Serve and Return: Deconstructing the Language of Maternal Mental Health

My professional curiosity lies in the power of language to limit, or liberate the lived experience of the childbearing woman—particularly those with perinatal mental health concerns.

Maternal Depression Can Undermine the Development of Young Children (2009) illustrates the positive strides being made to increase awareness of perinatal and postpartum mental health. This Harvard University working paper was a joint effort of the National Forum on Early Childhood Program Evaluation, and the National Scientific Council on the Developing Child, and published by the Center on the Developing Child at Harvard University.  As a psychologist, Ph.D. student in Transpersonal Psychology, birth doula, and mother managing the disease of major depression, I fully recognize that my personal experience influences my professional view.

Maternal Depression Can Undermine the Development of Young Children offers insights as to how childhood development experts view and describe maternal depression.  Increasing awareness of PPMAD (perinatal, postpartum mood/anxiety disorders) in all aspects of family care is crucial to making changes to prevent and treat it. However, the terminology used in the paper, and omission of the full spectrum of PPMAD demonstrate how casual use of language perpetuates stigma and stereotypes regarding maternal mental health.

Titles Are Important

The title, Maternal Depression Can Undermine the Development of Young Children reads, to me, as something I would hear on cable news, rather than a professional paper. Moreover, the term “maternal depression” is the primary descriptor used throughout the paper, rather than the more accurate “perinatal”, or even the somewhat outdated “postpartum” maternal depression.  Not using a puerperal adjective removes context of recent birth.  There is a difference.

“Because chronic and severe maternal depression has potentially far-reaching harmful effects on families and children, its widespread occurrence can undermine the future prosperity and well-being of society as a whole.” (p. 1)

Wow. Not only do depressed mothers hurt children; apparently we also have power to take down all of civilization!  I picture myself the ultimate evil villainess, “depressed mom” in my lair. In my never ending desire to undermine the future prosperity and well-being of society as a whole, I send out my far-reaching harmful effects to terrorize civilization in search for Zoloft. Children and family be damned! I have society to ruin.

The mental health of our mothers is a crucial component to healthy families and communities. But unless we unpack this kind of language, we perpetuate an unconscious belief that “mentally ill” mothers are dangerous mothers.

What is Maternal Depression?

“Characterized by a low mood and loss of interest in usually enjoyable activities, depressive symptoms include difficulty sleeping and concentrating, loss of appetite, feelings of worthlessness or guilt, and low energy. In the face of major clinical depression, the drive, energy and enjoyment needed to build and maintain positive family relationships recedes.”

Set within the prose of the article opinion, leaves symptoms in the realm of the murky. I hate to say it but for much of science, if it isn’t codified, it doesn’t exist.  If the reading audience is not medical professionals, all the more reason to be extremely clear with how medicine describes the disorder. Omitting the full DSM-IV-TR, or ICD 10 diagnostic criteria is a subtle invalidation.  It remains a “mood”/emotional/mental disorder. Furthermore, it is not an accurate representation of the actual diagnostic criteria.  There is no indication of time of onset, duration of symptoms, co-morbidities, symptoms of anxiety with depression, differential diagnosis, or how many symptoms need to present simultaneously to fit criteria.  (Go here for complete list of criteria.)

Prevalence and Effects
According to the authors, in the section subtitled: What Neuroscience and Developmental Research Tells Us, the majority of research on this subject is on maternal postpartum depression.  This is Harvard University. The power of that should not be diminished. When a group holding academic status defines something, we believe it, we repeat it to others.  Not having included all perinatal and postpartum mood/anxiety disorders (PPMAD) in the literature review missed the opportunity to recognize the research that has been done in PTSD after childbirth, and perinatal anxiety disorders.


“About one in eleven infants will experience their mothers’ major depression in their first year of life”.

This wording suggests mothers doing something to the infant. It personalizes a medical condition. That the relation to the object for our attachment theory readers, WILL be negative. I doubt a public health paper would say, “About one in eleven infants will (powerful word) experience their mother’s diabetes in their first year of life”.

“When raised by a chronically depressed mother, children perform lower, on average, on cognitive, emotional, and behavioral assessments than children of non-depressed caregivers….such patterns forecast difficulties later in adult life across a variety of important domains”.

Some readers may find this language suggests that depressed mothers are bad mothers, and cannot take care of children. This is myth.  Depressed women are not inherently incapable women.  Depressed mothers are not inherently incapable mothers; they are suffering a medical condition that challenges some of their current capabilities but is also completely amenable to proper treatment. I would encourage readers to read my interview with Katherine Stone at www.givingbirthwithconfidence.org for an example of resiliency.

