Katharine: Hey, everyone.
This is part two of our discussion with Dr. Catherine Monk.
It picks up right where we left off in part one.
Welcome back.
What should we think about this?
I mean, if a child, a baby, a 2-year old, a 4-year old, a 10-year old has a more or
less active amygdala?
Is that what...?
Who cares?
Dr. Monk: Wow, it's another great question.
So, and an important one because, for two reasons.
In developmental research and we think about plasticity.
The brain is in its development is plastic, meaning that nothing is set in stone, nothing
is permanent.
There are gonna continue to be influences that shape it throughout development.
So we want, we really need to remember that this is a brain getting shaped.
And just because we're seeing these two early indications of a certain trajectory, a path,
a future for development, doesn't mean it's set in stone and that we necessarily know
what it means.
What we're seeing is that this is a brain...
These seem to be brains getting shaped differently based on mother's depression and anxiety during
pregnancy.
And there may actually, a theory goes, be something from an evolutionary perspective
might have been advantageous about this, and that is that the mother would potentially
with her anxiety for example, wanna communicate to the fetus by mechanisms we're still trying
to understand, possibly a stress hormone, cortisol, crossing the placenta, influencing
brain and behavior development in utero, to say, "It's a dangerous world out there, be
ready.
I'm anxious because it's dangerous out there, so get prepared."
So some of the thinking is that this brain behavior differences you're noting, it's not
necessarily that we think they're bad or good, they may be accelerating development to be
aware of the future out there sooner and be prepared.
And what people often think about now, and it's so important in terms of raising children
to think this way, is the match between that developing organism and the baby's environment.
And that can be on a macro level.
Meaning, are you anticipating those bears in the woods we all learned about as children,
learning about fear and how the brain works?
Or, are you in a 21st century classroom?
It can also be on a more micro level.
How are you and your parents?
Are you a very good match and how to make you even a better match to continue shaping
your brain behavior development?
For example, a baby who is very reactive and a parent who's extremely calm could find it
annoying and not understand their baby, or a baby and a mother who are both extremely
reactive and anxious could make each other more uncomfortable and less well-regulated
as a unit.
Katharine: So, I know that you have a clinical practice, and you're also running a program
that is working with pregnant women and then the first couple of years after their babies
are born.
Can you say a little bit about that and how you're seeing those dynamics play out in that
work?
Dr. Monk: Yes absolutely.
I guess what I will say is more from years of clinical experience, that it's so important
to bear in mind this idea that I'm focusing on women right now, on mothers and being a
little biased in that, but that every woman learns their baby and even if it's a second
or third baby, because all babies are different.
And again, that in some ways there's already happening in utero because the woman is shaping
that baby.
But they are a unit.
And in clinical work, I try to support them reading each other's cues to optimize how
well they fit each other.
In our clinical intervention, I...it's not, I can't quite say it's a program yet because
we have preliminary data and we're about to start some new large work with a lot more
women.
But we've developed an intervention that starts in pregnancy, and then goes to the postpartum
period and it's for women at risk for postpartum depression.
And, one of the biggest risk factors for postpartum depression is being distressed in pregnancy.
So, having anxiety and depression.
So, we're really targeting it in pregnancy.
It's called PREPP, which stands for Practical Resources for Effective Postpartum Parenting.
And it's a very brief intervention, just five sessions and we are...we have three foci,
how to optimize baby regulation and feeling competent as a parent, some mindfulness skills
and then what we call psycho-education or information.
So starting with the latter, it's what to expect from your baby.
The mindfulness is the kind of mindfulness we all try to...many of us at least try to
practice nowadays to help ourselves find calmness in a way to deal with challenges.
And then probably the biggest part of this is engaging women where they're at, even in
pregnancy before the baby is born which is wanting the best for their baby and wanting
to feel that they have all the tools that can help their baby sleep as best as possible,
and fuss and cry as little as possible while still communicating.
Part of why we've oriented PREPP this way is to reduce stigma around getting behavioral
health services.
So it's very much focused on the baby and you, and you the mother, and we are approaching
the risk for postpartum depression as something that happens to a mother and her baby because
not only the research I've described to you indicating that the fetus is being affected
but there are decades of research showing that postpartum depression dramatically affects
children's development, particularly cognitive and emotional attachment development.
So it affects both of them.
So, our approach starting in pregnancy is meeting women where they're thinking, which
is often very much about their baby as well as about themselves, and reducing stigma by
orienting this intervention for both of them, and away from mental health per se.
And we've had very good results.
So far we have zero attrition which is amazing for behavioral health interventions.
It's only two in pregnancy, I should say.
We visit them at birth, there's a check-in phone call, and then there's a six week session.
So we've had zero attrition when we've run this and we've cut the rates of serious postpartum
depression in half.
Kathariner: And are these, what kind of women are these?
Dr. Monk: That's a great question, too.
We really do know what are risk factors for postpartum depression, but they're probably
not as well advertised as say, risk factors for breast cancer and they should be.
So, past depression is one of the biggest, meaning in one's life, being depressed during
pregnancy, low social support, poverty.
The rate of postpartum depression is about double in a poverty sample, up to almost 40%
where it's 10% to 15% in a non-depressed sample.
Katharine: So, what are the primary risk factors that you've identified?
Dr. Monk: Well, I should say that this has been known for a while.
