Maternal depression and anxiety: the effect on face-to-face
interaction between mothers and their 4-month-old infants
Masterthesis Childstudies University of Amsterdam Student: A.M. Weide (6161065) First assessor: drs. E. Aktar Second assessor: dr. M. Majdandzic
Abstract
Objective: We investigated the effect of maternal lifetime depression and/or anxiety on
mothers’ and their infants’ facial expressions during interaction. Methods: Participants consisted of 100 4-month-old infants and their mothers. Mothers were healthy (n = 40) or were diagnosed with lifetime depression with or without comorbid anxiety (n = 30) or with lifetime anxiety (n =30). Mother-infant interactions were videotaped and coded afterwards. The duration of mother’s and infant’s positive, negative and neutral facial expressions were compared between the depressed, anxious and healthy mothers. The duration mothers and infants matched their affective states was measured as an index of synchrony. Also infant’s gender was analyzed. Results: Depressed mothers vs. healthy mothers displayed increased neutral affect and decreased positive affect. No effects were found in anxious mothers. The amount of infant’s facial expressions was not affected by the mother’s psychological status, neither was mother-infant synchrony. Furthermore boys and girls did not differ in the amount of facial expression, neither was infant’s gender related to their mother’s facial expressions.
Conclusion: Future research is needed to get a better understanding of how lifetime
depression and anxiety manifest and how this affects the parent-infant interactions and related to this, later child outcomes.
Key words: maternal depression, maternal anxiety, infants, children, interaction, emotional communication, synchrony, patterned interaction.
Samenvatting
Doel: In de huidige studie is het effect van depressie en/of angst bij moeders onderzocht op de
gezichtsuitdrukkingen van moeder en kind tijdens interactie. Methode: Er participeerden 100 4-maanden oude baby’s met gezonde moeders (n = 40), moeders met lifetime depressie met of zonder co-morbiditeit (n = 30) en moeders met een lifetime angststoornis (n = 30). Moeder-kind interacties werden gefilmd en naderhand gecodeerd. De totale duur van positieve,
negatieve en neutrale gezichtsuitdrukkingen van zowel moeder als kind is vergeleken tussen de gezonde, depressieve en angstige groep. De duur van het gelijktijdig tonen van eenzelfde gezichtsuitdrukking bij moeder en kind is geanalyseerd als maat voor synchroniciteit. Geslacht van het kind is eveneens meegenomen in de analyses. Resultaten: Depressieve moeders toonden meer neutrale en minder positieve gezichtsuitdrukkingen dan gezonde moeders. Een angststoornis bleek echter niet van invloed op de hoeveelheid
gezichtsuitdrukkingen. Tevens bleek depressie/en of angst niet van invloed op de duur van gezichtsuitdrukkingen van het kind en op de mate van synchroniciteit. Geslacht bleek verder niet van invloed op de gezichtsuitdrukkingen van kinderen en hun moeders. Conclusie: Toekomstig onderzoek is nodig om meer inzicht te krijgen in de manier waarop angst en depressie bij moeders naar voren komt en hoe dit de moeder-kind interactie beïnvloed.
Key words: maternal depression, maternal anxiety, infants, children, interaction, emotional communication, synchrony, patterned interaction.
Index Abstract Samenvatting 1. Introduction 5. 2. Method 12. 2.1 Participants 12. 2.2 Diagnostic Instrument 12. 2.3 Procedure 12. 2.4 Coding 13. 2.5 Data-analysis 13. 3. Results 15. 4. Discussion 19. References
1. Introduction
Humans have an innate ability to interact with others around them. This ability can be seen as one of the most important adaptations of human species (Darwin, 1872; Grossman & Johnson, 2007) because humans learn about the world through these interactions (Grossman & Johnson, 2007). Research has shown that early dyadic face-to-face interactions contribute to the social learning of children (Feldman, 2007; Tronick et al., 1978; Tronick, 1989). By expressing emotions and perceiving emotional responses, children learn to regulate their emotions and learn to give meaning to their own and the emotions of others. Also, during face-to-face interaction children learn about the interactive styles of their caregivers and receive affective and cognitive information, which stimulates the development of the self, self-regulation, and the perception of others (Feldman, 2007; Tronick et al., 1978; Tronick, 1989).
