Depression in Parents, Parenting, and Children Opportunities to Improve Identification, Treatment, and Prevention (2009) / Chapter Skim
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4 Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning
4 Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning
Pages 119-182
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From page 119... ...
• The poorer parenting qualities may not improve to levels com parable to those of never-depressed parents, despite remission or recovery from episodes of depression. • These patterns of parenting have been found in depressed mothers of infants and young children as well as in depressed mothers of school-age children and adolescents.
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From page 120... ...
• Depression in parents has been consistently associated with a num ber of behavior problems and psychopathology in children, includ ing higher rates of depression, earlier age of onset, longer duration, greater functional impairment, higher likelihood of recurrence, higher rates of anxiety, and higher rates and levels of severity of internalizing and externalizing symptoms and disorders in children and adolescents. Mediators and Moderators • Depression in parents is more likely to be associated with adverse outcomes in children with the presence of additional risk factors (e.g., poverty, exposure to violence, marital conflict, comorbid psy chiatric disorders, absence of father when the mother has depres sion, and clinical characteristics of the depression, such as severity and duration)
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From page 121... ...
With this in mind, the committee's task was to review the literature that focused on (1) direct association between depression in parents and parenting, child health, and child functioning; (2)
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From page 122... ...
with asthma symptoms recruited from pediatric emergency departments, also found evidence consistent with negative parenting as a partial mediator of the relation between maternal depressive symptoms and children's internalizing problems. However, despite the many strengths of this study, the reliance on a cross-sectional design limits conclusions that can be drawn about mediation.
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From page 123... ...
Parenting practices are also of concern because they are associated with depression not only during periods of elevated symptom levels or during episodes that meet diagnostic criteria for depression but also when parents who have experienced depression may be relatively symptom free. Negative parenting has been found to persist even after controlling for the presence of major depressive disorder, suggesting that depressed parents continue to parent poorly following a depressive episode (Seifer et al., 2001)
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From page 124... ...
Researchers who observed mothers in face-to-face interaction with their babies or toddlers found higher levels of depressive symptoms to be associated with less maternal responsiveness or sensitivity, less verbal and visual interaction, and more intrusiveness (Campbell et al., 2004; Civic and Holt, 2000; Easterbrooks, Biesecker, and Lyons-Ruth, 2000; Ewell Foster, Garber, and Durlak, 2007; Horwitz et al., 2007; Marchand and Hock, 1998; Murray et al., 1996a; NICHD Early Child Care Research Network, 1999; Oztop and Uslu, 2007)
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From page 125... ...
examined the associations between maternal mood and parenting behaviors through direct observations of mothers with and without a history of depression interacting with their adolescent children during a positive and a negative task. Mothers with a history of depression were significantly more likely to exhibit sad affect and disengaged and antisocial parenting behaviors than mothers with no history of depression across the two interactions, but these differences were largely accounted for by mothers' current depressive symptoms.
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From page 126... ...
. Depressed mothers exhibit both intrusive and withdrawn behaviors, and the alteration or unpredictability itself may be perceived as stressful by their children (Gelfand and Teti, 1990; Jaser et al., 2005; Palaez et al., 2008)
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From page 127... ...
As described previously, a large-scale study recently found support for parental behaviors (nurturance, rejection, and monitoring) as mediators in the association between depressive symptoms in both mothers and fathers and 10- to 15-year-olds' emergence of emotional and behavioral problems (Elgar et al., 2007)
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From page 128... ...
Research thus indicates that maternal depression increases risk for child maltreatment when it occurs in some combination with other factors, such as a maternal history of maltreatment, maternal substance abuse, or domestic violence. Mediators and Moderators of Associations Between Depression and Parenting Given the strong and consistent evidence linking depression and parenting, it is important to ask what factors might mediate the relations between parental depressive symptoms and parenting behaviors.
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From page 129... ...
