6200WK2 DISCUUSIN1

  

Each day in the United States, 80 newborns are diagnosed with neonatal abstinence syndrome, in which they experience withdrawal from a drug they have been exposed to in the womb (Centers for Disease Control and Prevention, 2020). Researchers know now that parental smoking, drinking, and drug use put a fetus at increased risk for disabilities and health disorders. However, adults who are addicted to these substances may not have the capacity to quit and/or may not be fully educated in the risks.

Each day in the United States, 80 newborns are diagnosed with neonatal abstinence syndrome, in which they experience withdrawal from a drug they have been exposed to in the womb (Centers for Disease Control and Prevention, 2020). Researchers know now that parental smoking, drinking, and drug use put a fetus at increased risk for disabilities and health disorders. However, adults who are addicted to these substances may not have the capacity to quit and/or may not be fully educated in the risks.

As a social worker, you will meet families in complicated situations that may require a variety of resources for support. These situations can involve parental drug use and the short- and long-term effects on children and the family. In this Discussion, you learn about one such family.

Reference: 
Centers for Disease Control and Prevention. (2020, August 13). 
Data and statistics about opioid use during pregnancy. https://www.cdc.gov/pregnancy/opioids/data.html

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE:

· Review this week’s Learning Resources on biological development and development theories.

· View the video case introducing new parents Jim and Sarah in the Learning Resources.

BY DAY 3

Post your initial response to the video case:

· Identify 1–2 developmental challenges that baby Jane may exhibit as a result of parental substance abuse. Explain how these challenges may impact typical developmental milestones. 

· Describe how the dimensions of the person-in-environment perspective can be applied in this case.

· Identify two practice skills that you as the social worker could employ in working with the parents.

BY DAY 5

Respond to 
two colleagues by describing the following:

· A strategy your colleague could use to assist Jim and Sarah with an identified developmental challenge 

· A support resource available to parents to address a developmental challenge your colleague has identified

REFERENCES

Required Readings

· Zastrow, C. H., Kirst-Ashman, K. K., & Hessenauer, S. L. (2019). 
Understanding human behavior and the social environment (11th ed.). Cengage Learning.

· Chapter 2, “Biological Development in Infancy and Childhood” (pp. 45–94)

· Cohen, A., & Mosek, A. (2019). 

“Power together”: Professionals and parents of children with disabilities creating productive partnershipsLinks to an external site.

. 
Child & Family Social Work, 
24(4), 565–573. https://doi.org /10.1111/cfs.12637

· O’Sullivan, A., & Monk, C. (2020). 

Maternal and environmental influences on perinatal and infant developmentLinks to an external site.

. 
The Future of Children: Three Trimesters to Three Years: Promoting Early Development, 
30(2), 11–34.

Required Media

· Tsiaris, A. (2010). 

Conception to birth–visualizedLinks to an external site.

 [Video]. TED. https://www.ted.com/talks/alexander_tsiaras_conception_to_birth_visualized

Note: The approximate length of this media piece is 9 minutes.

· Walden University, LLC. (2021). 
Meet Ray [Video]. Walden University Blackboard. https://waldenu.instructure.com

Time Estimate: 1 minute

OR I G I N A L A R T I C L E

“Power together”: Professionals and parents of children with
disabilities creating productive partnerships

Ayala Cohen | Atalia Mosek

Department of Social Work, Tel Hai College,

Tel Hai, Israel

Correspondence

Atalia Mosek, Department of Social Work, Tel

Hai College, Tel Hai 12008, Israel.

Email: ataliamosek@gmail.com

Abstract

Disparity of power and authority in the relationship between parents and profes-

sionals has been shown to be a major challenge in creating a successful partnership

in caring for children with disability. The goal of this article was to evaluate workshops

attended by professionals and parents of children with disability by raising awareness

to barriers related to incompatible expectations and role definitions. The research

explored the experiences of the participants in order to identify factors that facilitated

or impeded their collaborations. Data were collected from three workshops attended

by 22 mothers of children with disability and 24 professionals (most of them are social

workers). This qualitative research used interpretative phenomenological analysis to

investigate the participants’ experiences. Findings showed that parents and profes-

sionals joined forces to create a productive working relationship by taking advantage

of power over and power together relationships. This mutual process required

participants to be aware, empathic, and respectful of one another’s needs and

limitations; acknowledge the contribution of experiential and professional knowledge;

and co‐operate in overcoming the effects of ineffective bureaucratic service systems.

Interventions geared to contain emotional burden, acknowledge differential

knowledge and experience, and structure the use of power are suggested.

KEYWORDS

parents of children with disability, partnerships between parents and professionals, power

embedded strategies: power over, oppression, co‐operation, and collusive power, professionals

working with parents of children with disability

1 | INTRODUCTION

Power and authority disparities in the relationship between parents

and professionals have been shown to be a major challenge in creat-

ing successful lay–professional partnerships in caring for children

with disability. Such partnerships are jeopardized by failure to estab-

lish a collaborative, trusting, empowering relationship that supports

effective service delivery (Blue‐Banning, Summers, Frankland, Nel-

son, & Beegle, 2004). This article examines three workshops

attended by professionals and parents of children with disability in

order to understand the disparity of power as a contributing factor

to successful relations.

1.1 | Parents–professional partnerships

Partnership is an agreement between equivalent but not necessarily

equal partners who share an understanding about caring and working

towards mutual goals (Rommetveit, 2011), and although the term

connotes shared responsibility, this is not always the case regarding

relations between professionals and parents of children with disability

(Vincent, 2000). A partnership between parents and professionals was

defined by Summers Hoffman, Marquis, Turnbull, Poston, and Nelson

(2005, p. 3) as “mutually supportive interactions … focused on meeting

the needs of children and families, and characterized by a sense of

competence, commitment, equality, positive communication, respect,

DOI: 10.1111/cfs.12637

Child & Family Social Work. 2019; :565–573. © 2019 John Wiley & Sons Ltdwileyonlinelibrary.com/journal/cfs 56524

https://orcid.org/0000-0002-3630-575X

https://orcid.org/0000-0003-3033-1903

mailto:ataliamosek@gmail.com

https://doi.org/10.1111/cfs.12637

http://wileyonlinelibrary.com/journal/cfs

and trust.” This relationship should be characterized by mutual respect

and trust, shared information and decision‐making, and intervention

processes that incorporate family beliefs, needs, and preferences

(Mihee & Palisano, 2014). The following sections describe parents’

and professionals’ expectations regarding their working relationships

and barriers to creating successful partnerships.

1.1.1 | Parents’ perspective

Parents have identified “trust” as one of the most important factors in

a partnership with professionals (Turnbull, Turnbull, Erwin, & Soodak,

2006). They also value communication, professional competence,

respect, commitment, equality, and advocacy (Hess, Molina, &

Kozleski, 2006). In addition, they expect professionals to acknowledge

their own knowledge of their family by actively seeking their input on

their situation and preferred solutions (Fereday, Oster, & Darbyshire,

2010). When these factors are absent, parents, who are inevitably

dependent on professionals as gatekeepers of the service systems

(Tétreault et al., 2013; Wilkins, 2015), cope with humiliating and disre-

spectful regulations or deal with breakdown in their relationships with

professionals (Blue‐Banning et al., 2004).

1.1.2 | Professionals’ perspective

A review of the literature showed that professionals approached their

working relationship with parents with responsibility and care. How-

ever, most do not view parents as equal partners and expect to control

the relationship (Blue‐Banning, Turnbull, & Pereira, 2000). They feel

that parents should be involved in planning for their child’s care, but

only to a certain degree. In conflict situations, they tend to blame par-

ents for being unco‐operative rather than assess their own practice

(Bezdek, Summers, & Turnbull, 2010). They also expect the parents,

not themselves, to take responsibility for securing the services their

children require. However, when parents use adversarial strategies

to this end, they are reluctant to assist them in addressing inadequa-

cies in the services (Clear, 1999).

1.2 | Factors in successful partnerships

Both professionals and parents stress the importance of communica-

tion, commitment, skills, respect, and trust as foundations for success-

ful partnerships and invest in flexible relations that contextualize,

individualize, and are responsive to family concerns (Gallagher, Smith,

Hardy, & Wilkinson, 2012). A trusting relationship is likely to develop

through warmth, friendliness, and humour and by conveying

compassion, empathy, and respect (Rommetveit, 2011). Professionals

who work with culturally and linguistically diverse families need to

be cross culturally competent and value the uniqueness of each family

(Kalyanpur, Harry, & Skrtic, 2000).

1.3 | Barriers to successful partnerships

Disparity between power and authority is a major obstacle to develop-

ing successful partnerships (Davis, Ravenscroft, & Bizas, 2015). Power

differentials relate to the different hierarchic power positions profes-

sionals and parents occupy in relation to the child. Professionals, as

experts, are considered powerful, whereas parents, as caretakers,

often feel powerless (Vincent, 2000). Consequently, both sides experi-

ence emotional stress. Together with the stress created by their child’s

disability, some parents develop defensive attitudes towards profes-

sionals, which the latter, in turn, assess as “pushy” and resisting assis-

tance instead of as need for support (Fereday et al., 2010). These

mindsets are exacerbated by confusion in and delayed access to

needed services (Green, 2007). To be able to support parents, profes-

sionals need to evaluate their own feelings towards raising a child with

disability and work through them (Choi, Lee, & Yoo, 2011).

Barriers to productive working relationships also often trace to

overly bureaucratic practice cultures, which are irreconcilable with

the service users’ needs (Gallagher et al., 2012). Likewise, profes-

sionals are hindered by barriers such as unclear service goals,

insufficient time, excessive workload, and lack of administrative

support (Bronstein, 2003).

1.4 | Disparity between power and authority

Both service users and professionals in their everyday interactions

experience sensations of power and powerlessness (Proctor, 2002).

Relationships underpinned by inequality and objectivity tend to com-

modify caring and thereby highlight power differentials (Clear, 1999).

Recognizing these inherent power imbalances in the relationship is

considered a major factor in developing a positive partnership

(Wilkins, 2015). Guilfoyle (2011, p. 14) warns against failing to make

the power dynamics visible in practice: “If we believe … that we are

at all times inescapably immersed in power relations and dynamics …

how we can facilitate clients’ participation as social beings within

social power relations?”

Parent–professional relations are governed by knowledge and

power. Foucault (2000, p. 341) defined power as “an act upon another

person and as a type of relationship between individuals.” Using this

definition, researchers understand how power dynamics shape how

practitioners convey, seek, and use knowledge (Heizmann & Olsson,

2015). Following Foucault’s (1981, p. 165) view of power as “a social

relation that may open up or close off opportunities for individuals

or social groups,” Tew (2006) conceptualized its operation as a

dualistic process—oppressive or limiting in some respects and

productive or protective in others—and so proposed a matrix of power

relations designed to distinguish between different modes of its

operation (Table 1).

As shown inTable 1, both vertical operations of “power over” and

“power together” combine with “productive” or “limiting” horizontal

operations. Protective power, the productive mode of power over,

deploys power to safeguard vulnerable people and their potential for

COHEN AND MOSEK566

advancement, whereas co‐operative power, the productive mode of

power together, shares mutual support and challenges by valuing com-

monality and difference. In contrast, oppressive power and collusive

power are the limiting modes of power. The former exploits differences

to enhance one’s own position and resources at the expense of others,

whereas the latter bands to exclude or suppress “otherness” either from

within or from without. In this research, Tew’s (2006) typology was

used to deconstruct the power relations that played out between

parents of children with disability and professionals during three work-

shops, which enabled us better to understand the facilitative factors

and barriers to successful partnership between the two groups.

1.5 | The workshops

The workshops were part of Shemesh (“Sun” in Hebrew), a programme

initiated in 2012 by two mothers of children with disability, that

focuses on empowering the parents and the family unit. The pro-

gramme was developed and funded by governmental and philan-

thropic organizations and a private donor. The authors of this article

were involved in a 3‐year evaluation of the programme.

The goal of the workshops was to improve the working relations

between professionals and parents. The process began by allowing

participants to become acquainted with one another and identify their

assumptions, attitudes, and expectations. This, in turn, enabled partic-

ipants to identify the conditions needed to create understanding,

empathy, and trust as a foundation for effective communication and

developing fruitful relations. The process was conducted in two

stages. The preparation stage composed of three separate meetings

of parents and professionals, enabling the participants of each group

to ventilate, share personal experiences, and clarify attitudes and feel-

ings towards members of the other group. These separate group

meetings were followed by three joint meetings that focused on shar-

ing experiences, identifying parallel processes and communication bar-

riers, and proposing tools for improved relationships. All the

workshops were moderated by veteran social workers experienced

in working with families of children with disability. The research

explored the experiences of the participants in these processes in

order to understand how they affected their ability to work together

and to identify factors that facilitated or impeded their collaboration.

1.6 | Research question

How did discourses expressed by professionals and parents of chil-

dren with disability during the workshops demonstrate the use of pro-

tective, oppressive, co‐operative, and collusive power as facilitating or

impeding factors in creating successful relationships?

2 | METHOD

2.1 | Research design

The research used interpretative phenomenological analysis (IPA),

which enables investigation of significant experiences in participants’

lives (Smith, 2004). IPA is affiliated with phenomenological epistemol-

ogy (Smith, Flowers, & Larkin, 2009) and a constructionist framework

(Watkin, 2011). It seeks to explore the participants’ world view and to

adopt, as far as possible, an “insider’s perspective” while recognizing

the researcher’s own conceptions in making sense of “that other per-

sonal world” (Brocki & Wearden, 2006). IPA is extensively used in

child and family health research due to its strength in exploring and

interpreting the ways people articulate and understand their experi-

ences (Biggerstaff & Thompson, 2008).

2.2 | Participants

The workshops were held in three cities in southern Israel. An email

invitation was sent to all parents of children with disability on

Shemesh’s email list, followed by personal invitations from the site’s

coordinator to parents who took part in the organization’s Parent to

Parent programme (107 parents) or Parent Leadership Group (56 par-

ents). Twenty‐two parents (7.4% of those personally invited) partici-

pated in the workshops, with an average of 15 per workshop. Twenty

were mothers and two were fathers. Their ages ranged from 33 to

57 years, with an average of 46.4 years. Their formal education level

ranged from high school to postdoctoral studies, with an average of

14.9 years. Most were middle class, half employed part time, and a third

full time. The age of their children with disability ranged from 3 to

20 years, whose impairments included mild to severe levels of hearing

deficiency, mental retardation, autism, cerebral palsy, pervasive devel-

opmental disorder, and Down syndrome. All the parents were familiar

with local organizations and services that could help their children.

Recruiting professionals for the workshops was done by sending

invitations to all social welfare, education, and health service profes-

sionals who worked with parents and children with disability at the

three sites. This was followed by a phone call from the site’s coordina-

tor, usually based on previous acquaintance, encouraging them to join.

