Depression is the most common psychiatric condition among mothers and is associated with significant psychiatric and functional problems for their children ( 1, 2, 3, 4 ). Understanding the mechanisms by which these poor outcomes develop is critical for designing preventive interventions to reduce the impact of maternal depression on children. Genetic factors are likely to play a significant role ( 5, 6 ), but the parenting and stressful family situations these children experience have also been shown to make substantial contributions to their mental health problems.
When mothers are depressed, they are less likely to have positive relationships and good communication with their children ( 7, 8 ) or to engage in proactive discipline strategies ( 3, 9, 10 ). Moreover, the family environments of depressed parents are characterized by major stressful life events and conflict ( 11, 12 ). They also have lower social support ( 13 ) and family cohesion ( 14 ) than families not affected by parental depression. These are critical factors known to lead to poor adjustment of children ( 3, 15, 16 ). Low-income families in urban environments are especially likely to experience major stressors associated with inadequate resources and unsafe communities ( 17, 18, 19, 20, 21, 22 ).
However, only a few studies have explicitly tested whether the quality of parenting and the family environment can explain the differences in children's behavior that are associated with maternal depression. Researchers who have studied mechanisms behind these differences have included as participant groups mothers with distress but without a diagnosis of major depressive disorder ( 23, 24, 25, 26 ) and have relied on depressed mothers' reports of child behavior, although these reports may be distorted by mothers' negative cognition ( 27, 28 ).
In this study we investigated the association of maternal depression, parenting, and family stressors in a group of children aged four to ten whose functioning and problems were rated by their fathers, teachers, and mothers in a cross-sectional design. It involved a non-treatment-seeking sample of mothers who had diagnoses of major depressive disorder and a similar sample of mothers and children from the same low-income urban communities who had not experienced maternal depression. Data were collected in 2000–2003. Most mothers were African American or Latina. We hypothesized that children of mothers with depression would have more problems and worse functioning than their peers whose mothers did not have depression and that poor-quality parenting and low support and high stress within the family would account for these negative effects.
Methods
Participants
Mothers of four- to ten-year-old children who were participating in a randomized controlled trial of the effectiveness of depression treatments for low-income women from racial-ethnic minority groups ( 29 ) were eligible to participate in a substudy focusing on children. In the treatment study, 66% of eligible women who screened positive for depression participated. Of the 223 mothers who were eligible for the child study, 133 (60%) participated. Mothers gave written informed consent to participate with their four- to ten-year-old child, and children seven and older gave their assent. Two-thirds of the mothers had major depressive disorder, and the others were free of psychiatric disorder. There were no differences between those who did and did not participate, in terms of maternal age, ethnicity, number of children, child's age, child's gender, or, among the women with depression, their initial depression assessment score.
Half of the children had a biological father living in the home with the mother and child. For the others, a father or father figure was selected to be interviewed if the child saw him at least once per week, with the selection prioritized for whom to interview as follows: biological father not in the home; foster father, stepfather, or adoptive father in the home; stepfather or adoptive father not in the home; or the person the mother described as "most like a parent" to the child. This procedure yielded a father figure (hereafter referred to as "father") for 122 (92%) children. Of these, 111 (91%) mothers gave consent to contact the father for a phone interview, and 83 interviews with fathers (62% of sample) were completed. Among participating fathers, 62 (75%) lived in the home and 50 (60%) were biological fathers—rates that were not significantly different from those of the nonparticipating fathers. For the 118 children who attended school, interviews were completed with 89 (75%) of their teachers.
Measures
Maternal depression. Women were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) ( 30 ), which has been validated as an effective method for identifying depression among primary care medical patients ( 31, 32 ). Women who screened positive were assessed by trained lay interviewers with the Comprehensive International Diagnostic Interview (CIDI) ( 33 ), a structured psychiatric interview that uses the criteria of the DSM-IV ( 34 ).
Sociodemographic characteristics. Mothers reported their age, ethnicity, education, marital and employment status, income, receipt of public income assistance, and their child's age, race-ethnicity, gender, and grade in school.