Right after birth, a newborn infant is exposed to maternal facial expressions and vocalizations (Lavelli & Fogel, 2005). Although vision and focus skills are not well developed yet, babies already show a preference for human faces (Farroni et al., 2005). In addition, newborn infants are already able to imitate some facial expressions such as
protruding the tongue and opening the mouth (Farroni et al., 2005; Meltzoff & Moore, 1992). A newborn’s vision is marked by seeing light and high contrasts during the first days and evolves gradually. After three months visual acuity increases by maturation of the nervous system (Mancini et al., 1998), which leads to a more differentiated perception of positive and negative facial expressions such as happiness, surprise and anger (Bornstein & Arteberry, 2003; Grossman, 2010; Serrano, Iglesias, & Loeches, 1995). The amount and different intensities of positive, negative and neutral facial expressions an infant is exposed to, is of paramount importance in the development of facial perception and emotion understanding skills (Bornstein, Arterberry, Mash & Manian, 2011; De Haan, Belsky, Reid, Volein & Johnson, 2004).A varied emotional environment in which the infant is exposed to various facial expressions, contributes to better recognition and discriminating skills of facial
expressions (Bornstein et al., 2011; De Haan et al., 2004).Apart from the ability of perceiving emotional communication, a newborn infant communicates by expressing a continuum of negative and positiveemotions. These emotions elicit reactions of the parent and as a result an interaction pattern arises (Messinger, 2002).
Dyadic face-to-face interactions between mother and infant increasingly take place
during the first four months of life and reaches its peak around 4-months of age (Hsu & Fogel, 2001). These early interactions are predominantly characterized by positive emotions of the mother (Belsky, Gistrap & Rovine, 1984), and rarely consist of maternal negative affect (Malatesta & Haviland, 1982). Looking at the development of infants’ emotion expression during the first 4 months, the amount of negative expressions of emotions such as fussing and crying decline, whereas exploring behavior and the expression of smiling and excitement increases. Simultaneously, mothers show an increase of overall engagement and positive affect until three months of the infant’s age, then a decline of these behaviors is visible while stimulating and responding behavior seem to increase (Belsky et al., 1984). After 4 months, parent-infant interactions shift to triadic interactions and face-to-face interactions start to decline (Adamson, 1995).
Two important modalities of face-to-face interaction are gaze and facial expressions (Lavelli & Fogel, 2005), which interact and occur together or separately (Colonnesi, Zijlstra, Zande & Bögels, 2012). Gaze direction and mutual gaze play a significant role in establishing interaction patterns (Frith, 2007) and can be seen as a basis from where emotional expressions are produced (Colonnesi et al., 2012). Facial expressions have the function of manifesting internal affective states (Camras, 1992). While interacting, humans coordinate and
accommodate communicative modalities which results in a rhythmic, reciprocal pattern. This can be observed for instance, when an infant’s positive facial expression is interpreted
positively by the mother after which she reciprocates this positive expression. This also works the other way around, when the infant changes his or her facial expression positively in reaction to their mother’s positive facial expression. This aforementioned pattern is also referred to as ‘synchrony’ (Cohn & Tronick, 1988; Feldman, 2007; Feldman et al., 2009). It has been found that the extent to which mothers and infants are able to synchronize their communicative modalities, is vital in the development of secure attachment (Isabella, Belsky & Von Eye 1989; Isabella & Belsky, 1991), intentional communication (Colonessi, Rieffe, Koops & Perucchini, 2008), later successful relationships and social skills (Feldman, 2007; Feldman et al., 2009; Tronick, 1989; 2009). To establish a successful synchronous interaction, several conditions should be met. Mother and infant should be able to match behaviors like gaze direction and facial expressions. Also, mothers need to be able to read and sense the emotional state of their infant. This is also called sensitivity or attunement. Finally it is essential that mothers adapt affectively and cognitively to their infant (Harrist & Waugh, 2002). Synchrony is not always achieved however. In fact, most of the time mother-infant
dyads consist of mismatches and miscommunications (Tronick, 1989; Tronick & Reck, 2009). Nonetheless, when infants experience sensitive parenting and attunement, these mismatches and miscommunications give the child opportunities to repair mutual engagement. This serves as a fruitful learning basis to experience efficacy and to develop self-regulatory skills
(Tronick, 1989; Tronick & Reck, 2009).
Although face-to-face interaction between mothers and children occur as a natural process in general, maternal psychopathology such as depression or anxiety can disrupt these natural interactions (Nicol-Harper, Harvey & Stein, 2007; Field, 2010). Depression and anxiety are associated with negative emotionality, recurrent negative thoughts and worrying (APA, 2002; Stein, Lehtonen, Harvey, Nicol-Harper & Craske, 2009). Considering this, it is not surprising that depressed and anxious mothers tend to show more negative and neutral affect, reduced positive affect and have difficulties in responding sensitively and responsively to their environment (Cohn, Campbell, Matias & Hopkins, 1990; Field, 1984; Stein et al., 2012, Weinberg & Tronick, 1998). Due to these changes in affect, mother-infant interactions can get disturbed which could serve as a risk factor in the early socio-emotional development of children (Field, 2010; Stein et al., 2012; Tronick & Reck, 2009; Weinberg & Tronick, 1998).