Twenty‐four professionals accepted (23 women and one man), most

of whom were social workers (17). The others were two educational

representatives, three health care personnel, and two members of

non‐governmental organizations. The parents and professionals had

no prior acquaintance with each other, and both noted the limited

number of men, physicians, and psychiatrists among them. Workshop

attendance averaged 82%. One parent and three professionals did not

continue to the second stage.

2.3 | Research procedure and instruments

Ethical approval for the research was granted by the Ethical Commit-

tee of the authors’ college, and the participants were informed that

TABLE 1 Matrix of power relations

Power over Power together

Productive modes of power Protective power Co‐operative power

Limiting modes of power Oppressive power Collusive power

COHEN AND MOSEK 567

the proceedings would be documented and the results published. Pro-

tection of privacy and confidentiality was assured, and all participants

provided signed informed consent forms. Shemesh site coordinators

attended all the workshops as nonparticipant observers responsible

for documenting the proceedings in light of the participants’ discom-

fort in using an audio recorder. Documentation included all verbal

communications and non‐verbal cues during the sessions. To

overcome the risk of the data collectors’ inadvertently interpreting

meanings rather than solely capturing them, this material was

complemented by phone interviews by the researchers with the work-

shop moderators, by the latter’s reflective notes, and by follow‐up

phone interviews with available parents and professionals who

attended the workshops. For presentation in this article, quotes from

these sources were translated from Hebrew to English by a native

English speaker, and an English editor then verified their authentica-

tion by performing a reverse translation.

2.4 | Data analysis

IPA was begun by reading and rereading the documented material by

both researchers and noting initial ideas, reactions, meaning, and pat-

terns. Each researcher used a systematically inductive approach to

choose the participants’ quotes that, in her opinion, represented the

major topics raised in light of how professionals and parents of chil-

dren with disability convey feelings, thoughts, and behaviours regard-

ing their working relationship during the workshops. We then

contrasted similarities and disparities and, in the next stage, reviewed

and compared our analyses of the data, clarified our interpretations,

and discussed discrepancies. In cases where agreement was not

reached, the data were not included in the identified themes. When

discussing the significance of our interpretive analysis, we focused

on answering questions identified by Braun & Clarke (2006, p. 94):

“What do these themes mean? What assumptions underpin them?

What are the implications of these themes? Why do people talk about

these things in this particular way (as opposed to other ways)? What is

the overall story that different themes reveal about the topic?” While

searching for answers to these questions, our reflections made us real-

ize that our understanding of the workshops was not detached from

our professional perceptions of social justice and evaluation of the

programme. We found that we were unable to separate our own con-

cerns regarding the impact of power relations on the parents’ and pro-

fessionals’ relationships. To assist us, we undertook a literature review

in search of a theoretical paradigm that could help us describe the

relationship and chose Tew’s (2006) matrix of power, previously

described in Table 1, as the theoretical framework for interpreting

our research question.

3 | FINDINGS

The following findings are presented under the four modes of power

identified by Tew (2006). Power over includes protective and oppres-

sive power. Protective power is the productive form of power over

that signifies deploying power in order to safeguard vulnerable people

and advance their possibilities for advancement. Oppressive power is

a limiting form of power over that utilizes differences to enhance one’s

own position and resources at the expense of others. Power together

includes co‐operative and collective power. Co‐operative power is a

productive form of power together that signifies sharing mutual sup-

port and meeting challenges by valuing commonality and differences.

Collusive power is the limiting form of power together that involves

banding together to exclude or suppress internal or external

otherness.

3.1 | Protective power

Professionals were aware of their power to protect parents. This

includes protection from “the truth” regarding their child’s prognosis:

“Parents ask to hear the truth. However, it is also important for the

truth to be presented in a way that will keep them safe.” Professionals

were aware that protective relations required from their self‐analysis

and reflection: “Very often, we come to a meeting with parents with

preconceptions. Therefore, I prepare myself for our meetings, as if I

know nothing and everything.” Another professional, aware of her

tendency to be practical, said that she prepares herself to be commu-

nicative with parents: “I have a tendency to offer solutions. I have

learned from my experience that you need to get to know a parent

first. This changes the conversation.”

In contrast, the perceived guardian role could serve to reinforce

professionals’ negative assessment of the parents’ capabilities: “Some

of the parents are not aware of their child’s needs. We see their inabil-

ity to make well considered decisions.” The professionals highlighted

their belief of the parents’ responsibilities to protect their children:

“Parents can also do something. They need to display their power,

and if they do not have power then they can bring someone along

with them,” or at least accept professional advice: “The mother is

not listening to our recommendations.” The failure to meet expecta-

tions for protection and deployment of power intensified the frustra-

tion, anxiety, and helplessness of both parties.

3.2 | Oppressive power

Parents complained that when professionals shared their knowledge,

they often did so condescendingly, using professional terminology

and “labelling,” which was perceived as alienating: “I didn’t understand

her terminology; it made me feel that she was trying to hide some-

thing.” They often felt insulted: “(Professionals) tend to label the child,

put a stamp on him. They say all autistic children are similar but all of

our fingers aren’t the same.” They also felt oppressed: “The profes-

sionals often label certain parents as “troublemakers,” a label which

is very hard to remove.”

Knowledge and experience are valuable assets in raising a child

with disability. This knowledge, however, was not appreciated: “When

I listen to you (a professional) I expect you to also listen to me.” The

preferential status accorded to professional knowledge was difficult

COHEN AND MOSEK568

to accept: “It’s hard for us (parents) that others determine what is good

for our child; I feel they (professionals) are against me.” In contrast,

professionals felt that “parents talk endlessly about their own

knowledge to belittle me.”

Parents expressed feelings of shame, guilt, and helplessness when

attempting to secure resources for their children. They clearly alluded

to the stigma attached to dependence on the services: “I was ashamed

to go to the welfare office. I don’t need money; I only wanted to know

where I can take my child for treatment.” They felt professionals were

not accessible: “When I was in crisis, my social worker didn’t have time

to listen to me.” Parents who sought to rely on professional

knowledge were sometimes disappointed: “I received only crumbs

from them, nothing new; there is no sharing on their part.” They also

expend a lot of energy in confronting the authorities. As one mother

said: “From the moment my daughter was born, I have been constantly

fighting with the medical and welfare services. Nobody informs me

of my rights.” Parents felt oppressed due to their unavoidable

dependency on professionals in caring for their child.

3.3 | Co‐operative power

As the participants moved from separate to joint groups, parents and

professionals focused on their shared experiences. Professionals

expressed their identification with the parents: “When I meet parents

in a difficult situation, it is very hard for me. I feel similar experiences

of helplessness, pain, grief and the inability to see a way out of the sit-

uation. I am overwhelmed.” Parents expressed their sensitivity to

professionals’ impatience: “There are professionals who say they do

not want to hear any more, they have troubles of their own.” They

noted that professionals were “afraid to smile” and interpreted this:

“as some of (them) are helpless.” They realize the difference between

their situation: “a parent with a child with disability is thrown into this

difficult situation: he didn’t really choose it, but professionals chose

their occupation.”

Professionals recognized the unique contributions in skills and

insights they bring to the co‐operative partnership: “A good relation-

ship with parents demands empathy and understanding, as well as

assisting them in their struggle to do what’s best for the child. Some-

times this means helping them distinguish between their own and

their child’s needs.” Parents, for their part, contribute experiential

knowledge. In the words of a professional: “Parents can bring what

they know about their child. That is their strength. If the professional

allows parents to do so, and if the parents are aware of what they

know, our power will be balanced and they will be prepared for

cooperative work.”

Professionals stated that addressing conflicts proved helpful: “We

talked about areas of conflict as an integral part of the dialogue. In

such situations you need to listen to others.” “Conflicts and different

opinions can raise different points of view that are valuable and

worthy of consideration.” Parents were also aware that they need to

modify their behaviour to foster co‐operation: “We need to act

according to the situation ‐ assertively but not aggressively.” “In a

war, there are always injuries and causalities. If I choose to cooperate,

I may find the acceptance and understanding that I need.” Profes-

sionals recognized that “parental involvement is the key. Professionals

need to return control to the parents.”

Parents and professionals also shared similar emotions: “We work

together in a painful area; there is the parent’s pain and also the pro-

fessional’s pain.” Professionals acknowledged that “parents raising a

child with disability have suffered an injury to their self‐esteem, and

experience fear, helplessness, anger, confusion.” Likewise, parents

empathized with the frustrations experienced by professionals:

“Professionals feel incompetent when they cannot meet the parents’

needs and offer a proper response to their expectations.” In fact,

“we and the professionals are in the same boat.” In order to create

their power together, professionals and parents need to acknowledge

and value the similarities and differences between them.

3.4 | Collusive power

In order to enhance their resilience, parents and professionals joined

forces for the good of the child. One parent commented: “We need

to bring our strength together, not to block it; every situation has a

solution.” Likewise, a professional stated that “We have mutual

interests in many respects. If we work together, with mutual

appreciation and respect, we can do a lot to benefit both families

and children.”

Parents wanted professionals to join them in educating and

changing public attitudes: “We need to think about ways of changing

social perceptions regarding people with disability. How are we

perceived by the public? How do normative families view our special

family? We need to work together to make them understand.” In the

words of another parent: “We believe that a partnership with

professionals will reinforce our power as parents. Once we establish

a mutual dialogue that brings us closer together, we can use our com-

bined power to act together.”

Both parents and professionals desired a productive relationship

with emotional bonds. “I expect a professional to be more pleasant,

to connect to the family,” one parent said. Professionals shared this

aspiration: “At the end of the day, it’s a meeting between people. It’s

not a question of titles, abilities or difficulties. I mainly see the

person opposite me.” Another professional talked about the value

of engagement: “I am always excited to see the parents. I want

to hear and feel them, and then I express myself. For me it is a

learning process.”

Parents shared the significance of joining forces with the profes-

sional: “My doctor from the developmental clinic is walking with us

… we are climbing the stairs together, hand in hand … there is a

wonderful sense of cooperation between us.” Another parent said:

“Our physiotherapist went against all conventional practices; she

fought for our child to remove all obstacles to his development, and

we developed a communicative and mutual world view.” When

parents are supported to reach a common goal, they feel they can

achieve the unexpected.

COHEN AND MOSEK 569

Parents and professionals worked together against the “system,”

which both perceived as inadequate. In the words of one parent: “Pro-

fessionals and parents alike are not empowered to make decisions and

implement them without the system’s consent.” Professionals, too, felt

confined by the system: “Every professional is sensitive, but his/her

hands are tied,” and “professionals have an inner drive to help, but

are trapped by the structural systems.” Parents expect the

professionals “to move quickly, but professionals are not prepared to

take risks that will not be approved by the system.” However, both

parents and professionals claimed to be trapped in an oppressive

system. It seems their abilities to escape are by uniting their strength

in creating collusive power.

4 | DISCUSSION

Workshops attended by professionals and parents of children with

disability provided the context for this research, which sought to iden-

tify and understand the elements that can support or obstruct their

partnerships. The findings show that the participants used all four

forms of power identified by Tew (2006) to negotiate their relation-

ships, albeit to a different degree and for diverse purposes.

Power over was exercised to meet the need of parents for

emotional support and protection. Parents expected professionals

to offer them emotional support and deploy their power to protect

them and their children. Professionals were aware that

protective relations require self‐analysis and reflection, because their

perceived guardian role could serve to reinforce professionals’

negative assessment of the parents’ capabilities. The failure to meet

expectations of protection and deployment of power intensified

the frustration, anxiety, and helplessness felt by both parents

and professionals.

Oppressive power was exercised by using knowledge. Parents

staked a claim to their knowledge gained in raising a child with disabil-

ity and expected professionals to value it. They expected professionals

to share their knowledge with them but felt condescended by profes-

sionals’ use of terminology and labelling. Professionals, for their part,

felt unappreciated and disrespected. Parents expressed feelings of

shame, guilt, and helplessness when attempting to secure needed

but inaccessible resources for their children.

Co‐operative power was noted as the preferred type of relation-

ship. Both groups sought a pleasant, genuine personal relationship

that would allow them to share the pain and emotional burden in rais-

ing a child with disability. At times, both felt helpless in dealing with

vulnerabilities: parents due to their unfulfilled aspirations and profes-

sionals due to their sense of incompetence. However, some parents

and professionals were able to recognize the unique contribution each

could make towards productive relationships.

Collusive power was relevant for parents and professionals who

felt trapped in an oppressive system. They shared mutual interest in

enhancing their resilience and achieving as much as possible for the

children. Parents wanted professionals to join them in educating and

changing public attitudes and to work together against the “system,”

which both perceived as inadequate.

During the workshops, we discerned changes in the purpose,

intensity, and prevalence in the use of different kinds of power. In

the preparation stage, the main goal was to enable each group to

create its own sense of togetherness by ventilating and levelling

complaints, mostly at members of the other group. Sharing collusive

power practices within each group enabled expressions and

legitimized feelings of anger, anxiety, and blame. The work

performed in the separate groups contributed to each group’s ability

to identify its power and alleviate anxiety over interacting with

members of the other group (Page‐Gould, Mendoza‐Denton, &

Tropp, 2008). These feelings were found to be more profound

within parent groups who experience professionals’ use of power

(Cross & Friesen, 2013).

In the second stage of the workshop, parents and professionals

worked together to overcome negative prejudice feelings for each

other in order to reach their common goals. These encounters

enhanced knowledge about each other, reduced anxiety, and

increased empathy and the ability for perspective taking (Pettigrew

& Tropp, 2008). When parents and professionals worked together

in the same group, they shared their experiences in dealing with

the service systems. These conversations focused on expectations

and experiences of co‐operation and explored the changes required

on both sides to achieve sustainable collaboration. The positive

experience of members of both groups contributed to an ability to

work together.

The progress achieved by the workshops may be conceived as a

shift from reality to fantasy. Parents and professionals joined the

workshops in the hope of ameliorating their tense relationships.

The former felt that professionals focused on their children and did

not appreciate them as parents; they felt chided and excluded from

making decisions regarding their children. Initially, they expressed

their anger and frustration towards professionals, unaware that the

latter were themselves caught between a rock and a hard place

due to limited resources and other service constraints. Both sides

needed to clarify issues such as: Who is the client—the child, the

parents, or the family? Why are parents and professionals so critical

of each other? Where does this mutual resistance stem from? Some

of the answers to these questions lie in both sides’ codependence

that limits their ability to differentiate their respective roles. In such

relationships, when one partner is weak, the other becomes stron-

ger. The ambivalence imbedded in codependence renders self‐

differentiation difficult and productive co‐operation impossible

(Daire, Jacobson, & Carlson, 2012). However, on moving from the

separate to the joint groups, both sides became aware that they

were, in fact, undergoing similar experiences: Both sought encoun-

ters based on empathy and appreciation in a safe environment.