Children's emotional and behavioral problems and adaptive skills. Mothers, fathers, and teachers completed the appropriate version of the Behavior Assessment System for Children (BASC) ( 35 ), which provides a parent report scale and teacher report scale for preschool-age children (ages four and five) and for children aged six through 11. The BASC is a set of conceptually based scales for rating child behavioral and emotional problems and social and adaptive functioning on a 4-point frequency scale. Results are reported as mean±SD T scores (T=50±10, range 0–100) that are age- and gender-normed based on a nationally representative sample. Both age versions of the parent and teacher report scales include two aggregate scales, the behavioral symptoms index (BSI) and the adaptive skills composite (ASC). The BSI is a measure of emotional and behavioral problems that combines the subscales of depression, anxiety, aggression, hyperactivity, attention problems, and atypicality. Higher BSI scores indicate more problems. The ASC measures social and adaptive functioning by combining the subscales of social skills, leadership, adaptive skills, and (from teachers only) study skills. Higher ASC scores indicate better functioning. The aggregate scales in both versions have excellent reliability, with internal consistency coefficients above .85 and retest reliability above .90 ( 35, 36 ).
Composite measures of parenting and family environment. In order to provide a single robust, composite measure of parenting and of family environment, multiple scales completed by mothers were subject to principal-components analysis. For both constructs, the first factor was used as the composite measure, because it explained a large amount of the variance and adequately fit the data (Kaiser-Meyer-Olkin test of sampling adequacy=.58 and .73 for parenting and family environment, respectively). The two composite scales were standardized with z scores (z=0±1, range -3.0 to 3.0) and coded so that higher scores indicated more positive parenting and family environment.
The parenting quality composite included four variables: two subscales from the Children's Report of Parental Behavior Inventory ( 37, 38 ), rejection (ten items; α =.72) and consistent discipline (eight items; α =.83), and two subscales from the Conflict Tactics Scales—Parent- Child version II ( 39 ), nonviolent discipline (four items; α =.76) and psychological aggression (five items; α =.77).
The family environment composite included five variables: stressful life events that the family had experienced in the previous year, adequacy of 15 resources assessed with the Family Resources Scale ( 40 ), family involvement based on the eight-item subscale from the parent report of the Child Health and Illness Profile—Child Edition ( 41 ), emotional and instrumental social support ( 42 ), and marital and relational conflict ( 42 ). Additional details on these composites are available from the first author.
Procedures
Recruitment was a multistage process involving screening for depression in more than 20 public health and social service settings and confirmation of the diagnosis by the CIDI structured interview. Eligible mothers were recruited into the child study by the staff of the treatment study ( 29 ). All procedures were approved by the relevant institutional review boards.
All mothers, with and without depression, completed a two- to three-hour interview in their home that was conducted by trained interviewers blind to mothers' depression and treatment status. Separate interviews with children lasted 45–90 minutes. Interviews were completed in Spanish, as needed, by bilingual interviewers. Interviews were completed an average of 7.8±5.0 weeks after mothers' identification for the treatment study, with 16 (19%) mothers in the depression group having a treatment visit at least one day before the baseline interview for the child study. No effects of beginning treatment before the baseline child study interview have been detected with the use of multiple analytic approaches.
Data analytic strategy
Multireporter, cross-situational assessments of children's behavior and social competence were obtained to reduce the bias of any one reporter, but the reports were too poorly correlated (range .21–.42) to simply combine them, a finding typical in the informant concordance literature ( 27, 43, 44, 45, 46, 47 ). Generalized estimating equation (GEE) methodology ( 48 ) was used to examine the extent to which mothers', fathers', and teachers' reports of each of the child outcomes were concordant. When reports were not concordant, linear regression models were fit that allowed the estimate of the association between child outcomes and independent variables to vary by rater, while appropriately taking into account the correlation of child outcomes across the three raters. Specifically, we estimated the association between the child outcomes (emotional and behavioral problems on the BASC BSI and adaptive skills on the BASC ASC) and maternal depression and sociodemographic control variables separately for each rater. Multivariate Wald statistics, appropriate with GEE methodology ( 49 ), were used to test whether the data supported the use of rater-specific associations for either maternal depression or for sociodemographic control variables. Simplified models were fit when associations were found not to vary across raters (Wald test p>.05), according to the mean of the associations for all raters. When associations varied by rater, we included rater-specific associations in the model. We then tested whether parenting and family environment characteristics mediated the association between maternal depression and children's outcomes by applying Baron and Kenny's ( 50 ) and Kenny and Kashy's ( 51 ) methodologies.