Depression and anxiety are the most prevalent psychological disorders in Western countries (Kruijshaar et al., 2005). Approximately 30% of the Western population suffers from a depression disorder or an anxiety disorder once during lifetime (Kruijshaar et al., 2005). Similar results are reported in the Netherlands. About 20% of the Dutch population suffers from a mood disorder (20, 2%) or an anxiety disorder (19, 6%) once during lifetime, with the highest rates found in women (De Graaf, Ten Have, Van Gool & Van Dorsselaer, 2012). Both depression and anxiety show a high heritability, which means that children of depressed or anxious parents are at risk for developing psychopathology (Hettema, Neale & Kendler, 2001; Sullivan, Neale & Kendler, 2000). Moreover, co-occurrences of anxiety and depression are very common. Approximately 10% to 30% of depressed adults meet criteria for an anxiety disorder as well and about 50% of the population suffering from anxiety experiences a mood disorder once in their lives (Gorman, 1996; Gorman & Coplan, 1996).
A review study by Field (2010) provides an overview of mother-infant interaction studies investigating the effects of maternal depression. In this study the effects of maternal current postpartum depression at mother-infant face-to-face interactions were measured, with infants aged between 3 and 7 months. The majority of the studies support the idea that
depressed mothers show difficulties when interacting with their infants compared to nondepressed mothers. It became evident that depressed mothers tend to interact with their infants in a more withdrawn or intrusive way and use less different interactive features such as smiling, imitating and vocalizing (Feldman et al., 2009; Malphurs, Raag, Field, Pickens & Pelaez-Nogueras, 1996). In addition depressed mothers are found to touch their infant in a less positive manner, show more negative affect (Herrera, Reisland & Shepherd, 2004) and show less positive expressions such as smiling (Righetti-Veltema, Conne-Perreard, Bousquet & Manzano, 2002). Other studies also provide evidence for increased negative affect (Cohn et al., 1990; Field, Healy, Goldstein & Gutherz, 1990) and less positive affect in depressed mothers (Campbell, Cohn & Meyers, 1995). These shortcomings that depressed mothers experience affect the communicative abilities of infants as well. Infants of depressed mothers show more gaze aversion and in accordance with the behavior of the mothers, display an increased negative affect and a decreased positive affect (Cohn et al., 1990; Field et al., 1990; Field, 1995; Tronick & Reck, 2009). Moreover, it has been suggested that the increased negative affect of these infants elicit more negative behavior from the mother which maintains and strengthens a negative interaction pattern (Field et al., 1988; Weinberg & Tronick, 1998). Furthermore, infants of depressed mothers seem to experience more difficulties in perceiving small differences in their mother’s facial expressions compared to infants of nondepressed mothers (Bornstein et al., 2011). Thereby depressed mothers’ infants have less opportunities to experience high quality interactions which results in poorer language, social and cognitive skills (NICHD Early Child Care Research Network, 1999).
A widely used observational method in mother-infant interaction studies concerning maternal depression, is the Still-Face Paradigm (SFP). The paradigm gained the function of simulating depression but was initially developed to identify the role of reciprocal interaction and to examine infants’ affect regulation during temporary maternal emotional unavailability (Tronick, Als, Adamson, Wise & Brazelton, 1978). The paradigm consists of three episodes. First normal interaction is encouraged, after which the mothers ceases interaction by turning away her head and turns back with an expressionless face. This flat facial expression is often found in depressed mothers (Trevarthen & Aitken, 2001). After a short period of exposing the infant to the expressionless episode, the mother re-engages into normal interaction. General findings reveal that infants show a decreased mean level of gazing at the parent and positive affect, and increased negative affect during the Still-Face (SF), compared to the first episode of normal interaction (Mesman, Ijzendoorn & Bekermans-Kranenburg, 2009). Similar
findings were described in a recent study analyzing the behavioral changes of 6-month-old infants during the episode of the SF. As the SF episode continued, infant’s negative facial expressions increased while gaze and positive expressions declined (Ekas, Haltigan & Messinger, 2013). The results of studies investigating the effect of the SFP on depressed mothers’ infants reveal diverging outcomes. It has been found that infants who are frequently exposed to flat, neutral facial expressions from their depressed mother, get more accustomed to these facial expressions (Hernandez-Reif, Field, Diego, Vera & Pickens, 2006c). In a study from Field and colleagues (2007) this idea is supported, showing that 4-month-old infants of mothers currently suffering from high symptoms of depression, were less distressed during the SFP compared to healthy mothers’ infants. However, contrasting findings are also evident. A study investigating the interaction between mothers and fathers with a history of depression and their children aged between 3 and 6 months, has shown that 3-month-old infants
displayed significantly more negative affect during the SF condition in comparison to the infants of nondepressed mothers. Nevertheless, the amount of maternal positive facial expressions was not affected by the degree (all below clinical cut-off) of depressive symptomatology (Forbes, Cohn, Allen & Lewinsohn, 2004). An additional important indication of this study is that not only current symptomatology of depression seems to account for negative influences on mother-infant interaction, but also prior episodes of a depression have negative effects. Nevertheless, there is also research that did not find any significant differences during the SF in the expression of emotions between infants from depressed mothers versus infants from nondepressed mothers (Rosenblum, McDonough, Muzik, Miller & Sameroff, 2002; Stanley, Murray & Stein, 2004).