The yearning for an ideal relationship, built on productive, protec-

tive, and co‐operative power relations, supported this vision. To

come to terms with reality, the discriminating use of all four types

of power relations is essential. Professionals and parents play differ-

ent roles in the life of a child with disability. Professionals act as the

COHEN AND MOSEK570

“responsible adult” in crisis situations, when action guided by profes-

sional knowledge is called for to protect the parent and the child.

However, because the relationship is a life‐long journey, both sides

need to invest in building a realistic partnership. Consequently, an

extensive period of work is required to bring about change in cur-

rent parent and professional attitudes and practices.

5 | RESEARCH LIMITATIONS

Rigour in qualitative data is supported by the degree to which the

data are credible, dependable, confirmable, and transferable (Tobin

& Begley, 2004). Triangulation of the three sources of data—written

documentation of the proceedings, phone interviews with the

moderators and their reflection logs, and interviews with available

participants of the workshops—strengthened its credibility. However,

the small sample and over representation of socially active parents

and social workers among the professionals limit the findings’

generalization.

The parent–professional relations described in this article were

embedded in the cultural, political, and service ideologies and policies

specific to Israel. The State of Israel is characterized by a multicultural

population, in which professionals usually represent the dominant cul-

ture (Freeman & Couchonnal, 2006) and families of children with

disability are evenly distributed in the population. Sensitivity to

these power relations was recently recognized by the Ministry of

Welfare that is leading a reform expected to reduce professional

power by promoting partnerships with service users (Schmid &

Morley‐Sagiv, 2018). This research should be considered an explor-

atory case study of a contextualized event that calls for caution when

making generalizations.

6 | PRACTICAL IMPLICATIONS

Three main domains were found to require clarification to create suc-

cessful parent–professional partnerships: containing emotional burdens,

acknowledging differential knowledge and experience, and defining and

structuring the use of power. Caring for a child with disability entails frus-

tration, disappointment, and feelings of helplessness as well as pride

and joy. Indeed, emotional burden is also felt by professionals, who

identify with the arbitrary universal destiny of caring for children with

disability (Choi et al., 2011). However, contrary to researchers’ interac-

tions with parents (Heiman, 2002), professionals tend to emphasize the

objective burden placed on parents and pay far less attention to the

parents’ own emotional burdens (Green, 2007). Yet parents’ emotional

stress should be acknowledged and contained by professionals. They

should also be aware of warning signs regarding their own emotional

burnout. Given the sensitivities of both parties that were found in this

research, replication of the workshops should be considered a routine

service provided for these populations.

Raising a child with disability requires both expert and experiential

knowledge and practice. Parents expect professionals to acknowledge

their experiential knowledge and to share their knowledge with them.

To achieve this goal, attention should be paid to parents’ concerns

regarding the professionals’ limited acquaintance with evidence‐based

practice (McGill, Papachristoforou, & Cooper, 2006) and their unfamil-

iarity with contextually appropriate practices.

Conclusions derived from a political perspective on participatory

discourse (Hickey & Mohan, 2004), which acknowledges the effects

of different kinds of power and their implications, have important

implications for the training and preparation of professionals working

with families of children with disability. The first step in building suc-

cessful partnerships involves paying respect, overcoming distrust,

and creating personal relations marked by concern and empathy

(Blue‐Banning et al., 2000). During this process, all participants

should be invited to reflect on any issues that surface and helped

to identify structural barriers that should be overcome. The neces-

sary changes in attitude and practice should be incorporated in train-

ing programmes in all service systems and made known to all

relevant stakeholders: practitioners, researchers, and policy‐makers

(Bruder, 2000).

The workshops provided an opportunity for professionals to share

with clients, organizational barriers created by overly bureaucratic and

managerial practice cultures, which often impinges on their ability to

provide the kind of service they would like to offer (Gallagher et al.,

2012). Professionals feel their ability to create successful partnerships

is jeopardized by structural factors related to unclear service goals,

insufficient time, excessive workload, scarce resources, and lack of

administrative support (Bronstein, 2003). Lessons can be learned from

innovative policy directives in England, which introduced self‐directed

support options that allow parents to design their care package and

sources of support (Hatton, 2013).

We believe that a productive partnership of professionals and

parents of children with disability should be grounded in the mutual

commitment of professionals, parents, and policy‐makers working

together to create productive power relations. Such an approach high-

lights potential benefit to understanding how professionals might use

their position better to support parents as informal caregivers and

how they can work co‐operatively to advance a stronger sense of coa-

lition. Parent–professional workshops can be a significant turning

point in this direction.

ORCID

Ayala Cohen https://orcid.org/0000-0002-3630-575X

Atalia Mosek https://orcid.org/0000-0003-3033-1903

REFERENCES

Bezdek, J., Summers, J. A., & Turnbull, A. (2010). Professionals’ attitudes on

parenting with families of children and youth with disabilities. Educa-

tion and Training in Autism and Development Disabilities, 45(3),

356–365. https://www.jstor.org/stable/23880110

Biggerstaff, D., & Thompson, A. R. (2008). Interpretative phenomenological

analysis (IPA): A qualitative methodology of choice in healthcare

research. Qualitative Research in Psychology, 5, 214–224. https://doi.
org/10.1080/14780880802314304

Blue‐Banning, M. J., Summers, J. A., Frankland, H. C., Nelson, L. L., &

Beegle, G. (2004). Dimensions of family and professional partnerships:

COHEN AND MOSEK 571

https://orcid.org/0000-0002-3630-575X

https://orcid.org/0000-0003-3033-1903

https://www.jstor.org/stable/23880110

https://doi.org/10.1080/14780880802314304

https://doi.org/10.1080/14780880802314304

Constructive guidelines for collaboration. Exceptional Children, 70(2),

167–189. https://doi.org/10.1177/001440290407000203

Blue‐Banning, M. J., Turnbull, A. P., & Pereira, L. (2000). Group action plan-

ning as a support strategy for Hispanic families: Parent and professional

perspectives. Mental Retardation, 38(3), 262–275. https://doi.org/

10.1352/0047‐6765(2000)038<0262:GAPAAS>2.0.CO;2

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qual-

itative Research in Psychology, 3, 77–101. https://doi.org/10.1191/

1478088706qp063oa

Brocki, J. M., & Wearden, A. J. (2006). A critical evaluation of the use of

interpretative phenomenological analysis (IPA) in health psychology.

Psychology & Health, 21(1), 87–108. https://doi.org/10.1080/

14768320500230185

Bronstein, L. R. (2003). A model for interdisciplinary collaboration. Social

Work, 48(3), 297–306. https://doi.org/10.1093/sw/48.3.297

Bruder, M. B. (2000). Family‐centered early intervention: Clarifying our

values for the new millennium. Topics in Early Childhood Special Educa-

tion, 20, 105–115. https://doi.org/10.1177/027112140002000206

Choi, E. K., Lee, Y. J., & Yoo, L. Y. (2011). Factors associated with emotional

response of parents at the time of diagnosis of Down syndrome. Jour-

nal for Specialists in Pediatric Nursing, 16, 113–120. https://doi.org/
10.1111/j.1744‐6155.2011.00276.x

Clear, M. (1999). Caring culture and the politics of parent/professional

relations. Australian Journal of Social Issues, 34(2), 119–136. https://
doi.org/10.1002/j.1839‐4655.1999.tb01073.x

Cross, T., & Friesen, B. (2013). Developing cultural competence and

youth‐and family‐driven services in systems of care. In M. Weil, M.

Reisch, & M. L. Ohmer (Eds.), The handbook of community practice

(pp. 725–740). Thousand Oaks, CA: SAGE. https://doi.org/10.4135/

9781412976640.n34

Daire, A. P., Jacobson, L., & Carlson, R. G. (2012). Emotional stocks and

bonds: A metaphorical model for conceptualizing and treating code-

pendency and other forms of emotional overinvesting. American

Journal of Psychotherapy, 66(3), 259–278. https://doi.org/10.1176/

appi.psychotherapy.2012.66.3.259

Davis, J. M., Ravenscroft, J., & Bizas, N. (2015). Transition, inclusion and

partnership: Child, parent and professional led approaches in a Euro-

pean research project. Child Care in Practice, 21(1), 33–49. https://
doi.org/10.1080/13575279.2014.976543

Fereday, J., Oster, C., & Darbyshire, P. (2010). Partnership in practice:

What parents of a disabled child want from a generic health profes-

sional in Australia. Health & Social Care in the Community, 18(6),

624–632. https://doi.org/10.1111/j.1365‐2524.2010.00935.x

Foucault, M. (1981). The history of sexuality ( ed., Vol. 1). Harmondsworth:

Penguin.

Foucault, M. (2000). The subject and power. In J. D. Faubion (Ed.), Power:

Essential works of Foucault 1954–1984 ( ed., Vol. 3) (pp. 239–297).
New York, NY: New

Press.

Freeman, E. M., & Couchonnal, G. (2006). Narrative and culturally based

approaches in practice with families. Families in Society, 87(2),

198–208. https://doi.org/10.1606/1044‐3894.3513

Gallagher, M., Smith, M., Hardy, M., & Wilkinson, H. (2012). Children and

families’ involvement in social work faking. Children & Society, 26,

74–85. https://doi.org/10.1111/j.1099‐0860.2011.00409.x

Green, S. E. (2007). “We’re tired, not sad”: Benefits and burdens of moth-

ering a child with a disability. Social Science & Medicine, 64, 150–163.
https://doi.org/10.1016/j.socscimed.2006.08.025

Guilfoyle, M. (2011). The ethical subject in post‐structural therapy. Journal
of Systemic Therapies, 30(4), 1–15. https://doi.org/10.1521/

jsyt2011.30.4.1

Hatton, C. (2013). Trends and variations in self‐directed support and

direct payments for adults with learning disabilities. Tizard Learning

Disability Review, 19(1), 35–38. https://doi.org/10.1108/TLDR‐10‐
2013‐0043

Heiman, T. (2002). Parents of children with disabilities: Resilience,

coping, and future expectations. Journal of Developmental and

Physical Disabilities, 14(2), 159–171. https://doi.org/10.1023/

A:1015219514621

Heizmann, H., & Olsson, M. R. (2015). Power matters: The importance of

Foucault’s power/knowledge as a conceptual lens in KM research and

practice. Journal of Knowledge Management, 19(4), 756–769. https://
doi.org/10.1108/JKM‐12‐2014‐0511

Hess, R. S., Molina, A. M., & Kozleski, E. B. (2006). Until somebody hears

me: Parent voice and advocacy in special educational decision making.

British Journal of Special Education, 33(3), 148–157. https://doi.org/10/
1111/j.1467‐8578.2006.00430.x. https://doi.org/10.1111/j.1467‐
8578.2006.00430.x

Hickey, S., & Mohan, G. (2004). Towards participation as

transformation: Critical themes and challenges. In S. Hickey, & G.

Mohan (Eds.), Participation: From tyranny to transformation. Exploring

new approaches to participation in development (pp. 3–24). London:

Zed Books.

Kalyanpur, M., Harry, B., & Skrtic, T. (2000). Equity and advocacy expecta-

tions of culturally diverse families participation in special education.

Development and Education, 47(2), 119–136. https://doi.org/10.1080/
713671106

McGill, P., Papachristoforou, E., & Cooper, V. (2006). Support for

family carers of children and young people with developmental

disabilities and challenging behaviour. Child: Care, Health and Develop-

ment, 32(2), 159–165. https://doi.org/10.1111/j.1365‐
2214.2006.00600.x

Mihee, A., & Palisano, R. J. (2014). Family–professional collaboration

in pediatric rehabilitation: A practice model. Disability and

Rehabilitation, 36(5), 434–440. https://doi.org/10.3109/09638288.

2013.797510

Page‐Gould, E., Mendoza‐Denton, R., & Tropp, L. R. (2008). With a little

help from my cross‐group friend: Reducing anxiety in intergroup con-

texts through cross‐group friendship. Journal of Personality and Social

Psychology, 95(5), 1080–1094. https://doi.org/10.1037/0022‐
3514.95.5.1080

Pettigrew, T. F., & Tropp, L. R. (2008). How does intergroup contact reduce

prejudice? Meta‐analytic tests of three mediators. European Journal

of Social Psychology, 38, 922–934. https://doi.org/10.1002/ejsp.504

Proctor, G. (2002). The dynamics of power in counselling and psychotherapy:

Ethics, politics and practice. Monmouth: PCCS Books.

Rommetveit, M. (2011). The mother’s voice in inter‐professional
collaboration in a client support group. Scandinavian Journal of

Disability Research, 13(4), 299–310. https://doi.org/10.1080/

15017419.2010.540825

Schmid, H., & Morley‐Sagiv, D. (2018). Reforming the social welfare

bureaus: Current situation, accomplishments and difficulties in

implementing change in social services. Society and Welfare, 38(1),

175–203. (Hebrew)

Smith, J. A. (2004). Reflecting on the development of interpretative phe-

nomenological analysis and its contribution to qualitative research in

psychology. Qualitative Research in Psychology, 1(1), 39–54. https://
doi.org/10.1191/1478088704qp004oa

Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological

analysis: Theory. Method and research. London: Sage.