Results
The mean±SD age of mothers was 31.0±6.1. A total of 58 (44%) mothers were African American, 70 (53%) were Latina first-generation immigrants (52%), and five (4%) were Caucasian. Almost all were biological mothers (N=130; 98%). The 84 women in the depression group met criteria for current major depressive disorder on the CIDI ( 33 ); the 49 women in the comparison group had no current or past psychiatric disorders. Sixty (71%) of the mothers with depression had comorbid anxiety disorders, but mothers were excluded if they had bipolar disorder, active substance dependence, or psychotic disorder or were pregnant or breast-feeding ( 29 ). Depressed mothers reported a mean age of 25 years for onset of depression (range age seven to age 53), a mean of 4.5±4.9 lifetime episodes of major depression (range 1–25 episodes), and assessments of mild to moderate depression.
Children included 63 boys and 70 girls (age 6.6±2.1 years). Children with severe learning disabilities, mental retardation, or other developmental disabilities were excluded. Descriptive information on each subsample is given in Table 1 .
Table 1 Sociodemographic characteristics, by mother's depression status
Mothers in the nondepressed group were more likely to be married, to have the child's biological father in the home, and to have families with slightly higher incomes ( Table 1 ). Only mothers' marital status and family income were used as control variables because having the biological father in the home was so highly correlated with marital status (r=.72, p<.001). Because nine mothers reported no monthly family income, we modeled income with two variables: a dichotomous variable of $0 versus any family income (labeled "zero income") and, among those reporting any income, a continuous measure of the natural log of annual income per household member (labeled "income level"). Child's age, gender, and race-ethnicity, although not significantly different between the groups, were also entered as controls. None of the associations between these control variables and the BASC scale scores varied according to the rater of the outcome.
Rater effects on association of depression with child outcome
Table 2 provides the scores for the parent and teacher ratings on the BASC BSI and ASC scales by maternal depression group. The statistical significance of these differences by rater was examined with multivariate models ( Tables 3 and 4 ). Significant differences by rater were found in the associations between maternal depression and emotional and behavioral problems (Wald χ2 =21.87, df=2, p<.001). Although all raters reported more problems among children of mothers with depression than of those without depression, the difference between the groups was statistically significant only for mothers' reports (B=1.16 standard deviations, p<.001) and fathers' reports (B=.50 standard deviation, p<.05). Teacher-reported problems among the children of mothers with depression were only .18 standard deviation higher than problems of children of mothers without depression, and this difference was not statistically significant ( Table 3 ). Hispanic ethnicity and having no family income were also significantly related to lower levels of behavior problems. Younger children tended to have fewer problems (p<.10).
Table 2 Behavior Assessment System for Children T scores from mothers, fathers, and teachers of four- to ten-year-old children, by mother's depression status
Table 3 Regression model on effects of maternal depression, sociodemographic factors, and potential mediators on children's emotions and behavior
Table 4 Regression model on effects of depression, sociodemographic factors, and potential mediators on children's adaptive skills
The association between maternal depression and children's adaptive skills did not differ by whether the rater was the mother, father, or teacher. All raters combined rated the children of mothers with depression as having statistically significantly lower adaptive skills by approximately one-third of a standard deviation (.35) than children of mothers without depression ( Table 4 ). In addition, children of married mothers were rated as having slightly higher levels of adaptive skills.