Regarding synchrony, evidence suggests that depressed mothers experience more difficulties in synchronizing effectively with their infants (Field, 2010). For example, unpublished results (Reck et al.) described in a review study of Tronick and Reck (2009), indicate that dyads between depressed mothers and their infants have lower reparation rates shifting from mismatching to positive interaction, compared to interaction with healthy mothers. A study of Bell and colleagues (2004), evaluated the proportion of time depressed mothers and their 3-month-old infants matched their affective state as an index of synchrony. The findings suggested that mothers and infants displayed less synchrony of positive affect. However contrasting findings are also evident. A research investigating synchrony between depressed and healthy mothers and their 2 to 3-month-old infants did not reveal significant differences, though mothers did reveal more negative affect (Cohn et al., 1990). Another
study concerning synchronous interaction between depressed mothers and their 5-month-old infants, revealed no relation between maternal depression and synchrony (Feldman, 2003) Compared to the amount of interaction studies found on maternal depression disorders, little research has been conducted within the field of maternal anxiety. Especially interaction studies investigating the behavior of mothers and infants up to 12 months old are scarce (Field et al., 2007; Kaitz & Maytal, 2005). Yet, there is good evidence that anxiety influences the interactive behavior of mothers negatively (Kaitz & Maytal 2005). A research from Warren and colleagues (2003) concerning maternal panic disorder (PD) indicate that mothers with PD behave less sensitive towards their 4-month-old infants compared to the controls.
Furthermore, anxious mothers versus healthy mothers rated themselves as displaying more anger during interaction with their 15-month-old children. Similar findings regarding to sensitivity and intrusive, overreactive behavior are found in a study comparing mothers with major depression to anxious and healthy mothers. In comparison to healthy mothers, anxious mothers displayed less sensitivity and more intrusiveness during interaction with their 9-month old infants. However, depressed mothers seemed to display the poorest outcomes (Feldman et al., 2009). Besides a lack of sensitivity and an increase of intrusive behavior, maternal anxiety is associated with a lower emotional tone. A study comparing interactional behavior between mothers with high and low anxiety and their 10 to 14-month old children revealed that next to a decrease of sensitive behavior, both high and low anxious mothers displayed less positive emotions than healthy mothers. Additionally, since anxiety often co-occurs with depression, the degree of depressive symptoms was also measured and analyzed to rule out the possibility that depression accounted for the outcomes. Excluding depression revealed a same pattern of interactional behavior between the high and low anxious mothers emphasizing the specific role of anxiety (Nicol-Harper et al., 2007). Comparable results are described in a study from Field and colleagues (2005), revealing that mothers with high anxiety compared to low anxiety display less positive facial expression (less smiling) while interacting with their 3-month-old infants. However, because of comorbidity the contribution of anxiety remained unclear. Contrary findings are described in a study from Murray and colleagues (2007) where no deficits in terms of sensitivity and controlling behavior were found between mothers suffering from social fobia (SF) versus non-anxious mothers. Referring to the effect of maternal anxiety on infants’ interactive behavior, the aforementioned studies yielded diverging outcomes. Some studies reported that infants display less positive affect, show an increased negative affect (Feldman et al., 2009; Field,
2005) and show more gaze aversion during mother-infant interaction (Feldman et al., 2009). Other studies did not find such differences (Murray, Cooper, Creswell, Schofield & Sack, 2007; Nicol-Harper et al., 2007; Warren et al., 2003).
With respect to synchrony and maternal anxiety, no specific studies were found. Nonetheless, as a consequence of the intrusive, overreactive behavior and the lack of sensitivity and responsivity (Kaitz & Maytal, 2005; Feldman et al., 2009; Warren et al., 2003), it is likely that anxious mothers tend to experience difficulties in matching behavior to their infants (Kaitz & Maytal, 2005).