Summers, J. A., Hoffman, L., Marquis, J., Turnbull, A. P., Poston, D., & Nel-

son, L. L. (2005). Measuring the quality of family‐professional

COHEN AND MOSEK572

https://doi.org/10.1177/001440290407000203

https://doi.org/10.1352/0047-6765(2000)038%3c0262:GAPAAS%3e2.0.CO;2

https://doi.org/10.1352/0047-6765(2000)038%3c0262:GAPAAS%3e2.0.CO;2

https://doi.org/10.1191/1478088706qp063oa

https://doi.org/10.1191/1478088706qp063oa

https://doi.org/10.1080/14768320500230185

https://doi.org/10.1080/14768320500230185

https://doi.org/10.1093/sw/48.3.297

https://doi.org/10.1177/027112140002000206

https://doi.org/10.1111/j.1744-6155.2011.00276.x

https://doi.org/10.1111/j.1744-6155.2011.00276.x

https://doi.org/10.1002/j.1839-4655.1999.tb01073.x

https://doi.org/10.1002/j.1839-4655.1999.tb01073.x

https://doi.org/10.1176/appi.psychotherapy.2012.66.3.259

https://doi.org/10.1176/appi.psychotherapy.2012.66.3.259

https://doi.org/10.1080/13575279.2014.976543

https://doi.org/10.1080/13575279.2014.976543

https://doi.org/10.1111/j.1365-2524.2010.00935.x

https://doi.org/10.1606/1044-3894.3513

https://doi.org/10.1111/j.1099-0860.2011.00409.x

https://doi.org/10.1016/j.socscimed.2006.08.025

https://doi.org/10.1521/jsyt2011.30.4.1

https://doi.org/10.1521/jsyt2011.30.4.1

https://doi.org/10.1108/TLDR-10-2013-0043

https://doi.org/10.1108/TLDR-10-2013-0043

https://doi.org/10.1023/A:1015219514621

https://doi.org/10.1023/A:1015219514621

https://doi.org/10.1108/JKM-12-2014-0511

https://doi.org/10.1108/JKM-12-2014-0511

https://doi.org/10/1111/j.1467-8578.2006.00430.x

https://doi.org/10/1111/j.1467-8578.2006.00430.x

https://doi.org/10.1111/j.1467-8578.2006.00430.x

https://doi.org/10.1111/j.1467-8578.2006.00430.x

https://doi.org/10.1080/713671106

https://doi.org/10.1080/713671106

https://doi.org/10.1111/j.1365-2214.2006.00600.x

https://doi.org/10.1111/j.1365-2214.2006.00600.x

https://doi.org/10.3109/09638288.2013.797510

https://doi.org/10.3109/09638288.2013.797510

https://doi.org/10.1037/0022-3514.95.5.1080

https://doi.org/10.1037/0022-3514.95.5.1080

https://doi.org/10.1002/ejsp.504

https://doi.org/10.1080/15017419.2010.540825

https://doi.org/10.1080/15017419.2010.540825

https://doi.org/10.1191/1478088704qp004oa

https://doi.org/10.1191/1478088704qp004oa

partnerships in special education services. Exceptional Children, 72,

65–83. https://doi.org/10.1177/001440290507200104

Tétreault, S., Freeman, A., Carrière, M., Beaupré, P., Gascon, H., & Marier,

Deschênes, P. (2013). Understanding the parents of children with spe-

cial needs: Collaboration between health, social and education

networks. Child: Care, Health and Development, 40(6), 825–832.
https://doi.org/10.1111/cch.12105

Tew, J. (2006). Understanding power and powerlessness: Towards a

framework for emancipatory practice in social work. Journal of Social

Work, 6, 33–51. https://doi.org/10.1177/1468017306062222

Tobin, G. A., & Begley, C. M. (2004). Methodological rigour within a quali-

tative framework. Journal of Advanced Nursing, 48, 388–396. http://
doi.org/10.1111/j.1365‐2648.2004.03207.x

Turnbull, A., Turnbull, R., Erwin, E., & Soodak, L. (2006). Families,

professionals, and exceptionality. Upper Saddle River, NJ: Pearson

Prentice Hall.

Vincent, C. (2000). Including parents: Education, citizenship and parental

agency. Buckingham: Open University Press.

Watkin, S. (Ed.) (2011). Social construction and social work practice:

Interpretations and innovations. New York, N.Y.: Columbia University

Press.

Wilkins, D. (2015). The impact of ‘being assessed’ by a disabled children’s

team: A personal reflective account. Child & Family Social Work, 20,

10–18. https://doi.org/10.1111/cfs.12026

How to cite this article: Cohen A, Mosek A. “Power

together”: Professionals and parents of children with disabil-

ities creating productive partnerships. Child & Family Social

Work. 2019;24:565–573. https://doi.org/10.1111/cfs.12637

COHEN AND MOSEK 573

https://doi.org/10.1177/001440290507200104

https://doi.org/10.1111/cch.12105

https://doi.org/10.1177/1468017306062222

http://doi.org/10.1111/j.1365-2648.2004.03207.x

http://doi.org/10.1111/j.1365-2648.2004.03207.x

https://doi.org/10.1111/cfs.12026

https://doi.org/10.1111/cfs.12637

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Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 11

Maternal and Environmental Influences on
Perinatal and Infant Development

Alexandra O’Sullivan and Catherine Monk

www.futureofchildren.org

Alexandra O’Sullivan is a research coordinator in the Perinatal Pathways Lab at Columbia University Irving Medical Center. Catherine
Monk is director of the Perinatal Pathways Lab and a professor in the departments of Obstetrics & Gynecology and Psychiatry at
Columbia University Irving Medical Center and the New York State Psychiatric Institute.

Summary

Mother and child wellbeing are intimately connected during pregnancy and the first 12 months
of the infant’s life. The fetus and child directly experience the mother’s life and are shaped by
it. A mother’s environmental experiences, physical health, and psychological distress affect her
interactions with her infant, which in turn have physiological, neurological, and psychological
consequences that extend far into the future.

In this article, Alexandra O’Sullivan and Catherine Monk explore the biological and behavioral
pathways through which the physical and psychological toll of environmental experiences such
as poverty, trauma, pollution, lack of access to good nutrition, and systemic disadvantage is
transmitted from mother to child, thus impairing fetal and infant neurobiological and emotional
development.

Fortunately, there are ways to buffer these risks and reorient both the child and the mother-
child pair toward a strong developmental trajectory. The authors examine promising avenues
for policy makers to pursue. Chief among these are policies that increase access to health care,
including mental health care, and those that reduce family stress during pregnancy and the
postpartum period, for example, by boosting family income or allowing parents to take paid
leave to care for their newborn children.

Alexandra O’Sullivan and Catherine Monk

12 THE FUTURE OF CHILDREN

Child development begins
before birth, and the womb
is an influential first home.
The perinatal period, which
spans pregnancy through

the first nine months of an infant’s life, is
characterized by dramatic physical and
neurobiological development. The mother
also experiences significant physical, mental,
biological, and social changes, all of which
may affect the child. Mother and infant
wellbeing are intimately connected. Research
demonstrates that the fetus experiences the
mother’s life and is shaped by it. Through
biological and social pathways, factors such
as her emotional and physical health or
experiences of discrimination and poverty
influence infant brain-behavior development
and contribute to long-term child psychiatric
and social-emotional outcomes. Accordingly,
clinical and policy interventions that aim to
improve maternal health care and ease stress
during the prenatal and postpartum periods—
such as increased access to behavioral health
screening and treatment, paid parental leave,
and extended insurance coverage—can
have positive downstream effects on child
development. These are early first steps that
can help to prevent the intergenerational
transmission of psychiatric illness and
disadvantage.

Developmental Origins of Health
and Disease

In the 1980s, epidemiologist David Barker
hypothesized that long-lasting health effects
flow to a child from early environmental
influences, even those experienced prenatally.
Now known as the Barker hypothesis or
prenatal programming, this concept of the
developmental origins of health and disease
(DOHaD for short) has more recently been

applied to the study of maternal mental
health and children’s neurobehavioral and
neurocognitive development and long-
term psychiatric outcomes, highlighting
a third, potentially preventable pathway
for the familial transmission of risk for
future mental illness. That is, pregnant
women’s psychological and physical health
may impact fetal brain development, with
significant consequences for the child’s
future wellbeing. Using evolutionary
theory as a framework, the DOHaD model
describes the fetus as adapting to the in
utero environment based on signals from
the mother that foreshadow the postnatal
environment to come, thereby promoting
survival in the postnatal world. As the
fetal brain continues to develop, these
biological adaptations become programmed
(and therefore long lasting), potentially
placing the child at risk for psychological or
developmental challenges if the prenatal and
postnatal environments are misaligned.

The Brain’s Beginnings: Fetal
Neurodevelopment

The transformation of a cluster of cells into a
nascent brain occurs in a mere nine months.
Over this time, inherent genetic patterns and
variations interact with characteristics of the
fetus’s environment to organize the different
elements of the brain into one complex and
remarkable organ. While the fetal brain is
developing, it is learning. The fetal brain’s
plasticity allows it to learn from and adapt
to environmental experiences. Though this
dynamic process continues throughout a
person’s life, the fetal brain’s heightened
responsiveness to new experiences makes the
prenatal period a time of great opportunity—
but also vulnerability.

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 13

Fetal brain development is typically divided
into three distinct phases: embryonic (from
conception to the eighth gestational week),
the early fetal period (up to mid-gestation),
and the late fetal period (lasting until birth).
By the end of the embryonic period, the
basic structures of the brain and central
nervous system, including the neural tube
(responsible for future neuron production),
are established—long before obvious signs
that a woman is pregnant and often before
even she knows. Because inadequate folic
acid and vitamin B intake can cause neural
tube defects leading to risks of serious birth
malformations, vitamin supplementation is
important for all women of childbearing age,
as is a healthy lifestyle. During the early and
late fetal periods, brain development centers
on producing, connecting, and differentiating
neurons. Fetal exposure to environmental
toxins that influence the speed and accuracy
of communication between neurons (such as
drugs of abuse or prescription medications),
inadequate nutrition, the effects of
preterm birth, and maternal infection and
inflammation all may impact the development
of neural circuits and neurotransmitter
systems, contributing to risk for poor
neurobehavioral development. Fetal alcohol
exposure is also linked to increased cell death
in the developing brain.

Throughout this extensive period of brain
development, fetal learning occurs. For
example, by late in pregnancy, fetuses can
distinguish different sounds, including music
and their mother’s voice. However, the
communication of information from mother to
fetus also includes biological signals related to
aspects of the mother’s life, such as relatively
high levels of the stress hormone cortisol.
Pregnancy is thus a period of dramatic
fetal brain growth as well as developmental

vulnerability during which the genetic
blueprint of the brain is altered through
qualities in the mother’s life that make up the
fetus’s environment.

Environmental Influences on
Fetal Neurodevelopment

The phrase environmental exposures readily
conjures adverse factors, such as pollution or
physical illness, that affect the mother and
her health. In DOHaD research, the concept
of environmental exposures also extends to
mothers’ psychological distress, including
depression, anxiety, and perceived stress,
all of which are associated with biological
changes in the mother that alter the fetus’s
environment.

Maternal Mental Health

In 2015, the World Health Organization
declared maternal mental health a major
public health concern, calling it one of the
most overlooked aspects of pregnancy care.
In the United States, the prevalence of
depressive disorders and anxiety disorders
during the perinatal period is estimated
to be between 18 and 19 percent and 12
and 13 percent, respectively. These rates
are more than twice as high in low-income
and minority populations. An estimated 30
percent of pregnant women report some kind
of stress in their daily lives. These statistics
matter. Substantial evidence demonstrates
that elevated maternal distress during
pregnancy increases the future child’s risk for
mental health disorders, including anxiety,
depression, attention deficit/hyperactivity
disorder (ADHD), and schizophrenia.

For example, a study of nearly 8,000 British
children found that children exposed to
higher prenatal maternal anxiety were at

Alexandra O’Sullivan and Catherine Monk

14 THE FUTURE OF CHILDREN

greater risk for overall behavioral problems
(for example, ADHD and conduct problems)
at age seven. These effects persisted:
exposure to high levels of prenatal anxiety
doubled the risk of having a mental health
disorder at age 13. This influence on
children’s health was evident even when
researchers also considered other adverse
prenatal influences, such as maternal smoking
and drinking, medical conditions during
pregnancy, socioeconomic status, and the
mother’s mood postpartum. Similar outcomes
were identified for prenatal maternal
depression. This association between
maternal distress during pregnancy and
children’s increased risk for social-emotional
problems has been corroborated by research
groups in many other countries.

Although these associations have been
found in both male and female children,
research suggests that male fetuses are more
vulnerable. In a recent study comparing
psychologically stressed, physically stressed,
and healthy mothers, researchers found
that the secondary sex ratio (in the general
population, 105 male infants are born for
every 100 female infants, for a ratio of
1.05:1) became 4:9 for physically stressed
mothers, and 2:3 for mothers experiencing
psychological distress; that is, highly stressed
women were less likely to give birth to
a male infant. This apparent heightened
male vulnerability to adverse prenatal
environments may be an evolutionary
response to natural selection pressures—
relatively few but healthy men are needed for
species survival, whereas many women are
needed to carry single pregnancies to term.

More recently, DOHaD researchers have
turned their attention to the brain itself.
Magnetic resonance imaging studies have

identified differences in newborns, older
children, and even adults associated with
prenatal exposure to maternal distress. A
study that followed children from the prenatal
period until they were six to nine years old
found that higher maternal prenatal anxiety
was associated with reduced gray matter
volume (an indication of fewer neurons) in
the brain’s prefrontal cortex, a region integral
to cognitive abilities such as reasoning,
planning, attention, and working memory.
Similar reductions have been found in adults
exposed to maternal stress in the prenatal
period, emphasizing the enduring nature of
these changes. Other studies have related
maternal prenatal depression to greater
cortical thinning (a characteristic of people
with depressive disorders) at age seven
and child depressive symptoms at age 12.
Each of these studies controlled for other
possible influences, such as the mother’s
physical health in pregnancy. A recent
imaging study confirmed that the prenatal
environment is responsible for these brain
changes: researchers found that resting state
connectivity between the amygdala and the
prefrontal cortex—a neural circuit that’s key
to regulating emotions—was different in the
brains of newborns exposed to untreated
prenatal depression compared to the
newborns of healthy women. This suggests
that the fetus adapts in anticipation of the
unfavorable postnatal environment indicated
by the mother’s depression.

The association between maternal mental state
and fetal neurodevelopment has even been
shown in real time in studies that demonstrate
fetal responsiveness to acute laboratory-
induced stress at the moment the mother
experiences it. These studies show that the
fetuses of distressed women are more reactive
to the biological cues of maternal acute stress,

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 15

with the magnitude of mid- to late-term
fetal response varying based on maternal
depression or stress levels, providing evidence
that in the latter part of pregnancy the fetus is
experiencing and being shaped by its mother’s
life. The public health significance of pregnant
women’s psychological wellbeing is thus clear.
Pregnant women’s mental health matters
both for them and for their future children.
Without access to timely and effective
interventions to alleviate mothers’ distress, the
intergenerational cycle of psychiatric illness
continues.

Other Environmental Factors
Influencing Fetal Neurodevelopment

Pregnant women don’t live in a vacuum. Every
day, women are exposed to environmental and
psychosocial sources of stress that impact both
their own psychological and physical wellbeing
and that of their unborn child.

Poverty and psychosocial factors. Major
adverse life events, such as death or illness
in the family or pregnancy-related health
problems, can occur during any woman’s
pregnancy. However, chronic psychosocial
stress factors such as poverty aren’t randomly
distributed throughout society. Poverty is
associated with reduced access to prenatal
care and to increased exposure to cigarette
smoking, poor nutrition, and distressed,
environmentally hazardous, or insecure
housing, each of which contributes to
compromised pregnancy outcomes, such as
small size for a fetus’s gestational age, preterm
birth, and low birthweight.

In each case, factors such as reduced access
to healthy food, transportation, and health
care contribute to these negative birth
outcomes. Opportunities to promote maternal

health and reduce stress in this context may
include better access to medical facilities
and public transport and adjustments to built
environments, such as support for developing
green spaces, which have been associated with
increased infant birth weight.

