 times greater
in infants of mothers with a previous but not postpartum history (PH group), and
9.8 times greater in those whose mothers had suffered from previous as well as
postpartum depression (PHPD group). Independently of maternal group, the odds
of insecurity are 3.6 times greater for boys than for girls. While the observed frequencies
in Table 8 are clearly consistent with this description of insecurity in terms of the
independent effects of maternal group and gender, examination of the figures for
each maternal group considered separately suggests, as they did with results on the
Reynell scales, that the gender effect was not uniform across the maternal groups.
Thus, although a statistical interaction between gender and maternal group was absent,
there was no evidence of any gender difference in attachment classification within
the control population, whereas in the case groups boys were consistently more insecure
than girls. This difference was significant in the group whose mothers had suffered
from postnatal but not previous depression (PD group) (X^ = 6.99, df = 1,
^ < 0.009).
With regard to the pattern of insecurity, it can be seen from Table 7 that no
insecurely attached girls were classified as either ambivalent/resistant or disorganized,
whereas six boys were classified in this way. However, this gender difference was
not statistically significant.

Table 7. Attachment at eighteen months by maternal group and by infant gender

Attachment
Insecure/
Insecure/ ambivalent, Insecure/
Secure avoidant resistant disorganized
Maternal group A^ (%) A^ (%) N (%) A^ {%)
Con 29 (76.3) 9 (23.7) 0 0
PD 15 (42.9) 16 (45.7) 2 (5.7) 2 (5.7)
PH 4 (40.0) 6 (60.0) 0 0
PHPD 6 (28.6) 13 (61.9) 0 2 (9.5)

Gender
Girls 33 (64.7) 18 (35.3) 0 n
Boys 21 (39.6) 26 (49.1) 2 (3.8) 4 (7.5)

Behavioural problems
The majority of infants in the study (60%) showed an absence of any behavioural
difficulty covered by the modified version ofthe Behaviour Screening Questionnaire.
Fifteen per cent experienced only mild problems; and, although 25% showed a marked
difficulty in at least one area of behaviour, no infant showed marked difficulties on
more than two items of the questionnaire. Because the results were skewed in the
direction of there being rather few behavioural problems overall, mean scores were
not used as the outcome measure; rather, infants were categorized either as showing
some difficulty (either mild or marked) in at least one area, or else as being free from
556 L. Murray

Table 8. Model of infant attachment by maternal group

and infant gender
Attachment
Secure Insecure
A^ (%) N (%)
Maternal group Actual predicted Actual predicted
Girls
Con 14 (15.8) 4 (2.2)
PD 12 (10.7) 7 (8.3)
PH 3 (2.3) 1 (1.7)
PHPD 4 (4.2) 6 (5.8)
Boys
Con 15 (13.2) 5 (6.8)
PD 3 (4.3) 13 (11.7)
PH 1 (1.7) 5 (4.3)
PHPD 2 (1.8) 9 (9.2)

behavioural problems. There was a significant effect of maternal group on this outcome
variable. As can be seen from Table 9, women who had suffered from postnatal
depression (PD and PHPD groups) were more likely to have an infant with some
behavioural problem than women who had never been depressed (Con group)
(X = 5.27, df= 1, /?<0.03). There were no differences in the number of infants
with difficulties between the two groups of mothers who had experienced postnatal
depression (PD groups vs PHPD group). Outcome was not more adverse for infants
whose mothers had previous but not postnatal depressions (PH group) compared with
controls. No other variable was significantly related to infant behaviour problems,
although there was a tendency for marital friction to be associated with increased
difficulties (x^ = 3.47, df= 1, p<0.07).
Most infant problems occurred in just four areas: amongst the 42 infants with any
behaviour difficulty, 66.7% suffered from sleep disturbance, 33.3% from temper
tantrums, 31 % from eating difficulties and 23.8% from excessive dependency. When
mild and marked behaviour difficulties were considered together it was found that
sleep problems were distributed uniformly across the four subject groups, the impact
of postnatal depression residing principally in the other three areas of behaviour
disturbance. However, when analysis was restricted to marked difficulties, there was
a trend for sleep problems to aggregate in the infants of mothers who had suffered
from postnatal depression (PD and PHPD groups) (x^ = 2.72, df= 1, p<OA; see
Table 10); and eating difficulties and temper tantrums occurred only in the context
of maternal postnatal depression. The presence or absence of any marked difficulty,
in contrast to any mild-marked difficulty, did not differ significantly between infants
in the different maternal groups, although there was a tendency for more infants of
postnatally depressed mothers (PD and PHPD groups) to have some marked problem
than infants of women who had never suffered from depression (x^ = 2.72, df= 1,
p<OA; see Table 9).
There was no relationship between the presence of behaviour difficulties and
attachment classification.
 Postnatal depression ^^'