Given the importance of early mother-infant interaction on the socio-emotional development of children and the negative impact maternal depression and anxiety seems to have on these early mother-infant interactions (e.g. Feldman et al., 2009; Field, 2010; Warren et al., 2003), it is of great interest and importance to complement current knowledge and to reveal new insights into the effects of maternal depression and anxiety on face-to-face interaction. In the present study we examined the effect of lifetime maternal depression and anxiety on face-to-face interaction between mothers and their 4-month-old infants. Including lifetime diagnoses is especially interesting since little research has investigated this so far and evidence suggests that also prior episodes of depression affects mother-infant interactions negatively (Forbes et al., 2004). Another distinguishing feature in this study is the use of similar coding protocols for both mother and infant. This is very informative when
investigating a reciprocal, synchronous interaction patterns as we attempted in the present study.
Based on the previous evidence, we hypothesized that mothers with a lifetime diagnose of depression and their infants would show more negative and neutral facial
expressions and less positive facial expressions compared to healthy mothers. Secondly, since the findings of maternal anxiety on mother-infant interactions are inconsistent and not firm yet, we explored the behavior of anxious mothers and their infants instead of having specific expectations. Finally, assuming a lack of sensitivity and responsivity in depressed and anxious parents, we hypothesized that mothers with a lifetime diagnose of depression and/or anxiety and their infants, will spend less time in expressing mutually positive, negative or neutral affect compared to healthy mother-infant interactions, which may indicate poorer synchrony.
2. Method 2.1 Participants
This study took place within a longitudinal study on the antecedents of social anxiety and used a subsample of its data (Colonnesi et al., 2012). Within this study 100 Dutch couples participated with their firstborn child at 4 months (44 boys and 56 girls). Through obstetrician offices in the cities of Amsterdam, The Hague and Utrecht and surrounding areas mothers with and without lifetime depression or anxiety were approached during pregnancy. The average age of mothers was 30.56 (SD = 4.37). The educational level of the mothers was high with an average value of 7.05 (SD = 1.23) on a scale ranging from 1 to 8 (1: primary school – 8: university degree). The professional level of the mothers was middle to middle high, 8.5 (SD = 2.16) based on a scale ranging from 1 to 11 (1: no education required – 11: university degree required). All participants were in good health; babies were full term with no pre- and postnatal medical histories.
2.2. Diagnostic Instrument
Depression and anxiety were measured with the ADIS (Anxiety Depression Interview Schedule) questionnaire (Di Nardo, Brown & Barlow, 1994).This is a semi structured clinical interview based on the DSM-IV criteria (APA, 2002). In this study mothers with the
following types of anxiety were included: panic disorder (PD), social anxiety (SA),
generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and acute stress disorder (ASD). From the sample (N = 100), 40 % of the mothers did not have a lifetime depression and/or anxiety diagnosis. Singular diagnoses of anxiety were present in 30 % of the mothers and singular depressions diagnoses occurred in 8% of the mothers. Depression with comorbid anxiety was observed in 22% of the mothers.
2.3 Procedure
Interactions took place in the baby lab at the Research Institute of Child Development and Education in Amsterdam. Mothers were instructed to interact with their infant during five minutes as they would normally do, without toys. The infant was placed in a baby-seat
mounted on a table with the mother sitting in front, facing the infant. Interactions took place in a sound attenuated room and were recorded with two cameras. In cases where the infant
was fussy and where the mother’s attempts to sooth the infant did not work, the mother was allowed to take a toy (placed underneath the seat of the child) to distract the infant.
2.4 Coding
Four students from the University of Amsterdam, who were blind to the psychological state of the mothers, were trained to code the videos. The first four minutes of the interactions were coded (240 seconds). The dimensions gaze, facial expressions and vocalizations were used on a 1-second time base using The Observer XT 11.0 software. Vocalizations were not analyzed in the present study.
Gaze and facial expression were both coded as frequency and duration in seconds. In this study we focused on the duration in seconds. Coding for “gaze” included gaze at the mother or infant and when mothers or infants were looking at the face, hand or body of their interaction partner. “Gaze otherwise” referred to looking away or non-observable looking, however this was not included in further analysis. Facial expressions of mothers and infants were coded in three main categories: positive, negative and neutral facial expressions. Positive facial expressions referred to closed and open smiles identified by raising corners of the lips, constriction of the eyes, raising of the cheeks and opening of the mouth. Additionally, pulling up the eyebrows and eyelids in mothers was also coded as positive. Negative facial expressions referred to frowns, identified by lowering the inner parts of the eyebrows, constriction of the eyes, moving down the corners of the lips. Negative facial expressions in mothers barely occurred and were therefore not included in separate analysis. Neutral facial expressions were coded when mothers or infants did not show a positive of negative facial expression.