Ping Pong and Problematic Parenting
The Paper authors acknowledge the evidence-based, substantive data demonstrating a correlation between “maternal depression” and fetal, neonatal, and early childhood development.  They are spot on to bring this data to the forefront of child development. However, word choice is extremely important when approaching an issue that has a history of stereotyping, particularly when describing it to professionals who may not be familiar with the issue. The data cited in the Harvard paper:

  • Chronic depression can manifest itself in two types of problematic parenting patterns that disrupt the “serve and return” interaction essential for healthy brain development: hostile or intrusive, and disengaged or withdrawn.
  • Children who experience maternal depression early in life may experience lasting effects on their brain architecture and persistent disruptions of their stress response systems.
  • Maternal depression may begin to affect brain development in the fetus before birth.
  • Depression often occurs in the context of other family adversities, which makes it challenging to treat successfully.

And, while not in bold-face, authors use the serve and return metaphor throughout the paper:

“When caregivers are sensitive and responsive to young child’s signals, they provide an environment rich in serve and return experiences, like a good game of tennis, or Ping-Pong.”

Sports analogies for the intimate interaction between mother and child are at best not creative, at worst insulting.  Perhaps one of the flaws of working papers is the assumption that readers can’t intellectually handle the material, and in an attempt to be understood, unfortunate metaphors are employed.

Suggestions and “Other Serious Adversities”

Hidden in all of the rhetoric, however, is good data. Shuffled off  in footnotes, there are wonderful studies referenced that offer serious contributions to what we are learning about the effects of untreated maternal mood and anxiety disorders. It is a shame in a way, as the second half of the paper offers learning opportunities around looking at program evaluation, policy, and implications for the future. But one has to weed through this kind of language to find the fruits of knowledge. A few more examples for our discussion:

Authors examine outcomes of current programs addressing “maternal depression” and conclude important issues regarding prevention and early intervention. Prevention is key. Early intervention is incredibly important. Treatment is essential and challenging. Here is their interpretation:

Prevention:Given the potential negative consequences of depression for both mothers and their children, a variety of interventions have been designed to prevent and treat it as well as to buffer children from its harmful effects.”

What is your reaction to this finding, and then to the wording?

Early intervention: “ It is not commonly understood that even young children are likely to be affected by their mother’s depression and these effects may be lasting. Moreover, ongoing depression after childbirth is linked to patterns of parenting that may disrupt the normal “serve and return” interactions between an infant and mother, thus potentially harming the child’s developing brain architecture and emerging skills.  By intervening early, before these effects can accrue, we increase the likelihood that children of depressed mothers will grow into healthy, capable, fully contributing members of society.”

Reflect on your reactions to this wording.

Treatment: “Intensive intervention efforts that focus specifically on mother-child interactions have shown promising results in several recent studies.

Wonderful information has emerged in studies showing improved cognitive behavior when mother-infant interaction is coached in brief sessions, over the first year of baby’s life.  Some of the best information the paper offers, and leaves wonderful questions about the efficacy of our current intervention paradigms.

“Research indicates that various combinations of psychotherapy and educational treatments focused exclusively on adults can be effective in reducing depressive symptoms in mothers but appear to have limited impacts on the development of their children. These findings have led several researchers to argue that therapies should not only treat the mother but should also focus on the mother-child relationship.”

I hold a deep belief in the potential of communities of women to facilitate tremendous growth through inclusive, expansive, and multiple levels of consideration and consciousness. Five studies are cited here, the most citations for any one single conclusion in the paper. Interestingly, the citations come from research in the disciplines of psychiatric, psychology, and infant mental health, in contrast to the traditional medical fields supporting first half of the paper (epidemiology, orthopsychiatry, neurobiology, biology, and immunology). The language is less of the uni-directional, mother-based disorder speak.  Traditional treatment paradigms are challenged. Here is where we can all become inclusive and expand professional and societal understanding of perinatal mood disorders. Cleaner language lends itself to learning.

Now, back to the crazy mommy bat cave to complete my mission to undermine civilization with mood swings, crying jags, coma-like responses to my children, and bad tennis.

Posted By: Walker Karraa, MFA, MA, CD

Patient Advocacy, Perinatal Mood Disorders, Research, Science & Sensibility, Uncategorized , , , , , , , , , ,

  1. February 17th, 2011 at 06:41 | #1

    “Because chronic and severe maternal depression has potentially far-reaching harmful effects on families and children, its widespread occurrence can undermine the future prosperity and well-being of society as a whole.” (p. 1)
    I don’t read it the way you do. I see it as a warning that we should take better care of mothers and that their mental state is important, which is positive, really. The feelings of mothers have so long been denied and brushed under the carpet of ‘get on with it’, ‘others have done it before you so you can too’, and ‘your baby is healthy’.
    it is the maternal depression that gives these results, not the mother.

