ACEs and Postpartum Depressive Symptoms

In This Post

Featured Article
Article Title
Authors
Abstract
Keywords
Summary of Research
Translating Research into Practice
Other Interesting Tidbits for Researchers and Clinicians

Featured Article

Journal of Child & Adolescent Trauma | 2025, Vol. 18, p. 905 - 914

Article Title

Patterns of Adverse Childhood Experiences and Postpartum Depressive Symptoms

Authors

Sunny H. Shin; College of Public Health, Department of Social Work, George Mason University, 4408 Patriot Circle, Fairfax, VA 22030, USA

Changyong Choi; Department of Social Welfare, Gachon University, Sujeong-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

Gabriela Ksinan Jiskrova; Research Centre for Toxic Compounds in the Environment, Faculty of Science, Masaryk University, Brno, Czech Republic

Camie A. Tomlinson; Kent School of Social Work and Family Science, University of Louisville, Louisville, KY, USA

Casey B. Corso; Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, US

Tiffany Kimbrough; School of Medicine, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA

Abstract

Adverse childhood experiences (ACEs) have been linked with increased risk for postpartum depression, which subsequently can lead to poor maternal and infant outcomes. The present study investigated how different patterns of ACEs are associated with postpartum depressive symptoms and with use of depression screening services. A racially/ethnically diverse sample of low-income women (N = 427) in an urban, university hospital in the Mid-Atlantic region reported their ACEs, depressive symptoms, receipt of depression screening, and receipt of a postpartum home visit. Three latent classes of maternal ACEs were identified: Low ACEs (57% of the sample), High Parental Separation/Divorce (30%), and High/ Multiple ACEs (13%). Participants in the High/Multiple ACEs classes reported the highest levels of depressive symptoms, followed by women in the High Parental Separation/Divorce class, then the Low ACEs class. There were no statistically significant differences in depression screening services used across the three classes. Findings highlight the importance of screening for maternal ACEs during the perinatal period and targeting depression prevention services based on ACEs. More specifically, findings suggest multiple types of ACEs at high levels may be a more important predictor of depressive symptoms postpartum than the specific types of ACEs that are experienced.

Keywords

Adverse childhood experiences, postpartum depression, Maternal health, depression screening, latent class analysis

Summary of Research

Postpartum depression (PPD) is described as “a common and significant public health issue,” with depressive symptoms associated with “a wide variety of negative maternal and child health outcomes, disrupted maternal-child bonding, and long-term cognitive, emotional, and behavioral development problems in children.” Although “there is a growing consensus on the importance of screening for PPD symptoms,” a significant proportion of women remain undetected or undiagnosed, making it “an important public health task to identify risk factors of PPD.” Adverse childhood experiences (ACEs) “have been linked to long-term physical, mental, and behavioral health challenges,” and “individuals with high ACEs exposure face increased risks for chronic mental health problems and mood disorders, such as PPD, due to the cumulative effects of early life stress on emotional regulation and neurobiological functioning.” Because previous research has predominantly examined “the dosage effect of ACEs on PPD by using a count of different types of ACEs,” the study used a person-centered approach to provide “a more nuanced examination of the relation between exposure to ACEs and PPD.” The study had three aims: “(a) to identify latent classes of women based on their patterns of exposure to ACEs, (b) to examine the associations between latent class membership and PPD symptoms, adjusting for the effects of covariates, and (c) to determine whether latent class membership is associated with PPD screening” (p. 905 - 906).

“The present study utilized a sample of 427 women at a large university medical center who participated in the Longitudinal Infant and Family Environment (LIFE) study.” “Follow-up data were collected around seven days via nurses at home visitation and three months postpartum via online survey.” Participants “retrospectively reported their exposure to ACEs before age 18,” while PPD symptoms were measured using “the modified version of the Patient Health Questionnaire-2 (PHQ-2).” Screening for PPD was assessed by asking whether participants had received “a postpartum checkup” and whether “a doctor, nurse, or other health care worker” had asked if they were “feeling down or depressed.” “Latent class analysis (LCA) was used to identify distinct ACEs exposure classes,” and “the associations between ACEs classes and two distal outcomes (i.e., PPD symptoms and screening for PPD) were examined using the maximum likelihood (ML) three-step approach” (p. 906 - 907).

Around “62.5% of the study participants were exposed to at least one ACE, 15.0% were exposed to four or more ACEs, and on average were exposed to 1.6 ACEs.” The analyses identified three groups: “Low ACEs (57% of the sample),” “High Parental Separation/Divorce” (30%), and “High/Multiple ACEs (13% of the sample).” The High/Multiple ACEs class “had a high probability of exposure to seven ACEs” and “a moderate probability of exposure to two ACEs.” After controlling for covariates, “a significant link between ACEs classes and depression symptoms” was found. Compared with women in the Low ACEs class, “those in the High Parental Separation/Divorce class… and High Multiple ACEs class… reported significantly greater PPD symptoms.” Moreover, “participants in the High Multiple ACEs class demonstrated significantly greater depressive symptoms than those in the High Parental Separation/Divorce class.” Despite these differences in symptoms, “no statistically significant differences in screening for depression were found across the three classes” (p. 907 - 909).