Potential mediators between depression and child outcomes
With the first criterion met for mediation—that of a significant relationship between the independent and the dependent variables—regression analyses were conducted to determine whether maternal depression was significantly related to the potential mediators in the presence of control variables, the second criterion for mediation ( 50 ). Maternal depression status was significantly related to both parenting quality (t=4.56, df=2, p<.001; effect size=–.86, 95% confidence interval [CI]=-.90 to –.36) and family environments (t=7.43, df=2, p<.001; effect size=-1.23, CI=–1.07 to –.67), indicating that both variables could be examined as potential mediators.
The third step in testing for mediation was carried out by adding parenting to the GEE models described above in which the children's outcomes were regressed on maternal depression status and sociodemographic control variables. More positive, less punitive parenting was associated with significantly fewer emotional and behavioral problems ( Table 3, B=–.23, p<.05). Furthermore, mothers' parenting quality appeared to mediate partially the association between maternal depression and children's behavioral problems, as reported by both mothers and fathers, because once parenting entered the model, the coefficient for maternal depression was reduced by the same magnitude (approximately .15 standard deviation) for reports by both mothers and fathers and became only marginally significant for fathers. Teacher-rated differences remained nonsignificant.
When parenting was added to the regression model for children's adaptive skills, the association of maternal depression with children's adaptive skills was greatly reduced and no longer statistically significant ( Table 4 ); the difference between adaptive skills of children of mothers with depression versus those without depression was reduced from –.35 to –.15 standard deviation on the BASC ASC. Thus parenting quality fully accounted for the relationship between maternal depression and children's adaptive skills and acted as a mediator between them.
Family environment was not a significant predictor of children's emotional and behavioral problems or adaptive skills, when maternal depression was controlled in the models. This eliminated the possibility that this variable was a mediator between maternal depression and child outcomes ( Tables 3 and 4 ).
Discussion
This study extends prior research in several ways. First, the application of GEE allowed us to use data from multiple raters, allowed sample sizes to vary by rater, controlled for rater effects when they existed, and demonstrated the pervasive extent of problems in functioning, emotions, and behaviors among the children of depressed mothers compared with similar children from low-income and primarily minority families whose mothers were not depressed. Findings showed that fathers reported a moderate effect of maternal depression on children's emotional and behavioral problems (.50 standard deviation difference between groups), that the effect (difference between groups with and without maternal depression) according to mothers was much larger (1.16 standard deviations), and that teacher-reported differences between the depression groups in regard to children's emotional and behavioral problems were nonsignificant. Quantifying these rater differences in emotional and behavioral problems helps to inform the literature about cognitive bias associated with maternal depression ( 27, 43, 44, 45, 46, 47 ) by highlighting the degree to which the perspectives of different raters differed. Also important in terms of measurement is that all raters observed similar levels of impaired adaptive functioning for children of depressed versus not depressed mothers—even teachers who did not observe differences in emotional or behavioral problems.
Second, we extended prior research indicating that parenting that lacks warmth, is inconsistent, and involves harsh discipline may be an important mechanism by which maternal depression is associated with children's emotional and behavioral problems and poor adaptive skills. The latter finding is consistent with prior longitudinal research using nonclinical but low-income samples ( 23, 24 ). The fact that mediation was observed for fathers' reports of child problems and functioning is particularly informative, adding an independent, potentially more objective outcome assessment than that of mothers who were depressed. Contrary to our hypotheses, family environment was not a mediator of these associations, primarily because it was not associated with the outcome variables once maternal depression was controlled for.
Despite large and statistically significant differences between the children of mothers with and without depression, the average BASC BSI and ASC scores were not in the clinical range for either group. Only about a fourth of the children of depressed mothers had scores in the clinical range, and less than 10% (N=3) of them had received any mental health services. The young age of this cohort may explain why their problems were not as severe as those typically observed in studies with older children of depressed mothers ( 3, 15, 16 ). As would be expected from the low number who showed a clinically defined need for services, less than 10% (N=3) of the children of depressed mothers and none of the children of nondepressed mothers had received any mental health treatment. Although Hispanic children had fewer behavior problems overall, separate analyses have demonstrated that the basic effect of maternal depression did not vary by ethnicity in that both Hispanic and African-American children of mothers with depression had significantly more problems than their peers whose mothers were not depressed.