Every day, women are
exposed to environmental
and physical sources of stress
that impact both their own
psychological and physical
wellbeing and that of their
unborn child.

Systemic racism in the United States also
produces significant discrimination-related
stress during pregnancy. A recent study
compared stress related to discrimination
experienced by non-Hispanic white and black
pregnant women of similar socioeconomic
level. Non-Hispanic black women reported
higher levels of discrimination (and worry
about discrimination); their blood samples,
taken over the second and third trimesters,
contained significantly higher levels of
adrenocorticotropic hormone (produced
in response to stress), suggesting biological
differences as a result of cumulative racial
disadvantage.

Nutrition. The quality of a mother’s diet
can have long-term implications for her
child’s future health. Pregnant women
with inadequate nutrition often experience
symptoms of depression or stress. Thus
high distress and poor nutrition are highly
interrelated and associated with similar
adverse neurobehavioral outcomes in children.

Alexandra O’Sullivan and Catherine Monk

16 THE FUTURE OF CHILDREN

Community supervision in the United States is uniquely punitive.

Financial and geographical barriers to the
fresh foods and vitamins required for a
healthy pregnancy often limit pregnant
women’s options, especially when they live in
disadvantaged environments.

Although macronutrient deficiencies (such
as reduced overall caloric intake) pose risks
to the developing fetus, relatively easy
access to processed foods in the United
States today has meant that most pregnant
women consume sufficient calories. Yet too
often this increase in calories isn’t associated
with a corresponding increase in intake of
micronutrients (such as zinc, iron, copper,
or vitamins including choline, folate, and
vitamin A). Both macro- and micronutrient
deficiencies during pregnancy are associated
with greater risks of neurobehavioral
developmental outcomes, such as cognitive
delays, ADHD, autism spectrum disorder,
and schizophrenia. A lack of dark leafy
greens, legumes, and oranges during
pregnancy can have particularly devastating
consequences for fetal neurodevelopment.
These foods contain high amounts of the
B vitamin folate, which plays a key role
in DNA synthesis and function. Research
relates varying levels of prenatal folate to
subtle differences in brain development; low
levels correlate with future developmental
challenges. Further still, inadequate
levels of folate during pregnancy, and
even in the month before conception,
dramatically increase the risk of neural tube
defects, which can lead to severe physical
disabilities such as spina bifida. Prenatal
folate deficiency has also consistently been
linked with infant and child emotional and
behavioral problems, particularly social
withdrawal, poor attention, and aggression.

Nutrition also plays a key role in mothers’

mental health. Deficiencies of folate,
vitamin B12, calcium, iron, selenium, zinc,
and magnesium have been associated with
symptoms of depression. Studies have
shown that people experiencing stress
and depression are more likely to choose
processed, high-fat, high-sugar foods at
the expense of fresh, nutritious options.
During pregnancy, poor nutrition affects two
generations.

Research into the effects of prenatal
nutrition underpinned the most effective
pregnancy-related public health campaigns
to date. Beginning in the 1990s—based
on clinical trials demonstrating the
benefits of dietary supplementation of
folic acid, a synthetic form of folate—
pregnant women were told about the
relationship between their own health
and their child’s development. Since
approximately half of US pregnancies are
unplanned, the US Preventive Services
Task Force now recommends that all
women of childbearing age take a daily
folate supplement. In addition, the US
Food and Drug Administration approved
folate supplementation for foods such
as cereals and, more recently, corn masa
flour. The effects of this campaign have
been significant. From the early 1990s to
the 2000s, the rate of neural tube defects
dropped from 11 to seven cases per
10,000 live births. It’s estimated that food
fortification prevents about 1,300 neural
tube defects a year. Nevertheless, rates of
daily folate supplementation today are still
low and falling. Between 2006 and 2016,
daily vitamin supplementation decreased in
women of childbearing age, falling from 32.7
to 23.6 percent. One reason for this decrease
may be a lack of patient understanding of

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VOL. 30 / NO. 2 / FALL 2020 17

the risks of neural tube defects; another
might be the cost of daily multivitamins.
Clearly, work remains to be done in both
public education and increasing access to
affordable prenatal vitamins and fortified
foods.

Chemicals and pollution. The developing fetal
brain is affected by maternal environmental
exposure to chemicals and air pollution.
Researchers who’ve collected mothers’
blood, urine, and hair samples have revealed
widespread exposure throughout pregnancy
to numerous chemicals, many of which are
known to have adverse health effects. For
example, easily metabolized chemicals (such
as the phthalates, parabens, and bisphenol
A, found in plastics and personal care
products) and heavy metals (such as lead
and mercury, found in contaminated water
or paint particles) are known to affect fetal
growth and lead to poor birth outcomes,
including low birthweight, preterm birth, and
associated developmental delays.

Understandably, pregnant
women diagnosed with
a high risk-pregnancy
complication are often
anxious or suffer from
depression.

Air pollution increasingly affects maternal
and fetal health as large US cities continue
to become more congested. Air pollutants
commonly inhaled by pregnant mothers, such
as nitrogen dioxide, carbon monoxide, sulfur
dioxide, and ozone, pose risks to fetal and
infant health and have been associated with

low birthweight, preterm birth, and future
respiratory illnesses. Studies have shown that
these adverse outcomes are heightened in
more socially disadvantaged women. Policies
to reduce traffic congestion and carbon
emissions positively impact all citizens,
including those not yet born.

Maternal physical health. Mothers’
psychological distress in the form of anxiety,
depression, or perceived stress is both a
risk factor for and a consequence of chronic
maternal diseases, such as diabetes and
preeclampsia, a disorder causing sudden
high blood pressure in pregnant women.
Both diseases cause pregnancy complications
and can affect infants’ neurodevelopment.

Understandably, pregnant women diagnosed
with a high risk-pregnancy complication
are often anxious or suffer from depression
related to the uncertainty surrounding their
pregnancy and the associated risks to their
child’s future health. This distress is not
unfounded. One studied showed that the
babies of “physically stressed” mothers (for
example, pregnant women with elevated
daily blood pressure or high caloric intake)
are more than twice as likely than the
babies of unstressed mothers to be born
preterm (22 percent compared to 8 to 10
percent). Hypertensive disorders during
pregnancy are also linked with higher risk
for child behavioral problems, ADHD, mood
disorders, and schizophrenia. Moreover,
psychological distress and psychosocial stress
factors can themselves induce gestational
diabetes mellitus, which is associated with an
increased risk for autism spectrum disorder.

Finally, many drugs of abuse cross the
placenta and so reach the fetus. Prenatal
drug exposure is related to prematurity,

Alexandra O’Sullivan and Catherine Monk

18 THE FUTURE OF CHILDREN

low birth weight, and neonatal abstinence
syndrome, a condition in which the baby goes
through withdrawal. In the past two decades,
neonatal abstinence syndrome diagnoses
have increased nearly fivefold in the United
States, resulting in estimated neonatal hospital
costs in excess of $1 billion per year. In
addition to contributing to serious pregnancy
complications, prenatal exposure to drugs of
addiction is associated with severe behavioral
dysregulation and cognitive impairment. For
example, prenatal opiate exposure has been
related to poor neurocognitive development
from age six months on, worsening by
school age and into adolescence. Similar
neurocognitive deficits have been found in
infants and toddlers exposed prenatally to
cocaine, alcohol, tobacco, and marijuana,
independent of risks associated with
premature birth and socioeconomic status.

The Growing Mind:
Neurodevelopment in Infancy

Birth brings considerable environmental
change for the infant, yet continuity remains
in the neurodevelopmental processes that
commenced nine months earlier. The
learning that began in the womb continues
and accelerates significantly over the first 24
months as the infant becomes familiar with
his or her new environment and the people
in it. At birth, the neonatal brain weighs
400 grams, approximately 25 percent of its
eventual adult size; by age two, the brain has
grown to 75 percent of its adult size, indicating
the importance of infancy and toddlerhood as
developmental periods. During this further
period of neural plasticity, the brain is highly
malleable and constantly evolving, as it is
custom built to reflect the child’s experiences
in the world.

Maternal Mental Health in the
Infant’s First Year

An infant’s neurobehavioral development in
the first year is exquisitely sensitive to the
postnatal environment, including the mother’s
mood. In the United States, an estimated
20 percent of mothers will experience an
episode of depression in the first three months
after giving birth. Women with a history of
depression, anxiety, or prenatal depression
or anxiety are at significantly greater risk
for postpartum depression. As we’ve noted,
the incidence more than doubles in at-risk
maternal populations, such as women in
poverty. One study looking at young, low-
income African American mothers between
two weeks and 14 months after delivery found
that 56 percent of the mothers met the criteria
for either major (37 percent) or minor (19
percent) depressive disorders. These mothers’
experiences play a significant role in early
infant development. Maternal depression
undermines mother-infant emotional
communication and dyadic reciprocity (the
sharing of emotional affect between mother
and infant) and has profound consequences
for an infant’s social-emotional development.
Laboratory studies show that infants are
stressed when their mothers display a
withdrawn affect. Using the well-established
still face paradigm, in which the caregiver
plays with and then emotionally withdraws
from the infant—a simulation of the
experience of maternal depression—studies
demonstrate that infants of depressed mothers
respond to the unpredictability of maternal
engagement with reduced activity, greater
behavioral dysregulation, and withdrawal.

The effects of maternal depression on child
neurodevelopmental processes don’t end in

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 19

infancy. Maternal postpartum depression
is also associated with reduced social
competence and compromised language
development in early childhood. These
effects are long lasting and stark. A large,
recently published study followed the course
of maternal depression and child outcomes
for 18 years. The study found that mothers
with severe postpartum depression at
both two and eight months after delivery
were more likely to still be depressed 11
years later, compared to mothers with
nonpersistent depression. Their children,
in turn, were four times more likely to
exhibit behavioral problems when they were
between three and four years old, twice as
likely to have lower math scores at 16, and
seven times more likely to have depression
themselves at 18. These intergenerational
effects of maternal depression show how
important it is to screen for depression at all
life stages and to promote a dyadic approach
to identifying and treating maternal mood
disorders.

However, maternal sensitivity—the mother’s
ability to interpret and effectively respond to
the infant’s signals—can mediate maternal
depression’s effects on infants. On the one
hand, insensitive maternal behavior during
caregiving tasks is associated with increased
infant neurobehavioral responsiveness to
stress and child psychopathology. Maternal
distress associated with depression and
social disadvantage can diminish a mother’s
ability to provide sensitive caregiving
and a responsive home environment that
stimulates early cognitive and language
development. On the other hand, sensitive
maternal behavior in infancy predicts better
social-emotional outcomes in children. In
addition—and importantly for intervention

purposes—sensitive maternal caregiving
can buffer the neurobehavioral effects of
prenatal distress. For example, only when the
quality of postnatal care at age four months
was low did the four-month-old infants of
mothers diagnosed with anxiety or depression
in the second trimester of pregnancy show
significantly higher cortisol levels (a biomarker
of stress) than the infants of healthy women.
In short, sensitive maternal caregiving
in the infant’s first year can enhance the
developmental trajectories of infants exposed
to maternal distress in the womb.

Biological Pathways for
Transmission of Risk

How does maternal distress shape fetal
and infant neurobiological and emotional
development? Through which biological
and behavioral pathways are environmental
experiences transmitted from mother to child?

Mechanisms during Pregnancy

Several pathways have been associated with
increased risk of autism spectrum disorder,
schizophrenia, mood disorders, and ADHD
in children. One is the hypothalamic–
pituitary–adrenal (HPA) axis, which plays
a central role in releasing stress hormones.
Atypical functioning of the mother’s HPA
axis is associated with maternal distress and
increased circulating levels of the stress
hormone cortisol. Cortisol can readily cross
the placenta and thereby reach the fetus,
affecting the development of the infant’s
own HPA circuitry and brain development,
which increases the risk of psychological
distress in the future child. Another pathway
is alterations in the mother’s immune system
that can affect brain connectivity. Maternal
immune activity—part of a stress experience

Alexandra O’Sullivan and Catherine Monk

20 THE FUTURE OF CHILDREN

and/or response to infection—may cause
placental inflammation or the release of
cytokines (signaling molecules that affect
the survival and differentiation of neurons in
the brain) into the mother’s system, where
they can cross the placenta and affect the
developing fetus.

Environmental influences also may alter
fetal neurodevelopment by modifying
the functioning of the placenta through a
process called epigenetics, which can result
in heritable modifications to gene expression
(whether a particular gene is activated or
suppressed). The most commonly studied
epigenetic mechanism, DNA methylation, can
change the activity of DNA without changing
the underlying sequence itself. For example,
the placenta regulates fetal exposure to
cortisol in part by DNA methylation of certain
genes. Changes to this placental function can
lead to high arousal and poor self-regulation in
newborns, each of which is an indicator of risk
for future behavioral problems. Considerable
research is under way to determine whether
epigenetic processes in the placenta and other
tissues that are key to development contribute
to the intergenerational transmission of
environmental experiences, such as poverty,
trauma, and systemic disadvantage.

The maternal microbiome offers another
possible way for prenatal maternal stress to
influence fetal neurodevelopment. Prenatal
distress is known to alter mothers’ gut
microbiota, and research shows the infant
microbiome is developed perinatally during
birth (for example, infants born vaginally show
gut microbiota that resemble their mother’s
vaginal microbiome) and even prenatally
via transmission through the placenta. The
microbiota that colonize the infant gut affect
important processes such as metabolism

and nutrient extraction. And because
infant brain development exerts a high
metabolic demand, microbial colonization
may influence brain maturation in a long-
lasting way. Animal studies that have found
evidence of this pathway have suggested that
probiotic supplementation, which alters gut
microbiome, may reduce the symptoms of
some psychiatric disorders, including autism
spectrum disorder and depression. However,
neither animal nor human studies have
yet considered whether prenatal maternal
stress, along with accompanying changes
to the infant microbiome, have long-term
behavioral and psychiatric implications.

But what of the role of shared genes? How
can genetic traits shared between mother
and child be disentangled from the mother’s
prenatal lifestyle factors and negative child
outcomes, particularly for characteristics
such as depression, known to run in families?
Studies that consider the influence of both
genes and environmental factors, such as
maternal mood, have found that maternal
distress remains a significant independent
factor. For example, one study identified
an independent effect of prenatal maternal
distress on children’s risk for behavioral
problems and anxiety in both related
children and unrelated children that were
conceived with the egg of another woman
via in vitro fertilization (that is, the risk was
found in both related and unrelated children
with prenatal exposures to their mothers’
lives). Another study, which controlled for
parental history of psychiatric symptoms
as a marker for genetic predisposition, also
found an independent effect of prenatal
stress on children’s psychiatric outcomes.
Researchers are currently trying to learn
more about the unique interactions between

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 21

prenatal maternal stress and infant genes
and to identify how these interactions
shape children’s risk profiles for future
psychopathology.