The inter-rater reliability for coding children was calculated in 14%1 of the data and for parents in 21 % of the data. The average Kappa was .84 for infants’ gaze and .78 for infants’ facial expressions (Colonnesi et al., 2012). The average Kappa was .81 (SD = .021, range = 0.60 - 1) for mothers’ gaze and .87 (SD = .10, range = .77 - .97) for mothers’ facial expressions.
2.5 Data-analysis
Two-factor analyses of variance (ANOVA) measures were performed to analyze the data. The between group factors consisted of three groups based on lifetime diagnoses 1
Calculation of additional reliability values for coding children up to 21% of the data is in process and not available yet at time of writing this part.
13.
retrieved from the ADIS (Di Nardo, Brown & Barlow, 1994). The control group consisted of healthy mothers without depression or anxiety (n = 40). The second group consisted of mothers who experienced one or more anxiety diagnosis (n =30) and the third group included mothers with lifetime depression, with or without comorbid anxiety (n = 30). To test the possibility that infants’ gender accounted for certain interactive behavior of both mothers and infants, the interaction between maternal depression and/or anxiety with infants’ gender was also tested (Feldman, 2003; Weinberg, Tronick, Cohn & Olson, 1999).
To analyze the effect of maternal depression and/or anxiety on facial expressions of mothers and their infants during face-to-face interaction, we used the total duration of positive, negative and neutral facial expressions during gaze to the other person as the main outcome variable. In order to analyze the effect of maternal depression and/or anxiety on synchrony, the outcome variable consisted of the total duration mothers and infants expressed the same facial expression at the same time, during gaze to each other. Mothers looked 98.3% of the time to their infants and the infants looked 71.1% of the time to their mother.
Bonferroni post-hoc comparisons were calculated for significant interactions to determine which group causes the significant result. The effect sizes (ηp²) for significant results were presented as an indication of the degree of relevance with 0.01 referring to a small effect size, 0.06 referring to a medium effect size and 0.14 referring to a large effect size (Field, 2005).
3. Results
Prior to the analyses, the normality of the distributions of positive, negative and neutral facial expressions in both mothers and infants were inspected. Outliers with values exceeding more than three standard deviations from the mean were removed (Field, 2005). First, to compare the emotion expressions of depressed and/or anxious mothers with healthy mothers, we tested the total duration of positive, negative and neutral facial
expressions (during gaze) between these groups. It appeared that mothers barely expressed negative facial expressions and when they did, it were brief moments which were rather related to maternal empathy than to maternal negative affect (in that situation). Hence we were not able to test the hypothesis about negativity and focused therefore on mothers’ positive and neutral facial expressions. ANOVAs revealed significant group differences (neutral: F (2, 93) = 3.73, positive: F (2.93) = 3.31). Post-hoc analysis showed that mothers with depression (with or without comorbid anxiety), expressed longer neutral facial
expressions (M = 51.45, SD = 56.84, p = .028, ηp² = .074) and less time positive facial
expressions (M = 186.92, SD = 56.33, p = .041, ηp² = .066) than healthy mothers (neutral: M = 22.62, SD = 24.03, positive:M = 214.98, SD = 24.83). The amount of mothers’ positive (F (2, 93) = 1.22) and neutral facial expressions (F (2, 93) = .89) did not differ between interactions with boys or girls, meaning that infant’s gender was not related to significant differences in mother’s facial expressions. See Table 1. for descriptive statistics.
Second, to investigate the facial expressions of depressed mothers’ infants and to explore the facial expressions of anxious mothers’ infants, we compared the total duration of these infants’ positive, negative and neutral facial expressions to infants’ of healthy mothers. ANOVAs revealed no significant group differences in the total duration of infants’ neutral (F (2, 94) = 1.22), negative (F (2, 91) = .77) and positive (F (2, 94) = .14) facial expressions. With respect to infants gender, boys and girls did not differ in the amount of neutral (F (2, 94) = .19), negative (F (2, 91) = 2.13) and positive faces (F (2, 94) = .107) to their depressed, anxious or healthy mothers. See Table 2. for descriptive statistics.
In order to compare synchronous parent-infant interactions between depressed and/or anxious mothers and healthy mothers we investigated the total duration mothers and infants simultaneously showed neutral and positive facial expressions. ANOVAs yielded no
significant group differences in the total duration of synchronous neutral (F (2, 92) = 1.42) and positive facial expressions (F (2, 94) = .13). Also, being a boy or a girl did not affect the
total duration of mothers and infants matching neutral (F (2, 92) = 1.84) and positive (F (2, 94) = .266) facial expressions. In line with our previous results, this reveals that infant’s gender is not related to significant differences in facial expressions in both mothers and infants. See Table 3. for descriptive statistics.