(2007) found that the association of maternal depressive symptoms and lax parenting was mediated by maternal locus of control and maternal parenting stress, and the relation between maternal depressive symptoms and harsh, overreactive parenting was mediated by maternal parenting stress and maternal self-esteem.
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From page 130... ...
studied the role of maternal depressive symptoms and family relationship stress in a community sample. Mothers' initial depressive symptoms generated perceived stress in both marital and mother-adolescent relationships a year later.
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From page 131... ...
Researchers also expanded the scope of psychological outcomes studied in children of depressed parents to include other aspects of psychopathology, including other internalizing disorders as well as externalizing disorders. Other aspects of psychological functioning, some of which may themselves be developmental precursors, vulnerabilities, or early signs of disorder, are also included in this review.
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From page 132... ...
Each of these alone and in combination has the potential to exacerbate or protect against the risks to children associated with depression in parents. Empirical support for moderators provides the information for targeting interventions to subgroups of children of depressed parents by revealing those who are at even greater risk for negative outcomes relative to others who also have a parent with depression.
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From page 133... ...
That is, it is essential to consider the normative developmental accomplishments expected of children at the ages at which the effects of parental depression are being studied as well as at the time of the child's previous exposures, if any. This is especially important with the risk factor of parental depression given that depression is an episodic disorder.
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From page 134... ...
Most of the outcomes studied are crosssectional (both the parent's depression and the child's functioning were studied at the same time) rather than longitudinal (studying the parent's depression and the child's functioning at two or more times to see if changes in depression over time, such as increases in depressive symptom levels, account for changes in child functioning, such as the emergence of psychological problems)
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From page 135... ...
Second, studies examine how the children of mothers with depressive symptoms have different patterns of physical illness and health care utilization. Third, studies have investigated the role of maternal depression when the child has a chronic health condition.
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From page 136... ...
In a more recent, large, prospective cohort study that began early in pregnancy (Li, Liu, and Odouli, 2009) , clinically significant levels of depressive symptoms were associated with almost twice the risk of preterm delivery relative to women with no depressive symptoms.
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From page 137... ...
. Minkowitz's study determined that higher levels of maternal depressive symptoms at 2 to 4 months postpartum predicted fewer well-child visits up to age 24 months in a prospective primary care
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From page 138... ...
. Among some subgroups of children with specific medical conditions, high levels of maternal depressive symptoms have been found to be more common.
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From page 139... ...
. Maternal depressive symptoms measured at age 6 were strongly correlated with key predictors, parenting, and child psychosocial problems.
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From page 140... ...
Moreover, the co-occurrence of maternal depression and a chronic health condition in the child places the child at additional risk of poor outcomes. Longitudinal studies that examine more closely the pathways by which depression influences health outcomes are needed to inform effective interventions.
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From page 141... ...
point to the importance of knowing more about associations between maternal depression and the emergence of depression in children and adolescents. Many of the studies of children of depressed parents have therefore examined associations between depression in parents and depression-related outcomes in their children, including depressive symptom levels and rates of depressive disorder.
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From page 142... ...
Positive emotions might be equally important to examine as an outcome for children with depressed mothers, given that depression disorders are uniquely characterized by low positive affect or anhedonia (Clark and Watson, 1991)
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From page 143... ...
, suggesting the importance of examining self-esteem, attributional style, and deficits in cognitive problem-solving skills. Another aspect of cognitive functioning, cognitive/intellectual functioning, is sometimes studied as an outcome in association with depression in parents, although it is sometimes conceptualized as a moderator in models of risk for children with depressed mothers (Goodman and Gotlib, 1999)
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From page 144... ...
Newborn Neurobehavioral Outcomes Researchers have reported varying degrees of consistency of support for associations between elevated levels of antenatal depression and poorer newborn neurobehavioral regulation. Studies shows consistent support for antenatal depression being significantly associated with newborns' greater inconsolability (Zuckerman et al., 1990)
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From page 145... ...