Table 9. Behaviour problems and maternal group

Mild or marked Marked problem
No problem problem only
Maternal group % % %

Con (A^=38) 73.6 26.4 18.4

PD {N=35) 45.7 54.3 37.1
PH (A/= 10) 60 40 0
PHPD (A^=21) 57.1 42.9 28.6

Table 10. Marked and mild behavioural problems according to maternal group
Mild or marked Marked only
Con PD PH PHPD Con PD PH PHPD

%''^ %T {N= 10) (^=21)

Sleep 23.7 31.4 20 28.6 15.8 25.7 0 23.8

Eating 2.6 28.6 20 0 0 11.4 0 0
Tempers 0 25.7 20 14.3 0 8.6 0 4.8
Dependency 5.3 11.4 10 14.3 2.6 0 0 0

Discussion
The results of this study demonstrate a significant impact on infant development
of maternal depression in the early postnatal months. The development of specific
cognitive functions, as measured by the object concept series, was affected, as was
the nature ofthe infant's attachment to the mother. Frank behavioural disturbance
is identified only rarely in 18-month old infants, and indeed, none was present in
the current sample. Nevertheless, there was some indication of an increase in behaviour
difficulties amongst the infants of postnatally depressed mothers. These occurred
particularly in the area of severe sleep disturbance, which has been found to be
associated with behavioural problems later on at age 3 (Zucherman, Stevenson &
Bailey, 1987); and in eating problems and temper tantrums. No overall effects of
maternal psychiatric status on general mental development (Bayley Scales) and
language development (Reynell Scales) were identified. However, maternal depression
in the postnatal months appeared to exacerbate the effects of variables that are
associated with poorer mental development (i.e. lower social class) and language
development (i.e. lower social class and male gender). The duration ofthe infant's
exposure to depression was unrelated to infant outcome on any measure, as was
maternal depression at the time ofthe assessments (although it should be noted that
the number of depressed women at 18 months was low).
These results are consistent with those of other studies that have found cognitive
deficits (Cogill et ai, 1986), and impairments in the quality ofthe mother-infant
relationship (Stein et ai, 1991), but not marked behavioural disturbance (Chodsian
558 T ..
L. Murray

et ai, 1984; Caplan et ai, 1989), to be significantly associated with the occurrence
of postnatal depression.
Although the social class distribution ofthe study population did not differ from
that ofthe population of Cambridge as a whole, it is clearly very different from that
of many studies ofthe impact of maternal depression which have been based in more
deprived areas. Some caution, therefbre, is required in generalizing the results of
this study to other populations. Since maternal depression in this sample was associated
with lower scores on the scales of mental development only in the context of low social
class, it is possible that in populations more disadvantaged than the Cambridge one,
a strong association would obtain between maternal depression and poorer cognitive
outcome on scales of general mental development.
As well as examining the effects on infant development of maternal depressive
episodes in the postnatal months the study addressed two further issues concerning
maternal functioning.
(i) First, it was designed to determine whether adverse infant outcome arises in
the absence of depressive symptoms but in the context of maternal vulnerability to
depression. None ofthe comparisons between infants of mothers who had never been
depressed and infants of mothers who had suffered from depression prior to but not
since childbirth showed significant differences, although there was a tendency for
attachments to be more insecure in the latter group. The findings suggest that general
vulnerability to depression is not sufficient to bring about a significant deleterious
effect on infant development. Nevertheless, some caution is required when considering
these results, since the number of women with a history of depression prior to childbirth
who remained free from depression in the 18 months postpartum was small.
(ii) Second, the suggestion that infant development might be more adversely affected
if maternal depression was focused principally on the infant and motherhood was
explored by comparing infant outcome between two groups of postnatcdly depressed
mothers—those who had experienced their first episode of depression following
childbirth, and those for whom the episode after childbirth represented just one of
a series of episodes of depression. There was limited support for this hypothesis:
although the results for the two groups were broadly comparable at 18 months,
cognitive performance at 9 months was significantly poorer in infants of mothers with
first episodes of depression following childbirth; and at 18 months there was evidence
of greater susceptibility to the adverse effects of lower social class and male gender
in these infants.
An important area for future enquiry concerns the mechanisms by which maternal
depression leads to adverse infant outcome. This issue is being addressed in the present
study by the analysis of videotaped mother-infant and stranger-infant interactions,
and maternal interviews recorded throughout the 18-month period. The finding that
infant outcome was unrelated both to depression at the time of assessment and to
the duration of maternal depression in the 18-month period postpartum is consistent
with the existence of a sensitive period early on in development when maternal
functioning has an impact on the infant that influences outcome later on. An alternative
explanation is that difficulties in the mother's ability to communicate with her infant
in the first few months, arising in the context of depression, lead to the setting up
of impaired patterns of interaction between mother and infant that become established
 Postnatal depression