Table 1.
Average values of facial expressions of mothers with and without depression and/or anxiety during interaction with their 4-month old infants
Duration in seconds(max 240 seconds)
Healthy (n = 39)
Anxiety (n = 30)
Depression with or without Anxiety
(n = 30) F df p ηp²
M (SD) Proportion(SD) M (SD) Proportion(SD) M (SD) Proportion(SD)
Mother’s neutral facial expression
during interaction 22.62 (24.03) 10.93(13.73) 36.69 (31.56) 15.28 (13.13) 51.45 (56.84)* 21.44 (23.68) 3.73 2,93 .028 .074 Mother’s positive facial expressions
during interaction 214.98 (24.83) 88.05 (13.93) 201.49 (32.02) 83.92 (13.37) 186.92 (56.33)* 77.86 (23.46) 3.31 2,93 .041 .066 Note. * p < .05
Table 2.
Average values of facial expressions of infants during interaction with their mothers with and without depression and/or anxiety
Duration in seconds (max 240 sec) Healthy Anxiety Depression with or without Anxiety F df p ηp²
n M (SD) Proportion (SD) n M (SD) Proportion (SD) n M (SD) Proportion (SD)
Infant’s neutral facial expression
during interaction 40 163.36 (49.00) 68.05 (20.41) 30 156.24 (49.77) 65.08 (20.74) 30 169.67 (50.50) 70.68 (21.05) 1.22 2,94 .299 .025 Infant’s negative facial expression
during interaction 38 23.87 (34.42) 8.19 (10.06) 29 30.18 (42.62) 12.14 (17.57) 30 25.82 (35.97) 9.00 (11.69) .77 2,91 .464 .017 Infant’s positive facial expression
during interaction 40 44. 79 (40.32) 18.66 (16.79) 30 48.49 (47.80) 20.20 (19.92) 30 41.73 (47.92) 17.38 (19.96) .14 2,94 .873 .003 Note. * p < .05
Table 3.
Average values of synchronous facial expressions of mothers with and without depression and/or anxiety and their infants
Duration in seconds(max 240 sec) Healthy Anxiety Depression with or without Anxiety F p ηp²
n M (SD) Proportion (SD) n M (SD) Proportion (SD) n M (SD) Proportion (SD)
Mother neutral – Infant neutral
39 17.26 (20.54) 7.19 (8.56) 30 24.89 (25.35) 10.36 (10.56) 29 35.62 (43.77) 14.84 (18.23) 1.42 .248 .030
Mother positive – Infant positive 40 44.34 (40.49) 18.47 (16.86) 30 46.77 (46.90) 19.48 (19.54) 30 40.35 (47.44) 16.81 (19.75) .13 .879 .003 Note. * = P value < 0.05
4. Discussion
In this study, we examined the effects of lifetime depression and/or anxiety on face-to-face interaction between mothers and their 4-month-old infants. The sample consisted of mothers with depression (with or without comorbid anxiety) or anxiety and mothers without depression and/or anxiety.
First, an important finding of this study is that mothers with lifetime depression (with or without comorbid anxiety) compared to healthy mothers spent more time in a neutral affective state and less time in a positive state during interaction with their infant. These outcomes are consistent with our expectations and literature that an increased neutral/flat facial expression and a decrease of positive affect is a typical characteristic of depression (see review Field, 2010). Moreover, the results of this study showed that even a prior episode of depression is related to more neutral and less positive affect, which stresses the importance of taking into account lifetime diagnoses. Anxious mothers (without comorbidity), compared to healthy mothers did not differ in the amount of facial expressions. As compared with mothers currently suffering from anxiety (Feldman et al., 2009; Field et al., 2005; Murray et al., 2007; Nicol-Harper et al., 2007; Warren et al., 2003), this may indicate that having a history of anxiety does not have prolonged effects on the emotion expressions of mothers. Important to note is that the anxious group was heterogeneous in terms of anxiety types. Different anxiety diagnoses were included (see section 2.2) and various anxiety disorders might elicit different interactive behavior of the mother. This makes it difficult to draw conclusions about the anxiety group as a whole (Murray et al., 2007; Kaitz & Maital, 2005). Social anxiety for instance is characterized by avoidance of novel social situations and is accompanied with a fear of behaving in an embarrassing or humiliating manner (APA, 2002). In this vein, social anxious mothers in this study may have attempted to behave well because they were exposed to a novel social situation (laboratory setting) and were conscious of being filmed.