. Temperament Several researchers have found that infants of depressed mothers, relative to controls, have more difficult temperament.
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From page 146... ...
. Future research not only needs to continue to address the role of child temperament but also needs to include measures of temperament, parenting, and parents' depressive symptoms that are not limited to maternal self-report for all of these variables.
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From page 147... ...
From a methodological perspective, it is important to note that findings on depression's associations with child temperament are not the result of potential biases in depressed parents' perspectives. For example, not all studies relied solely on depressed mothers' perceptions of child temperament.
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From page 148... ...
. Children of depressed mothers or mothers high in depressive symptom levels have been found to score lower on measures of intelligence in several studies (Anderson and Hammen, 1993; Hammen and Brennan, 2001; Hay and Kumar, 1995; Hay et al., 2001; Jaenicke et al., 1987; Kaplan, Beardslee, and Keller, 1987; Murray et al., 1993; Sharp et al., 1995)
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From page 149... ...
Across multiple studies, depression in mothers and high levels of depressive symptoms in mothers are associated with children, as young as age 5, showing early signs of cognitive vulnerability to depression, including being more likely than controls to blame themselves for negative outcomes, having a more negative attributional style, hopelessness, pessimism, being less likely to recall positive self-descriptive adjectives, and having lower self-worth (Anderson and Hammen, 1993; Garber and Robinson, 1997; Hammen and Brennan, 2001; Hay and Kumar, 1995; Jaenicke et al., 1987; Murray et al., 2001)
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From page 150... ...
. They found, for example, that associations between adolescents' reports of parental stress and parents' reports of adolescents' anxiety/depressive symptoms were related to adolescents' self-reported use of secondary control engagement coping and adolescents' stress reactivity (Jaser et al., 2005, 2008; Langrock et al., 2002)
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From page 151... ...
. Studies of young children interacting with their depressed mothers, best illustrated by the work of Radke-Yarrow and colleagues, revealed that children whose mothers have been depressed engage in excessive compliance, excessive anxiety, and disruptive behavior that, when the children were followed into adolescence, were found to persist over time (RadkeYarrow, 1998)
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From page 152... ...
. Even 1-week-old infants of depressed mothers, as well as 1-month-old infants, showed greater relative right frontal EEG asymmetry compared with infants of nondepressed mothers, and these early EEGs are correlated with EEGs at 3 months and 3 years (Jones et al., 1997a)
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From page 153... ...
Many studies show that rates of depression are higher in children with depressed mothers, whether the maternal depression is determined by meeting diagnostic criteria or clinically significant levels of depressive symptom scale scores, relative to a variety of controls (Beardslee et al., 1988; Billings and Moos, 1985; Goodman et al., 1994; Lee and Gotlib, 1989; Malcarne et al., 2000; Orvaschel, Walsh-Allis, and Ye, 1988; Weissman et al., 1984; Welner et al., 1977)
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From page 154... ...
In two seminal studies on this topic, based on two distinct samples (Gross et al., 2008; Gross, Shaw, and Moilanen, 2008) , most associations between maternal and paternal depression and children's internalizing or conduct problems revealed that higher levels of both mothers' and fathers' depressive symptoms predicted later increases in children's internalizing or conduct problems.
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From page 155... ...
We conducted our analysis separately among 759 male and 1,035 female respondents, ages 18–35 at the time of the NCS-R interview. The respondents' reported recall indicated that primary independent risk factors for self-reported major depressive disorder diagnosis (defined by Diagnostic and Statistical Manual of Mental Disorders, fourth edition)
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From page 156... ...
In contrast, those whose fathers experienced 2 or more weeks of sadness alone and those whose fathers had drug or alcohol problems alone had elevated rates of major depression compared to those with neither risk factor, with odds ratios of 3.65 and 1.73, respectively. In addition, the summary score of paternal closeness during childhood was highly significantly associated with major depression in the past 12 months (p = 0.01)
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From page 157... ...