Several limitations must be considered when interpreting these results. First, cross-sectional evidence of mediation by parenting is only the first step in demonstrating a possible causal pathway. Longitudinal analyses are needed to confirm the mediating pathways between maternal depression and child outcomes. Participant recruitment was an anticipated and significant difficulty, because the very characteristics that make the lives of these mothers and families important to understand also create challenges to involving them in research. Consequently, in both the women's treatment study and this study of children, approximately one-third of eligible participants did not complete data collection, largely because of difficulty in contacting them. Furthermore, sample sizes varied depending on the reporter of the measures, and many mothers were interviewed later than planned. Finally, a few mothers had their first treatment appointment—and a few others knew their treatment assignment—before their child study interview, so expectations regarding treatment may have influenced their ratings. However, we have not been able to detect any evidence of this effect. Further longitudinal analyses with this sample will explore the extent to which children's behavior and functioning improves when mothers' depression is treated, as well as whether their need for mental health services increases over time when maternal depression does not remit.
Conclusions
This study provides evidence that the behavioral, emotional, and functional problems of children of depressed mothers living in low-income, high-risk urban environments are significantly greater than those of similar children whose mothers do not have depression. These differences in outcomes were observed by mothers, fathers, and teachers, despite important distinctions in their perceptions. The multi-informant, cross-situational nature of the data about children's problems and adaptive functioning and our ability to control for rater effects enhanced the strength of the finding that the associations with maternal depression were likely to be mediated through the quality of mothers' parenting. We did not find that the family environment made an independent contribution to poor child outcomes. This may be partly attributable to the specific stressors and strengths in the composite measure. But the lack of effect may be due to having a comparison group of low-income, minority families who are also affected by factors associated with poverty and discrimination, although not those unique to maternal depression.
Depression is most common in low-income, racial-ethnic minority, urban families ( 52, 53 ), and the results of this study indicate that depression appears to confer a level of risk for children over and above that of poverty. It is worth noting that although children of mothers with depression had significantly more problems than children of mothers without depression, and approximately a quarter had clinically severe problems, most children's problems were not in the clinical range on the problem scales. This finding suggests that some children and their families are more able to cope, at least during childhood, with the stressors associated with maternal depression. Nonetheless, such early problems often increase the likelihood of significant emotional and physical health problems for children later in life ( 54, 55 ), highlighting the importance of developing policies and practices to address the health services needs of these children and families ( 8, 56 ).
Ensuring effective treatment for depressed mothers is critical ( 57, 58, 59, 60 ). However, these results indicate that family-level services are likely to also be necessary, consistent with theoretical models ( 3, 9, 56, 60 ). It is important to translate promising new family interventions ( 56, 60, 61, 62, 63 ) into routine services designed to enhance parenting in families affected by maternal depression. To produce an impact, these interventions will have to not only be effective but also accessible. Adequate mechanisms for reimbursing family intervention services will be needed in order to stimulate the development and adoption of such services. Enhancing the opportunities for intervening with families affected by maternal depression is one important avenue for addressing the multiple needs of these children and their families and may to help reduce the distress and problems they often experience.
Acknowledgments and disclosures
This research was supported by grants MH-58384 to Dr. Riley and MH-56864 to Dr. Miranda from the National Institute of Mental Health. The authors thank the families and many clinic staff who participated in this project and acknowledge the analytic assistance of Maureen Keefer, Judy Robertson, and Carrie Mills. This work was not conducted as part of Dr. Broitman's official duties as a U.S. government employee.
The authors report no competing interests.
Footnote
Dr. Riley is affiliated with the Department of Population, Family, and Reproductive Health and Dr. Bandeen-Roche and Dr. Colantuoni are with the Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe St., E4539, Baltimore, MD 21205 (e-mail: [email protected]). Dr. Coiro is with the Department of Psychology, Loyola College, Baltimore. Dr. Broitman is with the National Institute of Mental Health, Bethesda, Maryland. Dr. Hurley is with the Department of Pediatrics, University of Maryland, Baltimore. Dr. Miranda is with the Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles.
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