“The present study illuminates the relationship between maternal ACEs and PPD.” Maternal ACE patterns “were differently associated with PPD symptoms,” such that women with “high levels of exposure to ACEs (i.e., high parental separation/divorce and high/multiple ACEs) reported significantly higher levels of depressive symptoms in comparison to those exposed to low ACEs.” Most notably, “those exposed to high/multiple ACEs reported the highest rates of depressive symptoms.” The findings “suggest screening for more nuanced ACEs profiles, rather than cumulative measures alone, are critical for more effective PPD screening” and provide “a more comprehensive picture of how maternal ACEs relate to both mental health and service engagement in the early postpartum period.” The authors further suggest that “exposures to multiple types of ACEs at high levels are a more important predictor of PPD symptoms than the specific types of ACEs that are experienced” (p. 910).

This pattern “may be due to stress sensitization that occurs as a result of frequent exposure to external stressors, such as ACEs.” According to this model, “exposure to multiple and/or repeated ACEs lowers the threshold necessary for future stressors to trigger symptoms of mental disorders, such as major depressive disorder.” Exposure to early life stress “has been shown to alter the regulation of cortisol, the primary stress hormone, resulting in either hyper- or hypo-responsiveness to stress in adulthood,” and “exposure to multiple types of ACEs may increase vulnerability to PPD through disruptions in stress-related neuroendocrine circuits.” Women with multiple ACEs may also face increased risk “due to re-traumatization upon recall of their own childhood experiences and memories” and may “lack social support (e.g., family support), which is a key promotive factor for mental health during the transition to motherhood.” Although the study “found no significant differences in screening for PPD based on patterns of ACEs,” the findings indicate that “screening for maternal ACEs can help to identify women who may be at higher risk for PPD symptoms during the perinatal period” (p. 910 - 911).

Translating Research into Practice

The clinical implications emphasize that “screening for ACEs is…an important aspect of perinatal care,” because “exposure to ACEs increases women’s risk for PPD and other deleterious mental health outcomes.” Although there were “no significant differences in screening for PPD based on patterns of ACEs,” the findings indicate that “screening for maternal ACEs can help to identify women who may be at higher risk for PPD symptoms during the perinatal period and for whom PPD screening should be prioritized.” Specifically, “individuals who report high exposure to ACEs should be flagged to ensure that they receive screening for depressive symptoms and PPD throughout the perinatal period.” This approach can “target women who may benefit the most from more thorough mental health assessment and timely treatment.” Women should also be offered “multiple types of resources including formal support, such as psychiatric or therapeutic care, and informal resources including meditation and physical exercise to ensure the health and wellbeing of both the mother and infant” (p. 910-911).

Other Interesting Tidbits for Researchers and Clinicians

“Interpretation of results should consider limitations of the current study. First, maternal ACEs were measured by retrospective binary self-report. While retrospective self-reports of ACEs of adult respondents have relatively high test-retest reliability, recall bias may be present. Further, frequency, severity, or duration of ACEs were not considered, and there may be other types of ACEs and adult stressful life events (e.g., intimate partner violence, racism) that may contribute to PPD risk that were unexplored. Maternal depressive symptoms were also measured by self-report and assessed in the early postpartum period in which some mothers may experience baby blues (i.e., fluctuation in mood, no interests, fatigue, anxiety). However, baby blues symptoms spontaneously resolve within 10 days while PPD symptoms have been found to emerge early and persist up to 6-months postpartum. Furthermore, only about half of the study population reported PPD screening experiences due to high attrition. While all participants were part of the LIFE study, which focused solely on infant sleep and did not include depression screening, the lack of significant differences in screening across ACEs-based classes may be more related to reduced power due to missing screening data. Finally, the generalizability of findings may also be limited by the characteristics of the sample, which was primarily composed of single, low-income, and racially/ethnically minoritized young women in an urban Mid-Atlantic setting. While this is a critically important population that is often underrepresented in research, findings may not extend to all postpartum populations. Additionally, there is potential for selection bias in that individuals who enrolled and remained in the study may differ meaningfully from those who did not participate or were lost to follow-up. For example, those with more severe PPD symptoms, unstable housing, or higher levels of adversity may have been less likely to participate or complete follow-up surveys, potentially underestimating the associations observed. Future studies should assess whether similar patterns are found in more demographically and socioeconomically diverse samples and consider strategies to reduce selection bias and improve retention” (p. 911).