0.02 Any PTSD before age 18 3.23 (1.36, 7.69) 0.008 NOTES: PTSD = Posttraumatic stress disorder; N = 759, 65 with major depression, 694 without; model p-value = 0.003; generalized R2 = 0.10; C-statistic = 0.65.
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From page 158... ...
< 0.0001 NOTES: PTSD = Posttraumatic stress disorder; N = 1,035 (176 with major depression, 859 without) ; model p-value < 0.0001; generalized R2 = 0.12; C-statistic = 0.66.
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From page 159... ...
Typical of these studies are two that focused on children of preschool age through adolescence. Children of depressed parents continued to be at risk for psychological problems despite reductions in parents' depressive symptoms (Billings and Moos, 1985; Lee and Gotlib, 1991; Timko et al., 2002)
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From page 160... ...
Some studies that included an active treatment component for the mothers' depression also included mother-infant assessments, providing an opportunity to more directly test the hypothesis that parenting is one of the mechanisms in the transmission of risk from depressed mothers to their children. Treatment studies are reviewed in Chapter 6, but we focus here on the small subset of treatment studies that allow us to address this issue.
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From page 161... ...
And although the depressed mothers as a group did not show a significant improvement in parenting over time, reductions in depression, after 12 weeks of treatment, were associated with (1) improvements in the quality of their interaction with their infants and (2)
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From page 162... ...
The committee also notes several gaps in the literature related to the physical health of children of depressed parents. More tracking is needed of health care utilization, missed school days, and other aspects of daily functioning in association with depression in parents.
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From page 163... ...
Families with one or more depressed parents often have additional factors that generally impose risk for children, such as substance use disorders, poverty, exposure to violence, minority status, cultural and linguistic isolation, and marital conflict, which interfere with good parenting qualities and healthy child rearing environments. These additional risk factors are sometimes found to work independently and at other times found to be additive or interactive with the effects of depression in parents.
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From page 164... ...
. Preschool children at social risk: Chronicity and timing of maternal depressive symptoms and child behavior problems at school and at home.
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From page 165... ...
. Chronicity, severity, and timing of maternal depressive symptoms: Relationships with child outcomes at age five.
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From page 166... ...
. Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample.
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From page 167... ...
. Towards a family process model of maternal and paternal depressive symptoms: Exploring multiple relations with child and family functioning.
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From page 168... ...
. Gender-specific pathways between maternal depressive symptoms, family discord, and adolescent adjustment.
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From page 169... ...
. Maternal depressive symptoms and depressive symptoms in adolescents.
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From page 170... ...
. Depressed mothers perceptions of infant vulnerability are related to later development.
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From page 171... ...
. Reciprocal models of child behavior and depressive symptoms in mothers and fathers in a sample of children at risk for early conduct problems.
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From page 172... ...
. Interpersonal impairment and the prediction of depressive symptoms in adolescent children of depressed and nonde pressed mothers.
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From page 173... ...
. Intergenerational transmission of depressive symptoms: Gender and develop mental considerations.
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From page 174... ...
. Maternal depressive symptoms are adversely associated with prevention prac tices and parenting behaviors for preschool children.
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From page 175... ...
. Longitudinal study of maternal depressive symptoms and child well-being.
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From page 176... ...
. Maternal depressive symptoms and children's receipt of health care in the first 3 years of life.
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From page 177... ...
. Chronicity of maternal depressive symptoms, maternal sensitivity, and child functioning at 36 months.
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From page 178... ...
. Attributional style and depressive symptoms among children.
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From page 179... ...
. Cognitive reactivity and depressotypic information processing in children of depressed mothers.
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From page 180... ...
. Making up is hard to do, especially for mothers with high levels of depressive symptoms and their infant sons.
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From page 181... ...
. Depressive symptoms during pregnancy: Relationship to poor health behaviors.
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