Mechanisms Extending beyond
Pregnancy

Sensory experience, which is common to both
the prenatal and postnatal periods, is another
way that risk for future neurodevelopmental
and social-behavioral problems is transmitted.
Researchers in one animal study found that
pig fetuses learned to associate a particular
human voice with a negative (for example,
painful) maternal experience; once born,
the piglets emitted more distress calls
upon hearing that voice. This suggests that
the fetal brain may learn in the womb to
associate maternal experiences (experienced
by the fetus via maternal hormones or
cardiorespiratory activations) with external
sounds, including voices. One question for
future research is whether children who are
primed to associate their mother’s angry or
upset words with biological stress cues may be
more sensitive to their mother’s (or others’)
distress. Another is whether children be can
primed to respond with similar sensitivity
to sounds associated with intimate partner
violence, learned before birth.

Studies have also shown that consistency
in fetal and infant sensory experiences is
important. Mere unpredictability of sensory
signals (for example, disjointed maternal
emotional states during pregnancy or
unpredictable postnatal maternal care) may
be a form of chronic stress to the offspring
that affects the structural and functional
development of the brain during a vulnerable
period. In this context, “unpredictability”
doesn’t refer to how sensitive the mother is,

The fetal brain may learn
in the womb to associate
maternal experiences with
external sounds, including
voices.

but rather the consistency of her behavior.
Remarkably, some researchers have found
greater positive mental development in one-
year-old children whose mothers experienced
consistent pre- and postnatal depressive
symptoms than in children with mothers
whose emotional state improved postnatally.
Scientists have since shown that the
neurodevelopmental effects of unpredictable
sensory experiences (including visual, auditory,
and tactile signals) are associated with long-
term emotional difficulties, poor cognitive
outcomes, and immature executive function
(associated with vulnerability to future mental
illness) in both early and late childhood.

Opportunities for Intervention

A considerable body of evidence has
established that the foundational experiences
of the fetus during pregnancy and the infant
postpartum are critical to early development.
In particular, untreated maternal prenatal
distress and poor mother/infant attachment
can lead to long-term adverse cognitive and
behavioral outcomes. Interventions aimed
at easing maternal distress and improving
maternal health care in both the prenatal and
postpartum periods have downstream positive
effects on child development. Here we review
promising avenues for intervention and
treatment; most of them focus on addressing
maternal mood because stress, depression,

Alexandra O’Sullivan and Catherine Monk

22 THE FUTURE OF CHILDREN

and anxiety independently affect outcomes
or accompany other adverse experiences that
affect mothers and their offspring.

Cognitive behavioral therapy and
interpersonal psychotherapy are first-line
behavioral treatments consistently found to
reduce the symptoms of perinatal depression
and anxiety. In 2019 the US Preventative Task
Force recommended that at-risk pregnant
and postpartum women be referred to these
types of counseling.

In-home visiting programs have proven
particularly successful as a means of reaching
at-risk women during the perinatal period,
and adding a cognitive behavioral therapy
component to the home-visiting model has
helped prevent perinatal depression. One
such program is Mothers and Babies, a
prenatal and postpartum cognitive behavioral
therapy program that gives mothers a
“toolkit” that encourages them to take part
in enjoyable activities, gives them access
to increased social support, and promotes
healthier ways of thinking. A recent
randomized controlled trial (RCT) found
that adding the Mothers and Babies model
to a regular perinatal home-visiting service
for primarily single, low-income Latina or
African American women reduced women’s
depressive and anxiety symptoms at six
months after birth compared to women who
received only the home visit.

Other in-home programs, such as Minding
the Baby (MTB), are directed toward young
first-time parents (ages 14 to 25) who are
at heightened risk for difficulty adjusting
to the postnatal period. These programs
use an interdisciplinary, attachment-
focused approach that aims to improve
mothers’ mental health and strengthen the

mother-infant relationship. An initial RCT of
the MTB program demonstrated a range of
beneficial health and attachment outcomes,
including more child immunizations at
one year, fewer reports to child protective
services, an increased likelihood of secure
attachment, and less likelihood of infant
behavioral disorganization at 12–14 months.
Follow-up studies have found significantly
fewer externalizing behavioral problems in
MTB mothers, and lower levels of obesity in
Hispanic MTB toddlers relative to control
groups. Recently, the second phase of the
RCT found that the ability of mothers in the
MTB group to understand their child’s mental
state (a mental process called “reflective
functioning,” which is often impaired in
stressed mothers but is essential for secure
mother-infant attachment) increased over the
course of the program compared to control
mothers.

Recent work from our group has also shown
that prenatal social support for the mother
from family, friends, or community is
important. A physically or psychologically
stressed mother’s social support can act as
a protective factor against adverse birth
outcomes, including preterm birth and
younger gestational age at birth. Thus
enhancing a mother’s social support—for
example, through home visits or mothers’
group programs—may be an effective clinical
intervention.

Finally, although much research on the
developmental origins of health has focused
on identifying the causes of negative
outcomes and how to prevent them,
researchers are increasingly exploring the
beneficial consequences of positive maternal
mental health. For example, the Growing
Up in Singapore Towards Healthy Outcomes

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 23

project has established that self-reported
maternal positive mood and sense of self is
uniquely and positively associated with better
cognitive, linguistic, and socioemotional
development among two-year-olds. The
potential beneficial downstream effects,
for both the individual and society, of such
adaptive developmental processes in early
childhood should make positive maternal
mental health a top public health priority.

Psychotherapy for Mother and Child

Despite the progress researchers have made in
developing interventions to alleviate maternal
distress, too few studies consider maternal
and child outcomes together. Because
improvements in pregnant women’s mood and
wellbeing can have a beneficial effect on the
developing child, prenatal interventions can
aim to treat at least two patients, the mother
and her child. This kind of dyadic approach
to treatment would take advantage of the
profound bidirectional psychological and
biological influences between them: as the
infant brain develops before birth, so too does
the parental brain.

It would be a grave
perversion of science
if research into the
consequences of maternal
experience were used to
blame women for their
children’s development.

Increasingly, clinical researchers point to two
factors that impact infant neurodevelopment:
maternal depression (with associated risks

via prenatal programming of poor mother-
infant attachment) and related dysfunctional
parenting behaviors, which may be easier to
target in the short term. RCTs in progress
of two innovative programs—one of which
offers women resources for effective parenting
in the postpartum period and the other of
which offers interpersonal therapy—ask
the key question about prenatal parenting
interventions, namely, whether reducing
pregnant women’s depression positively affects
infants’ neurobehavioral development, thus
reducing the risk of later psychopathology.
These trials will function as an experimental
test of the fetal programming hypothesis,
and the results will have direct implications
for programs that seek to improve pregnant
women’s behavioral health and treat maternal
distress.

How Not to Blame the Mother

It is clear that mothers’ experiences are crucial
to children’s outcomes. Yet it would be a
grave perversion of science if research into
the consequences of maternal experience
were used to blame women for their
children’s development. Women already feel
intense pressure regarding the mothering
role, particularly in the era of social media.
DOHaD researchers and other developmental
researchers therefore must stress that
maternal health is one of a complex patchwork
of factors that influence children’s brain-
behavior development. Others include shared
genes, as well as paternal factors such as the
quality of the father’s sperm and his support
for the mother’s wellbeing during pregnancy.
Broader social factors are also relevant. The
maternal distress and exposures frequently
associated with poor child outcomes, such as
air pollution, lack of nutrition, and inadequate
housing, are in many cases the products of

Alexandra O’Sullivan and Catherine Monk

24 THE FUTURE OF CHILDREN

systemic disadvantage and discrimination.
Such stress factors take a particularly heavy
toll on racial minorities and low-income
populations. Poverty is the magnet that attracts
risk factors for toxic stress and other social
determinants of health, thus perpetuating the
cycle of disadvantage. Policy interventions
to improve these psychosocial risk factors,
as well as women’s mental health, must be a
priority if we are to make substantial progress
in improving the lives of women and future
generations.

Policies for Perinatal Success

Chief among policy proposals that mesh with
the aims of clinical interventions are those that
emphasize increasing access to health care,
including mental health care, and reducing
family stress during pregnancy and the
postpartum period.

Improving Access to Behavioral Health
Care

Complex issues of family, stigma, cost,
and availability are common obstacles
to women accessing mental health care
services. Following recommendations from
the American College of Obstetricians and
Gynecologists, prenatal care increasingly
includes mental health screening, particularly
for anxiety and depression. Yet screening
alone doesn’t mean women will receive
treatment. By helping women access the care
they need, perinatal home-visiting programs
have significantly improved family and
child outcomes. But given their high cost,
these programs should be reserved for the
most vulnerable families. One proposal for
increasing access is to embed cost-effective
mental health care in primary obstetric offices.
Pregnancy represents a unique period in

which nearly all women, including women
from underserved communities, are both
motivated and, via Medicaid for pregnant
women, able to regularly see health care
professionals for prenatal checkups. Even
low-risk pregnancies typically involve 12–15
visits to obstetrics practices in less than a year.
This increased contact offers an opportunity
to screen for and treat prenatal psychological
distress. Embedding behavioral health
professionals in primary obstetric care reflects
the collaborative care model developed
at the University of Washington as part of
its Advancing Integrated Mental Health
Solutions program, which is designed to treat
common but chronic mental health conditions
such as anxiety and depression requiring
systemic follow-up. RCTs in the United States
and other countries have consistently found
that collaborative care leads to better patient
outcomes, greater patient and provider
satisfaction, and reduced health care costs: in
short, it works.

The Massachusetts Child Psychiatry Access
Program for Moms (MCPAP for Moms) offers
another approach to increasing access to
mental health services. This program builds
obstetrics practices’ capacity to care for
perinatal women’s mental health by providing
resources and training on depression
screening and treatment, telephone access
to perinatal psychiatric specialists, and
the means to link women with individual
psychotherapy and support groups. This
low-cost model, funded by the Massachusetts
legislature, was piloted in 2016. Since then,
MCPAP for Moms has enrolled 145 obstetric
practices and served 3,699 women and has
received positive feedback from health care
providers. The same group has recently
designed a practice-specific program, the

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 25

Program In Support of Moms (PRISM),
which incorporates MCPAP for Moms
but aims to help obstetrics practitioners
provide stepped care treatment for perinatal
depression. In pilot trials, both programs
reduced depressive symptoms, and a five-year
RCT is now under way to further assess their
effectiveness.

In 2018, following MCPAP for Moms’
success, the Health Resources and Services
Administration of the US Department of
Health and Human Services announced
a five-year grant program that aims to
scale up this model in other states, with a
focus on rural and medically underserved
communities; Florida, Kansas, Louisiana,
Montana, North Carolina, Rhode Island,
and Vermont were awarded funds. It
remains to be seen whether the MCPAP
for Moms model can succeed in these
states, which, unlike Massachusetts, lack
enhanced state-based health care. We
also need further research to see whether
placing the management of perinatal
behavioral health in the hands of time-poor
obstetricians—as opposed to embedding
behavioral health professionals in obstetrics
practices—will result in an unwarranted
emphasis on pharmacology. Evidence shows
that the best model for mild to moderate
depressive symptoms is psychotherapy,
while a combination of psychotherapy and
pharmacology works well for moderate to
severe symptoms.

One successful example of embedded
interdisciplinary care focuses on the
crucial period from birth to toddlerhood.
HealthySteps, a program of nonprofit Zero
to Three, offers embedded behavioral
health services in conjunction with standard
primary care well-child visits. In pediatric

practices that include HealthySteps, a
behavioral health professional can address
common but complex family concerns
such as sleeping, attachment, and parental
depression, and social determinants of health
such as insecure housing and lack of social
support. A great deal of evidence supports
the model’s effectiveness. Select outcomes
include substantial improvements in timely
developmental assessments, continuity of
care, and children’s nutrition (including
breastfeeding), along with reductions in
children’s emergency room visits.

Finally, economic policy can help to alleviate
the psychological and biological effects of
maternal stress. Researchers have found
that the increased income from the dramatic
expansion in the Earned Income Tax Credit
(EITC)—a refundable tax credit providing
cash payments to low-income families with
children—after passage of the Omnibus
Reconciliation Act of 1993 helped to protect
mothers’ health. Specifically, mothers who
received higher EITC payments reported
better health and fewer poor mental
health days; their biomarkers of stress also
decreased, particularly blood pressure and
inflammation. Thus public policies that put
more money in low-income families’ pockets
represent one clear way to address the
intergenerational transmission of psychiatric
illness. Although such redistributive programs
are expensive, the public health costs of
inaction on perinatal maternal distress may
be higher. In the United States, research firm
Mathematica recently estimated that over the
six years from the beginning of pregnancy
until children reach age five, the cost of
untreated maternal mental health disorders
for all US births is $14.2 billion, or $32,000
for every untreated but affected mother-child

Alexandra O’Sullivan and Catherine Monk

26 THE FUTURE OF CHILDREN

pair. Most of these costs are incurred in the
first year postpartum.

Improving Access to All Health Care

Financial barriers frequently impede adequate
prenatal and postpartum health care, either
directly through a lack of sufficient insurance
coverage or indirectly through lack of time
to attend medical appointments once family
finances or lack of job security require the
mother to return to work. Health insurance
during pregnancy is essential to ensure that
all women and their children have access to
sufficient prenatal care. However, affordable
access to health care before conception and
during the postpartum period is also required
to guarantee timely treatment of maternal
conditions, such as diabetes, hypertension,
and psychiatric illness, that put children’s
development at risk. In the United States,
even women with insurance often lack
coverage for mental health care, forcing a
choice between forgoing treatment altogether
or costly out-of-network care.

Today nearly 50 percent of births in the
United States are covered by Medicaid, the
government program for low-income families
without health insurance, which has offered
safety-net coverage for pregnant women since
the 1980s. A recent study found that women
receiving Medicaid during pregnancy had
attended 75 percent fewer well-woman visits
before conception than did privately insured
women. They were also 18 percent more likely
to receive late prenatal care and three times
more likely to visit an emergency department
for a pregnancy-related problem. Other
comparable nations provide comprehensive
health insurance for women before, during,
and after pregnancy, but Medicaid pregnancy
coverage ceases 60 days after delivery. Without

private insurance (often financially unrealistic)
or Medicaid recertification (unavailable to
many women due to family income levels,
particularly in states that haven’t expanded
Medicaid), many women lose coverage
altogether only two months after their
child is born. The reform that would do
the most to improve postpartum access to
care, then, is the extension of pregnancy
Medicaid coverage from two to 12 months
postpartum. Proposals to extend Medicaid
coverage are currently being advocated at
both the state and federal level; one such
proposal is contained in a bill—S.1343,
or the MOMMIES Act—introduced by a
number of US senators in May 2019. The
2020 Democratic presidential nominee, Joe
Biden, has also released a proposal to expand
Medicaid coverage to low-income individuals
who are otherwise uninsured. Losing health
care not only deprives new mothers of
screening and treatment opportunities but
also increases the risk that their children will
suffer neurodevelopmental problems related
to maternal health.