  2. February 17th, 2011 at 06:43 | #2

    but I completely agree that the rest of the article – as quoted here – makes the mother into a culprit, which is so totally wrong!

  3. February 18th, 2011 at 14:38 | #3

    You know I love you, Walker, but I have to disagree with some of this. While I do think that it is important for Harvard and others to be very careful about their language so that women aren’t blamed and shamed, I also think we have to be open and honest about what can happen to the long-term health of both women and children when perinatal mood and anxiety disorders go untreated. The fact that these illnesses have the potential to undermine early childhood development is true. It’s not that depressed moms can’t take care of their children. They can and they do. And research shows that those who are treated are able to build bonds and essentially eliminate any attachment issues via healthy parenting. But when moms are untreated and the illness continues, some of their children are going to be effected, and those effects often don’t show up until later. We can’t ignore that. I think part of the reason that only 15% of women with PPD are treated is because people think the illness usually goes away on its own and everyone will be just fine. I don’t think that’s true, and I don’t think research shows that’s true. So while it is, as you say, SO IMPORTANT to be careful how we portray these things, I also think it’s very important to look at the real consequences of untreated perinatal mood and anxiety disorders. Does that make sense?

  4. February 18th, 2011 at 15:52 | #4

    Dear Katherine,
    Yes…makes total sense and I agree. These are complex issues that don’t have one answer. And when I started writing this piece, I wanted to share the significance of the effects of untreated ppmad on children as cited in this working paper–basic give the statistics and hope someone listens. But as I worked my way through it, I realized the issue was holoarchic, not hierarchic. You hit it exactly. It is about both. The effects are devastating. The language we still use to discuss it, is extremely limited, and when used by establishment, potentially punitive.

    I love your comment, and discussion. It leads to my wondering about the efficacy of quantitative research methodologies to provide the answers we so desperately need for childbearing women. My examination of the language leans in the qualitative direction.

    I truly believe the stigma is socially rooted in the limitations of quantitative language, and on some level is a mechanism of patriarchy. We need the information, they need our experiences.

  5. February 21st, 2011 at 19:01 | #5

    I don’t quite understand Katherine’s disagreement. To me, it is exactly because it is so important that peripartum mental illness be treated promptly, that we need to consider all the factors that currently lead to so much of it being untreated. Depression and anxiety often lead to guilt and self-blame which put up huge barriers to seeking help, and it’s vitally important that there’s no external reinforcement of that guilt and self-blame, particularly not from care providers. That means having to pay a lot of attention to the language you use.

  6. February 21st, 2011 at 23:10 | #6

    Dear Ingrid,
    Thank you for being the only other person to read my article! I truly appreciate it. And, I am happy for any discussion regarding this issue. Language is so very important, particularly for childbearing women. I so often see us have to adopt “science-speak” just to gain a seat at the table to talk about our lives, experiences, and reproduction.

    I suppose I will remain a steadfast qualitative kind of gal, and I appreciate your comments and appreciation for the “external reinforcement” that stigmatizing language permits.

    Thank you!

  7. February 22nd, 2011 at 21:06 | #7

    I doubt I’m the only other person to have read your article – I read most posts but rarely comment, and imagine many other readers who rarely comment. I’m in an awkward position in that I’m a scientist (evolutionary genetics) who’s pregnant and I’ve now done a lot of reading and while I’m pretty sure I know more about pregnancy than most women, I’m not confident that I know enough to be participating in a place like this, alongside professionals.

    But I’m not afraid of getting my hands dirty with “science-speak” when needed and maybe that’s a way I can contribute? I have quite a lot of experience analysing “science-speak” that doesn’t actually mean anything, and I know (you mentioned patriarchy first!) how it’s often used to bully and intimidate those “less scientific”, but once analysed by another scientist, it’s laughable.

  8. February 22nd, 2011 at 22:34 | #8

    Hi Ingrid,
    Thanks again. And I am fascinated by epigenetics. Do you work in that area? I would love to pick your brain. Please feel free to email me: walkerkarraa@yahoo.com

  9. September 17th, 2012 at 09:33 | #9

    I do believe there is a way to express concern and awareness without causing undue distress on a new mother. Very well written, Walker/Batgirl. : )

  1. February 17th, 2011 at 08:57 | #1
  2. February 17th, 2011 at 20:45 | #2
  3. July 3rd, 2013 at 09:15 | #3