and persist beyond any improvement in maternal symptoms, and underlie poorer
infant performance at 18 months. It is not clear what the relative contributions of
mother and infant might be to such perpetuation of impaired patterns of engagement.
The finding of Field et al. {1988) that infants of depressed women who are avoidant
with their mothers generalize this response to interactions with other adults, and in
turn cause non-depressed adults' behaviour to become more subdued, suggests a
transactional model (Sameroff, 1991) in which the infant may make a significant
contribution to the process.
Analysis of these interaction data will also bear on the question of how different
patterns of outcome for boys and girls, and for different social class groups, arise
in the context of maternal depression. With regard to gender, the poorer outcome
for boys in the context of parental psychiatric disorder early on in development has
been well documented (e.g. Rutter & Quinton, 1984), but the reasons for gender
differences in outcome remain unclear. Boys may be more susceptible to the adverse
impact of environmental stress; or depressed mothers, who are often in difficult marital
relationships, may respond more negatively to their sons and show more empathy
for their daughters. Alternatively, gender differences in infant behaviour may provoke
different patterns of maternal response.
The question of direction of effects is less problematic with respect to social class
where the independent variable is unambiguous. However, the details of how social
class interacts with maternal emotional state to influence infant development remains
to be determined.
A further finding of the present study requiring elucidation is the deterioration
in performance on the Piagetian object concept task between 9 and 18 months of
infants whose mothers had experienced depression prior to as well as following
childbirth. Similar findings ofa deterioration in infant functioning between 12 and
18 months in the context of maternal psychological unavailability have been reported
in a number of studies (e.g. Egeland and Sroufe, 1981a,b; Schneider-Rosen,
Braunwald, Carlson & Cicchetti, 1985). The literature on infant social development
describes marked alterations in the quality of mother-infant communication towards
the end ofthe first year (Stern, 1985). At this time the infant begins to monitor adult
expressions of affect more closely, and seeks more active engagement with the mother
when she becomes angry or distressed (Radke-Yarrow, 1987). It is possible that such
developmental shifts may lead to fresh difficulties in the relationship between mother
and infant which are associated with deteriorating infant performance.
Finally, the findings that the remission of maternal depression by 3 months does
not bring about an improvement in the mother-infant relationship and confers no
significant advantage to infant outcome carry important therapeutic implications.
They indicate that the focus of therapeutic intervention should extend beyond maternal
depressive symptoms to the mother-infant relationship. Unlike treatment for
depression itself, effective therapies of this kind have yet to be established.

Acknowledgements—This research was undertaken with the financial support of the Medical Research
Council. I am indebted to Claire Kempton, Richard Hooper, Dr Ruth Sagovsky, Dr Nicola Totterman,
Tabitha Brufal, Matthew Woolgar, Dr Dymph van den Boom, Elizabeth Meins and Dr Rulh Morley
for their assistance in dala collection and analysis. I thank Dr Peter Cooper and Dr Alan Stein for
 L. Murray

their comments on the manuscript and Dr Martin Richards for the facilities provided in the Child Care
and Development Group. In particular I am grateful to the mothers who participated in the study.
The author was supported by a Fellowship from the Winnicott Trust whilst carrying out this research.

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