Problems with access to health care are
also compounded by race, ethnicity, and
citizenship status. In the United States,
Black women are three to four times more
likely to die of pregnancy-related causes
than are non-Hispanic white women; they
are also more likely to suffer life-threatening
complications during pregnancy and
childbirth. In addition to patient, community,
and system-level factors that pregnant women
may contend with, health care providers may
have entrenched implicit or unconscious
bias against minority groups that significantly
affect patient-provider interactions, treatment
decisions, and health outcomes. Implicit bias
education and training for providers could

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 27

make culturally competent maternal health
care more widely available.

Paid Parental Leave

Another way to reduce maternal stress and
depression would be to build in a longer
period of adjustment to the postpartum
period for parents through a federal paid
family leave policy. Parents need time to learn
their infant’s signals, facilitate breastfeeding
(recommended until at least six months of age
by the American Academy of Pediatrics and
the World Health Organization), and attend
well-child medical visits, while infants need
time to learn their caregiver’s voice, face, and
smell. Close parental monitoring of infants in
the early months also increases the likelihood
that developmental delays, estimated to affect
up to 13 percent of infants and toddlers, will
be noticed and addressed early, preventing
long-term impairments to social-emotional,
cognitive, and language capabilities. Research
supports these arguments. Studies of policies
in California and New Jersey have found that
paid family leave increases the likelihood of
exclusive breastfeeding at six months and
reduces hospitalizations for infections and
illnesses that an infant with good preventative
care is less likely to contract. Other outcomes
include improved health in school-aged
children through reductions in ADHD and
hearing and weight problems, all of which
improve the long-term bottom line of public
health budgets.

Over four million babies are born in the
United States each year, and almost 60 percent
of mothers with infants are in the labor force.
A comprehensive federal paid family leave
policy of at least 12 weeks’ duration would
improve outcomes for these mothers and their
children. Studies show an inverse relationship

between maternal depressive symptoms and
leave duration up to six months postpartum.
Although the Family and Medical Leave
Act (FMLA) allows 12 weeks of unpaid,
job-protected parental leave, 40 percent of
workers are ineligible for the federal program
because they work for employers with fewer
than 50 employees, work part time, or have
spent insufficient time on the job to qualify.
And even among eligible employees, nearly
half are unable to take it because it is unpaid.
A welcome development is the Federal
Employee Paid Leave Act, signed into law in
December 2019 and effective as of October
2020, which provides 12 weeks’ paid parental
leave for federal employees eligible under the
FMLA. But families that fall outside the reach
of these laws need more help. The United
States is the only country in the Organisation
for Economic Co-operation and Development
that doesn’t provide paid leave for mothers
employed in the private sector. Although
corporate America has begun to recognize the
benefits of strong family leave policy—many
leading Fortune 500 companies, including
Apple, Amazon, and Bank of America offer
plans ranging from six to 16 weeks’ paid
leave—this progress often exclusively benefits
relatively well-off, highly educated women
rather than low-income, hourly employees.
A national 12-week paid leave policy, such as
that reflected in legislation introduced in the
United States Senate in March 2019 (S.463, or
the FAMILY Act), could reduce anticipatory
and actual distress during pregnancy and the
postpartum period and alleviate systemic
racial disparities in maternal and child health
outcomes (both of which, research suggests,
can lead to reduced rates of preterm birth and
low birthweight infants). Parents need time
needed to build the foundational relationships
and skills essential for developmental success.

Alexandra O’Sullivan and Catherine Monk

28 THE FUTURE OF CHILDREN

Conclusions

The four trimesters that make up the

perinatal and early postpartum period and

the following nine months of a baby’s life

represent a time of both great vulnerability

and opportunity for the mother and child.

Almost one American woman in four will

experience psychological distress during

these periods, and increased exposure to

health care providers would provide more

opportunities to help women get mental

health care, parenting help, and social

services. Similarly, though biological
pathways for the transmission of risk
for psychiatric illness emphasize the
importance of the womb as the infant’s
influential first home, qualities of the
mother’s life, experiences of optimal early-
infancy childcare, and other reinforcing
social factors can buffer risks and reorient
both the child and the mother-child pair
toward a strong developmental trajectory.
Maternal health and life experiences matter
not just for the mother but for the health of
the generation that follows.

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 29

Endnotes

1. David. J. Barker, “The Wellcome Foundation Lecture, 1994: The Fetal Origins of Adult Disease,”
Proceedings of the Royal Society B 262 (1995): 37–43, https://doi.org/10.1098/rspb.1995.0173.

2. Catherine Monk, Claudia Lugo-Candelas, and Caroline Trumpff, “Prenatal Developmental Origins of
Future Psychopathology: Mechanisms and Pathways,” Annual Review of Clinical Psychology 15 (2019):
317–44, https://doi.org/10.1146/annurev-clinpsy-050718-095539.

3. Miia Artama et al., “Congenital Structural Anomalies in Offspring of Women with Epilepsy—A
Population-Based Cohort Study in Finland,” International Journal of Epidemiology 35 (2005): 280–87,
https://doi.org/10.1093/ije/dyi234.

4. Gregory Z. Tau and Bradley S. Peterson, “Normal Development of Brain Circuits,”
Neuropsychopharmacology 35 (2010): 147–68, https://doi.org/10.1038/npp.2009.115.

5. Nuri B. Farber, Catherine E. Creeley, and John W. Olney, “Alcohol-Induced Neuroapoptosis in
the Fetal Macaque Brain,” Neurobiology of Disease 40 (2010): 200–206, https://doi.org/10.1016/j.
nbd.2010.05.025.

6. Carolyn Granier-Deferre et al., “A Melodic Contour Repeatedly Experienced by Human Near-Term
Fetuses Elicits a Profound Cardiac Reaction One Month after Birth,” PLOS One 6 (2011): e17304,
https://doi.org/10.1371/journal.pone.0017304.

7. Oriana Vesga-López et al., “Psychiatric Disorders in Pregnant and Postpartum Women in the United
States,” Archives of General Psychiatry 65 (2008): 805–15, https://doi.org/10.1001/archpsyc.65.7.805.

8. Linda H. Chaudron et al., “Accuracy of Depression Screening Tools for Identifying Postpartum
Depression among Urban Mothers,” Pediatrics 125, no. 3 (2010): e609–e17, https://doi.org/10.1542/
peds.2008-3261.

9. Bea R. H. Van den Bergh et al., “Prenatal Developmental Origins of Behavior and Mental Health: The
Influence of Maternal Stress in Pregnancy,” Neuroscience & Biobehavioral Reviews, corrected proof,
July 28, 2017, https://doi.org/10.1016/j.neubiorev.2017.07.003.

10. Kieran J. O’Donnell et al., “The Persisting Effect of Maternal Mood in Pregnancy on Childhood
Psychopathology,” Development and Psychopathology 26 (2014): 393–403, https://doi.org/10.1017/
S0954579414000029.

11. Van den Bergh et al., “Prenatal Developmental Origins.”

12. Kate Walsh et al., “Maternal Prenatal Stress Phenotypes Associate with Fetal Neurodevelopment and
Birth Outcomes,” Proceedings of the National Academy of Sciences 116 (2019): 23996–24005, https://
doi.org/10.1073/pnas.1905890116.

13. Claudia Buss et al., “High Pregnancy Anxiety during Mid-Gestation Is Associated with Decreased Gray
Matter Density in 6–9-Year-Old Children,” Psychoneuroendocrinology 351 (2010): 141–53, https://doi.
org/10.1016/j.psyneuen.2009.07.010.

14. Klára Marec̆ková et al., “Perinatal Stress and Human Hippocampal Volume: Findings from
Typically Developing Young Adults,” Scientific Reports 8 (2018): 4696, https://doi.org/10.1038/
s41598-018-23046-6.

15. Elysia Poggi Davis et al., “Prenatal Maternal Stress, Child Cortical Thickness, and Adolescent
Depressive Symptoms,” Child Development 91 (2019): e432–e50, https://doi.org/10.1111/cdev.13252.

16. Jonathan Posner et al., “Alterations in Amygdala–Prefrontal Circuits in Infants Exposed to Prenatal
Maternal Depression,” Translational Psychiatry 6 (2016): e935, https://doi.org/10.1038/tp.2016.146.

Alexandra O’Sullivan and Catherine Monk

30 THE FUTURE OF CHILDREN

17. Colleen Doyle et al., “Pregnancy Distress Gets under Fetal Skin: Maternal Ambulatory Assessment and
Sex Differences in Prenatal Development,” Developmental Psychobiology 57 (2015): 607–25, https://
doi.org/10.1002/dev.21317.

18. Amy M. Padula et al., “A Review of Maternal Prenatal Exposures to Environmental Chemicals and
Psychosocial Stressors—Implications for Research on Perinatal Outcomes in the ECHO Program,”
Journal of Perinatology 40 (2019): 10–24, https://doi.org/10.1038/s41372-019-0510-y.

19. Payam Dadvand et al., “Inequality, Green Spaces, and Pregnant Women: Roles of Ethnicity and
Individual and Neighbourhood Socioeconomic Status,” Environment International 71 (2014): 101–8,
https://doi.org/10.1016/j.envint.2014.06.010.

20. Ann Borders et al., “Racial/Ethnic Differences in Self-Reported and Biologic Measures of Chronic
Stress in Pregnancy,” Journal of Perinatology 35 (2015): 580–84, https://doi.org/10.1038/jp.2015.18.

21. Catherine Monk, Michael K. Georgieff, and Erin A. Osterholm, “Maternal Prenatal Distress and Poor
Nutrition—Mutually Influencing Risk Factors Affecting Infant Neurocognitive Development,” Journal
of Child Psychology and Psychiatry 54 (2013): 115–30, https://doi.org/10.1111/jcpp.12000.

22. Monk, Georgieff, and Osterholm, “Maternal Prenatal Distress.”

23. Sherry A. Ferguson et al., “Behavioral Effects of Prenatal Folate Deficiency in Mice,” Birth Defects
Research Part A: Clinical and Molecular Teratology 73 (2005): 249–52, https://doi.org/10.1002/
bdra.20111.

24. Jill Jin, “Folic Acid Supplementation for Prevention of Neural Tube Defects,” JAMA 317 (2017): 222,
https://doi.org/10.1001/jama.2016.19767.

25. Robert Freedman, Sharon K. Hunter, and M. Camille Hoffman, “Prenatal Primary Prevention of
Mental Illness by Micronutrient Supplements in Pregnancy,” American Journal of Psychiatry 175
(2018): 607–19, https://doi.org/10.1176/appi.ajp.2018.17070836.

26. Angelie Singh et al., “Micronutrient Dietary Intake in Latina Pregnant Adolescents and Its Association
with Level of Depression, Stress, and Social Support,” Nutrients 9 (2017): 1212, https://doi.org/10.3390/
nu9111212.

27. Rachel Baskin et al., “The Association between Diet Quality and Mental Health during the Perinatal
Period: A Systematic Review,” Appetite 91 (2015): 41–47, https://doi.org/10.1016/j.appet.2015.03.017.

28. US Preventive Services Task Force, “Folic Acid Supplementation for the Prevention of Neural Tube
Defects: US Preventive Services Task Force Recommendation Statement,” JAMA 317 (2017): 183–89,
https://doi.org/10.1001/jama.2016.19438.

29. Eugene C. Wong et al., “Trends in Multivitamin Use Among Women of Reproductive Age: United
States, 2006–2016,” Journal of Women’s Health 28 (2019): 37–45, https://doi.org/10.1089/jwh.2018.7075.

30. Padula et al., “Review of Maternal Prenatal Exposures.”

31. David M. Stieb et al., “Ambient Air Pollution, Birth Weight, and Preterm Birth: A Systematic
Review and Meta-Analysis,” Environmental Research 117 (2012): 100–11, https://doi.org/10.1016/j.
envres.2012.05.007.

32. Ariana Zeka, Steve J. Melly, and Joel Schwartz, “The Effects of Socioeconomic Status and Indices
of Physical Environment on Reduced Birth Weight and Preterm Births in Eastern Massachusetts,”
Environmental Health 7 (2008): 60, https://doi.org/10.1186/1476-069X-7-60.

33. Ruth A. Hackett and Andrew Steptoe, “Type 2 Diabetes Mellitus and Psychological Stress—A
Modifiable Risk Factor,” Nature Reviews Endocrinology 13 (2017): 547–60, https://doi.org/10.1038/
nrendo.2017.64.

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 31

34. Shanchun. Zhang et al., “Association between Mental Stress and Gestational Hypertension/Preeclampsia:
A Meta-Analysis,” Obstetrical & Gynecological Survey 68, no. 12 (2013): 825–34, https://doi.org/10.1097/
OGX.0000000000000009.

35. Walsh et al., “Maternal Prenatal Stress Phenotypes.”

36. Berihun Assefa Dachew et al., “Association between Hypertensive Disorders of Pregnancy and the
Development of Offspring Mental and Behavioural Problems: A Systematic Review and Meta-Analysis,”
Psychiatry Research 260 (2018): 458–67, https://doi.org/10.1016/j.psychres.2017.12.027.

37. Anny H. Xiang et al., “Association of Maternal Diabetes with Autism in Offspring,” JAMA 313 (2015):
1425–34, https://doi.org/10.1001/jama.2015.2707.

38. Stephen Patrick et al., “Increasing Incidence and Geographic Distribution of Neonatal Abstinence
Syndrome: United States 2009 to 2012,” Journal of Perinatology 35 (2015): 650–55, https://doi.
org/10.1038/jp.2015.36.

39. Su Lynn Yeoh et al., “Cognitive and Motor Outcomes of Children with Prenatal Opioid Exposure: A
Systematic Review and Meta-Analysis,” JAMA Network Open 2 (2019): e197025, https://doi.org/10.1001/
jamanetworkopen.2019.7025.

40. Jing Liu et al., “Neonatal Neurobehavior Predicts Medical and Behavioral Outcome,” Pediatrics 125
(2010): e90–e98, https://doi.org/10.1542/peds.2009-0204.

41. Elizabeth Werner et al., “Preventing Postpartum Depression: Review and Recommendations,” Archives
of Women’s Mental Health 18 (2015): 41–60, https://doi.org/10.1007/s00737-014-0475-y.

42. Miki Bloch et al., “Risk Factors for Early Postpartum Depressive Symptoms,” General Hospital
Psychiatry 28 (2006): 3–8, https://doi.org/10.1016/j.genhosppsych.2005.08.006.