So it's not just me identifying risk factors for postpartum depression.
And just to emphasize that, we all in the public probably know risk factors for certain
cancers better than we talk about the risk factors for postpartum depression, or frankly,
any depression even though they are well-known.
For postpartum depression in particular, depression in a woman's life previously, depression during
pregnancy is a huge risk factor for postpartum depression.
Low social support, ambivalence about having the baby, problems in the partner relationship
that has led to the pregnancy in the first place.
And some data indicating a difficult relationship with one's mother.
Those are some of the major, but I really also wanna emphasize that while the rate for
postpartum depression, I mean, it's really pretty high, 10 to 15% of women, and you can
compare that to say, gestational diabetes, which is about 3 to 5% of women, this is way
higher.
But when you get to a poverty sample, it's almost double.
So, the rates of postpartum depression in a poverty sample can be as high as 40%.
So it's very, very high.
The data we've had from our preliminary study of this was not a poverty sample per se.
So, it was really across the board but we...all of the women met criteria for being at risk
for postpartum depression and we cut the rates in half of their actually experiencing it.
So, we're really optimistic about working with another group of women.
Katharine: Mm-hmm.
So there was a study done just in the last couple of years looking at the social and
emotional readiness of kindergartners entering the Baltimore public schools.
They followed those kids through fourth grade.
And they found that kids who were assessed as not socially, emotionally ready in kindergarten,
meaning, they had trouble sitting quietly, they had trouble following directions, they
had trouble getting along with other kids, that those children were much, much more likely
by fourth grade to be behind academically, to have been suspended or expelled.
The other thing they found is that about 50% of the kindergartners entering the Baltimore
public schools, were not socially, emotionally ready to be successful in kindergarten.
So, probably the predominant policy response to looking at that, a lot of those, a lot
of the kids entering the Baltimore public schools are disadvantaged kids.
And what we're seeing is if they're not ready for kindergarten, they're gonna have trouble
as they're going through school.
So, one of the predominant responses to that is starting school earlier, or sending children
to pre-K to help them get ready for kindergarten.
What you're talking about makes it sound as though there are things, there are places
to be focusing much before pre-K.
And I'm wondering what your thoughts are based on your research, based on your work with
these women, what your thoughts are on the children that are entering kindergarten, not
socially, emotionally ready.
Are any of these pieces fitting together for you?
Dr. Monk: Absolutely.
And I wouldn't want to in any way be saying we shouldn't also be providing support and
intervention later.
But I would wanna, I do say that our data and that coming out of other labs suggest
that we can also be doing much more earlier.
The data will hopefully someday let us know that if...because I hope we do get to do this,
if we do more earlier, and I'll tell you what I mean by that, might we not need to do so
much later?
And so, what would that look like?
It would, in my view, look like a big public health campaign around the importance of maternal
mental health.
And, I acknowledge and I'm focusing on women right now but it is after all women who become
pregnant.
And, so that we attend to their mental well-being, their behavioral health as much as we do their
physical well-being, at least we...for most women they do get adequate prenatal care.
And that we would also in that first year or two, you know, the first postnatal, year
or two or three really be thinking about helping women and their families, having support for
raising this child.
And much more awareness of what our data is suggesting, and I assume we'll continue to
have these kind of data coming out and it will get refined, that what a woman experiences
is what the fetus is experiencing, that there is this phenomenal brain growth going on in
utero.
And so, there isn't it just obvious to think that we need to be attending then to that
baby's environment, the mother, while that brain is developing in utero, and then the
first couple of years of life around, you know, support for the woman and the family
so that they can be, you know, the all...I'm sure you know this work, all the serve, and
return, and the engagement, the cognitive development, and emotional development that
happens through relationships.
Katharine: So the interactions.
So, you're talking about supporting, making sure that women are, understand the importance
and are kind of psychologically able to engage with their very young babies.
Are you seeing in your research that that's something women have trouble with?
Dr. Monk: Well, certainly, if you are in your pregnancy and you're feeling very ambivalent
about having the baby, or you've had a tragedy in your life that's on top of a significant
amount of stress, or you're depressed, and this is, you know, another time in your life
when you're having a significant depression.
You know, already, the bond with a baby starts when you're pregnant.
I actually had a patient say to me the other day who is unfortunately at grave risk of
losing a baby with a genetic defect.
And she emphatically said to me, but you're a mother when you become pregnant.
And so, this, the experiences you have and already the preparation for that certain return
once the baby comes out, and of course, early on it's it's even more basic than serve and
return, is starting in your mind, and, of course, in your heart when you're pregnant.
So, if you're feeling very depressed and overwhelmed, the sense you have of this baby coming is
already overshadowed by that.
So, we need to be providing women the support they need and the understanding that their
experiences are affecting their baby.
And, you know, before the baby is born, and how can we provide support for everyone and
education?
Katharine: Mm-hmm.
So, thank you so much.
This has been absolutely fascinating.
And I look forward to following your research as you continue to work in this area.
Dr. Monk: Thank you so much for having me.
It's been really enjoyable.
Katharine: Hey, everyone.
That's the end of our discussion with Dr. Catherine Monk.
Thanks very much for watching.
As always, let us know what other topics you'd like AEI scholars to cover on ''Viewpoint.''
And to learn more about early childhood development, check the links in the description below.