Furthermore, despite our hypothesis about depressed and anxious mothers displaying increased negative affect, they barely showed negative facial expressions. In addition, when mothers did express negative faces, these moments were very brief and were rather
expressions of empathy than that mothers were negative themselves. For this reason we were not able to test the hypothesis about negative affect. A possible explanation is that mothers in this study lived in a relative high socioeconomic status (SES). Prior studies reporting
increased negative affect in depressed mothers used samples with lower SES (Cohn et al.,
1990; Field, 1990), which may imply that the expression of negative affect is not related to the mother’s psychological status per se, but also to environmental factors. One can imagine that when mothers experience hard times due to financial problems for instance, this would affect the emotion expression towards their infants. There are a couple of studies, using a similar middle or high class sample as we did, in which mothers also barely expressed negative facial expressions (Campbell et al., 1995; Forbes et al., 2004).
Second, we did not find significant differences in the duration of positive, negative and neutral facial expressions among infants of depressed, anxious mothers and healthy mothers. This indicates that depressed and anxious mothers’ infants were not visibly affected by the psychological state of their mother. Furthermore, boy and girl infants did not differ in the amount of facial expressions they presented, neither was infant’s gender of influence on the amount of their mother’s facial expressions. The lack of findings with respect to infants of depressed mothers, are in contrast with our expectations that maternal depression is reflected in their infants by showing increased negative and neutral affect and less positive affect (Cohn et al., 1990; Field et al., 1990; Field, 1995; Forbes et al., 2004; Tronick & Reck, 2009). It may be, as was also stated in previous studies, that the infants got accustomed to their mother’s manner of expressing emotions and were therefore not visibly affected (Field et al., 2005; Hernandez-Reif et al., 2006c). Another point of consideration is that within the normal development, infants around 4 months of age show a decrease of negative affect (crying, fussing) and an increase of exploring behavior and positive affect (Belsky, 1984). Prior studies reporting negative effects in infants included infants younger than 4 months (Cohn et al., 1990; Field et al., 1990; Field, 1995; Forbes et al., 2004; Tronick & Reck, 2009). This may imply that the negative effect on infant’s emotion expressions diminishes at 4 months of age. Also, in the specific study which yielded support for negative effects in infants when mothers suffered from a history of depression, they exposed the infants to the SF condition (Forbes et al., 2004). The SF episode is a more intense flat affective state than depressed mothers in general reveal during normal interaction with their infant. According to this, it may be that lifetime psychopathology is not reflected in infants within regular mother-infant interaction, but that its effect is only evoked during the more stressful SF situation. Referring to anxious mothers’ infants, our findings confirm those of others (Murray et al., 2007; Nicol-Harper et al., 2007; Warren et al., 2003), revealing that maternal anxiety is not reflected in amount of infants’ emotion expressions.
Finally synchrony, which was measured as the total duration mothers and infants were
able to match their affective states, did not differ between depressed and/or anxious mothers and their infants. These findings are in contrast with our expectations that depressed (Field, 2010; Tronick & Reck, 2009) and anxious mothers are less sensitive and responsive and would show poorer synchrony. Because as far as known no others studies investigated
synchrony related to maternal anxiety, we were not able to compare our results with previous studies. Regarding to maternal depression, two comparable studies support our finding that synchrony does not differ between depressed and nondepressed mother-infant dyads (Cohn et al., 1990; Feldman, 2003).
Because the sample sizes per maternal diagnose group were quite small, the results should be interpreted with some degree of caution. For future investigations concerning maternal anxiety, more homogenous groups should be compiled in order to clarify the contribution of specific types of anxiety. It would also be informative to examine the effects of comorbidity to a broader extent since comorbidity seems to reflect more severe symptoms compared to a single depression or anxiety diagnose (Kaitz & Maital, 2005). Furthermore, it is essential to research the effects of paternal psychopathology on father-infant dyads as well, since the role of fathers in childrearing becomes increasingly important (Forbes et al., 2004). In summary, with this study we attempted to reveal new insights into the effects of maternal lifetime depression and especially lifetime maternal anxiety on face-to-face with mothers and their 4-month-old infants. Evidence was found for prolonged negative effects of a prior episode of depression on mothers’ facial expressions, reflected in increased neutral and decreased positive affect. Our study yielded no support for negative effects of maternal
lifetime anxiety on mothers’ facial expressions, neither was maternal lifetime depression and/or anxiety related to the amount of the infant’s facial expressions. Although, the results are not totally in line with what we had expected, the results contribute to future research considering this topic. More research is needed in order to get better understanding of the way lifetime depression and anxiety manifests and how this affects mother-infant interactions and related to this, how this affects later child outcomes. With better knowledge potential risk families can be recognized earlier and treatments can be adjusted to meet the specific needs of families suffering from parental psychopathology.
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