43. Chaudron et al., “Accuracy of Depression Screening Tools.”

44. Tiffany Field, “Postpartum Depression Effects on Early Interactions, Parenting, and Safety Practices: A
Review,” Infant Behavior and Development 33 (2010): 1–6, https://doi.org/10.1016/j.infbeh.2009.10.005.

45. Catherine Monk, Kristin L. Leight, and Yixin Fang, “The Relationship between Women’s Attachment
Style and Perinatal Mood Disturbance: Implications for Screening and Treatment,” Archives of Women’s
Mental Health 11 (2008): 117–29, https://doi.org/10.1007/s00737-008-0005-x; Laurie A. Chapin and
Shannon Altenhofen, “Neurocognitive Perspectives in Language Outcomes of Early Head Start:
Language and Cognitive Stimulation and Maternal Depression,” Infant Mental Health Journal 31 (2010):
486–98, https://doi.org/10.1002/imhj.20268.

46. Elena Netsi et al., “Association of Persistent and Severe Postnatal Depression with Child Outcomes,”
JAMA Psychiatry 75 (2018): 247–53, https://doi.org/10.1001/jamapsychiatry.2017.4363.

47. Amie Ashley Hane and Nathan A. Fox, “Ordinary Variations in Maternal Caregiving Influence
Human Infants’ Stress Reactivity,” Psychological Science 17 (2006): 550–56, https://doi.
org/10.1111/j.1467-9280.2006.01742.x.

48. Eric D. Finegood et al., “Parenting in Poverty: Attention Bias and Anxiety Interact to Predict Parents’
Perceptions of Daily Parenting Hassles,” Journal of Family Psychology 31 (2017): 51–60, https://doi.
org/10.1037/fam0000291.

49. Esther M. Leerkes, A. Nayena Blankson, and Marion O’Brien, “Differential Effects of Maternal
Sensitivity to Infant Distress and Nondistress on Social-Emotional Functioning,” Child Development 80
(2009): 762–75, https://doi.org/10.1111/j.1467-8624.2009.01296.x.

50. Lauren A. Kaplan, Lynn Evans, and Catherine Monk, “Effects of Mothers’ Prenatal Psychiatric Status
and Postnatal Caregiving on Infant Biobehavioral Regulation: Can Prenatal Programming Be Modified?,”
Early Human Development 84 (2008): 249–56, https://doi.org/10.1016/j.earlhumdev.2007.06.004.

Alexandra O’Sullivan and Catherine Monk

32 THE FUTURE OF CHILDREN

51. Catherine Monk et al., “Distress During Pregnancy: Epigenetic Regulation of Placenta Glucocorticoid-
Related Genes and Fetal Neurobehavior,” American Journal of Psychiatry 173 (2016): 705–13, https://
doi.org/10.1176/appi.ajp.2015.15091171.

52. Zaneta M. Thayer et al., “Impact of Prenatal Stress on Offspring Glucocorticoid Levels: A Phylogenetic
Meta-Analysis across 14 Vertebrate Species,” Scientific Reports 8 (2018): 4942, https://doi.org/10.1038/
s41598-018-23169-w.

53. Monk, Lugo-Candelas, and Trumpff, “Prenatal Developmental Origins.”

54. Elisabeth Conradt et al., “The Roles of DNA Methylation of NR3C1 and 11ß-HSD2 and Exposure to
Maternal Mood Disorder In Utero on Newborn Neurobehavior,” Epigenetics 8 (2013): 1321–29, https://
doi.org/10.4161/epi.26634.

55. Pamela Scorza et al., “Intergenerational Transmission of Disadvantage: Epigenetics and Parents’
Childhoods as the First Exposure,” Journal of Child Psychology and Psychiatry 60 (2019): 119–32,
https://doi.org/10.1111/jcpp.12877.

56. Monk, Lugo-Candelas, and Trumpff, “Prenatal Developmental Origins.”

57. Ibid.

58. Frances Rice et al., “The Links between Prenatal Stress and Offspring Development and
Psychopathology: Disentangling Environmental and Inherited Influences,” Psychological Medicine 40
(2010): 335–45, https://doi.org/10.1017/S0033291709005911.

59. Nathalie MacKinnon et al., “The Association between Prenatal Stress and Externalizing Symptoms
in Childhood: Evidence From the Avon Longitudinal Study of Parents and Children,” Biological
Psychiatry 83 (2018): 100–108, https://doi.org/10.1016/j.biopsych.2017.07.010.

60. Céline Tallet et al., “Postnatal Auditory Preferences in Piglets Differ according to Maternal Emotional
Experience with the Same Sounds during Gestation,” Scientific Reports 6 (2016): 37238, https://doi.
org/10.1038/srep37238.

61. Tallie Z. Baram et al., “Fragmentation and Unpredictability of Early-Life Experience in Mental
Disorders,” American Journal of Psychiatry 169 (2012): 907–15, https://doi.org/10.1176/appi.
ajp.2012.11091347.

62. Ibid.

63. Elysia Poggi Davis et al., “Across Continents and Demographics, Unpredictable Maternal Signals
Are Associated with Children’s Cognitive Function,” EBioMedicine 46 (2019): 256–63, https://doi.
org/10.1016/j.ebiom.2019.07.025.

64. Nicole L. Letourneau et al., “The Effect of Perinatal Depression Treatment for Mothers on Parenting
and Child Development: A Systematic Review,” Depression and Anxiety 34 (2017): 928–66, https://doi.
org/10.1002/da.22687.

65. Susan J. Curry et al., “Interventions to Prevent Perinatal Depression,” JAMA 321 (2019): 580–87,
https://doi.org/10.1001/jama.2019.0007.

66. Tamar Mendelson et al., “Impact of a Preventive Intervention for Perinatal Depression on Mood
Regulation, Social Support, and Coping,” Archives Womens’ Mental Health 16 (2013): 211–18, https://
doi.org/10.1007/s00737-013-0332-4.

67. S. Darius Tandon et al., “Perinatal Depression Prevention through Home Visitation: A Cluster
Randomized Trial of Mothers and Babies 1-on-1,” Journal of Behavioral Medicine 41 (2018): 641–52,
https://doi.org/10.1007/s10865-018-9934-7.

Maternal and Environmental Influences on Perinatal and Infant Development

VOL. 30 / NO. 2 / FALL 2020 33

68. Lois S. Sadler et al., “Minding the Baby: Enhancing Reflectiveness to Improve Early Health and
Relationship Outcomes in an Interdisciplinary Home-Visiting Program,” Infant Mental Health Journal
34 (2013): 391–405, https://doi.org/10.1002/imhj.21406.

69. Monica Roosa Ordway et al., “A Home Visiting Parenting Program and Child Obesity: A Randomized
Trial,” Pediatrics 141 (2018): e20171076, https://doi.org/10.1542/peds.2017-1076.

70. Arietta Slade et al., “Minding the Baby®: Enhancing Parental Reflective Functioning and Infant
Attachment in an Attachment-Based, Interdisciplinary Home Visiting Program,” Development and
Psychopathology 32 (2020): 123–37, https://doi.org/10.1017/S0954579418001463.

71. Walsh et al., “Maternal Prenatal Stress Phenotypes.”

72. Desiree Y. Phua et al., “Positive Maternal Mental Health during Pregnancy Associated with Specific
Forms of Adaptive Development in Early Childhood: Evidence from a Longitudinal Study,”
Development and Psychopathology 29 (2017): 1573–87, https://doi.org/10.1017/S0954579417001249.

73. Vivette Glover and Lauren Capron, “Prenatal Parenting,” Current Opinion in Psychology 15 (2017):
66–70, https://doi.org/10.1016/j.copsyc.2017.02.007.

74. Sherryl H. Goodman and Judy Garber, “Evidence-Based Interventions for Depressed Mothers and
Their Young Children,” Child Development 88 (2017): 368–77, https://doi.org/10.1111/cdev.12732.

75. Elizabeth A. Werner et al., “PREPP: Postpartum Depression Prevention through the Mother-Infant
Dyad,” Archives of Women’s Mental Health 19 (2016): 229–42, https://doi.org/10.1007/s00737-015-
0549-5; Elysia Poggi Davis et al., “An Experimental Test of the Fetal Programming Hypothesis: Can
We Reduce Child Ontogenetic Vulnerability to Psychopathology by Decreasing Maternal Depression?,”
Development and Psychopathology 30 (2018): 787–806, https://doi.org/10.1017/S0954579418000470.

76. Claire Howorth, “Motherhood Is Hard to Get Wrong: So Why Do So Many Moms Feel So Bad About
Themselves?,” Time, October 19, 2017, https://time.com/4989068/motherhood-is-hard-to-get-wrong/.

77. Glover and Capron, “Prenatal Parenting.”

78. Janine Archer et al., “Collaborative Care for Depression and Anxiety Problems,” Cochrane Database of
Systematic Reviews (2012): https://doi.org/10.1002/14651858.cd006525.pub2.

79. Nancy Byatt et al., “Improving Perinatal Depression Care: The Massachusetts Child Psychiatry
Access Project for Moms,” General Hospital Psychiatry 40 (2016): 12–17, https://doi.org/10.1016/j.
genhosppsych.2016.03.002.

80. Nancy Byatt et al., “Massachusetts Child Psychiatry Access Program for Moms: Utilization and
Quality Assessment,” Obstetrics & Gynecology 132 (2018): 345–53, https://doi.org/10.1097/
aog.0000000000002688.

81. Nancy Byatt et al., “PRogram In Support of Moms (PRISM): Development and Beta Testing,”
Psychiatric Services 67 (2016): 824–26, https://doi.org/10.1176/appi.ps.201600049.

82. Tiffany A. Moore Simas et al., “The PRogram in Support of Moms (PRISM): Study Protocol for a
Cluster Randomized Controlled Trial of Two Active Interventions Addressing Perinatal Depression
in Obstetric Settings,” BMC Pregnancy and Childbirth 19 (2019): 256, https://doi.org/10.1186/
s12884-019-2387-3.

83. Health Resources and Services Administration, “HRSA Awards over $12M for Maternal & Child Mental
Health Programs,” news release, September 25, 2018, https://www.hrsa.gov/about/news/press-releases/
hrsa-awards-12-million-maternal-child-mental-health-programs.

84. Kimberly Ann Yonkers, Simone Vigod, and Lori E. Ross, “Diagnosis, Pathophysiology, and Management
of Mood Disorders in Pregnant and Postpartum Women,” Obstetrics & Gynecology 117 (2011): 961–77,
https://doi.org/10.1097/AOG.0b013e31821187a7.

Alexandra O’Sullivan and Catherine Monk

34 THE FUTURE OF CHILDREN

85. “HealthySteps Evidence Summary,” Zero to Three, 2017, https://ztt-healthysteps.s3.amazonaws.com/
documents/5/attachments/HealthySteps_OutcomesSummary.FINAL.10.09.18 ?1539967621.

86. William N. Evans and Craig L. Garthwaite, “Giving Mom a Break: The Impact of Higher EITC
Payments on Maternal Health,” American Economic Journal: Economic Policy 6 (2014): 258–90, https://
doi.org/10.1257/pol.6.2.258.

87. Mathematica, “New Study Uncovers the Heavy Financial Toll of Untreated Maternal
Mental Health Conditions,” April 29, 2019, https://www.mathematica.org/news/
new-study-uncovers-the-heavy-financial-toll-of-untreated-maternal-mental-health-conditions.

88. Stephen P. Melek, Daniel Periman, and Stoddard Davenport, Addiction and Mental Health vs. Physical
Health: Analyzing Disparities in Network Use and Provider Reimbursement Rates, Milliman (Seattle,
WA: Milliman 2017), https://www.ncsl.org/documents/health/SPC19MKeller_study_34161 .

89. Yhenneko J. Taylor, Tsai-Ling Liu, and Elizabeth A. Howell, “Insurance Differences in Preventive
Care Use and Adverse Birth Outcomes Among Pregnant Women in a Medicaid Nonexpansion State:
A Retrospective Cohort Study,” Journal of Womens Health (2019): 29–37, https://doi.org/10.1089/
jwh.2019.7658.

90. Jamie R. Daw, “Missed Opportunities to Support Women’s Health: A Tale of a Medicaid Nonexpansion
State,” Journal of Women’s Health (2019): 3–4, https://doi.org/10.1089/jwh.2019.8071.

91. Usha Ranji, Ivette Gomez, and Alina Salganicoff, “Expanding Postpartum Medicaid Coverage,”
Women’s Health Policy (Kaiser Family Foundation), May 22, 2019, https://www.kff.org/
womens-health-policy/issue-brief/expanding-postpartum-medicaid-coverage/.

92. Biden for President, “Health Care,” JoeBiden.com, August 25, 2020, https://joebiden.com/healthcare/#.

93. Elizabeth A. Howell, “Reducing Disparities in Severe Maternal Morbidity and Mortality,” Clinical
Obstetrics and Gynecology 61 (2018): 387–99.

94. William J. Hall et al., “Implicit Racial/Ethnic Bias among Health Care Professionals and Its Influence
on Health Care Outcomes: A Systematic Review,” American Journal of Public Health 105 (2015): e60–
e76, https://doi.org/10.2105/ajph.2015.302903.

95. Howell, “Reducing Disparities.”

96. Zero to Three, Early Intervention: A Critical Support for Infants, Toddlers, and Families (Washington,
DC: Zero to Three, 2017), https://www.zerotothree.org/document/981.

97. Ariel Marek Pihl and Gaetano Basso, “Did California Paid Family Leave Impact Infant Health?,”
Journal of Policy Analysis and Management 38 (2019): 155–80, https://doi.org/10.1002/pam.22101.

98. Lindsey Rose Bullinger, “The Effect of Paid Family Leave on Infant and Parental Health in the United
States,” Journal of Health Economics 66 (2019): 101–16, https://doi.org/10.1016/j.jhealeco.2019.05.006.

99. Rada K. Dagher, Patricia M. McGovern, and Bryan. E. Dowd, “Maternity Leave Duration and
Postpartum Mental and Physical Health: Implications for Leave Policies,” Journal of Health Politics,
Policy, and Law 39 (2014): 369–416, https://doi.org/10.1215/03616878-2416247.

100. Matthew Melmed, “The Importance of Paid Family Leave for American Working Families,” statement
submitted to the US Senate Committee on Finance, Subcommittee on Social Security, Pensions, and
Family Policy, July 11, 2018, https://www.zerotothree.org/document/1096.

101. Julia M. Goodman et al., “Analyzing Policies through a DOHaD Lens: What Can We Learn?,”
International Journal of Environmental Research and Public Health 15 (2018): 2906, https://doi.
org/10.3390/ijerph15122906.

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