Among the various factors influencing child behavioral and developmental outcomes, parental functioning, parent-child relationships, and the home environment have consistently emerged as important variables. Being raised in a family where one or both parents experience mental health problems, particularly depression, can result in detrimental cognitive, social-emotional, and behavioral outcomes in their children.1 Although genetic factors certainly contribute to this relationship, environmental factors also contribute substantially. Most research has looked at maternal depression, with little attention on paternal depression. Additionally, although parent-child influences are bidirectional and having a child with special needs or a difficult temperament affects the emotional functioning of the parent, it is believed that parental functioning more strongly influences child behavior and development than vice versa. Therefore, this article primarily focuses on the effects of maternal versus paternal depression upon the child, and the environmental factors that mediate this association, specifically, the quality of the parent-child relationship and the quality of the home environment. In order to understand the effects of maternal depression on children, it is first important to review adult depression in general.
DEPRESSION IN ADULTS
Depression is a highly prevalent disorder that affects 1 in 5 women and 1 in 10 men at some time during their lives.2 At any point in time, 5% to 10% of adults are clinically depressed, and another 10% to 15% experience subclinical levels or milder forms of depression.3 Approximately 75% of adults who experience a depressive episode have a recurrence, with up to 40% recurring within 2 years.4 Underrecognized, fewer than 25% receiving adequate treatment, depression affects all socioeconomic levels and ethnicities.5
Women are particularly vulnerable to depression, especially during the childbearing years.6 Recent media publicity has highlighted the relatively common experience of maternal post-partum depression. Up to 70% of women experience transient postpartum "blues," sadness, or emotional instability attributed to situational hormonal imbalances as well as the stress of new motherhood. Thirty percent remain depressed up to 6 months post-partum. Approximately 10% of new mothers are diagnosed with new onset clinical depression postpartum.7,8. More critical, in terms of its impact on children, is growing up in a setting of chronic or recurrent maternal depression.9
Depression exists on a spectrum from an acute single occurrence to a chronic state with symptoms varying in intensity. The core symptoms include a persistent sadness and/or a persistent loss of pleasure in activities lasting for two or more weeks. Additional symptoms associated with the diagnosis include decreased energy, diminished appetite, sleep changes, increased agitation, slowed speech, excessive guilt, feelings of worthlessness, indecisiveness, and persistent suicidal ideas or suicidal intent. If a number of these symptoms are present and cause significant impairment in functioning, a diagnosis of depression is warranted (See Sidebarl, page 198).
The etiology of depression is multifactorial and includes biological, psychological, and social influences.10 Depression is highly heritable. Offspring of a parent with an affective disorder are three times more likely to develop depression than offspring of parents without psychopathology. " Individual psychological factors contributing to the risk for depression include a negative cognitive and attributional style (ie, pessimistic, expect the worse), as well as poor coping skills to deal with life stresses. Finally, a number of social risk factors, such as interpersonal difficulties, financial problems, medical problems, marital discord, poor social supports, and exposure to violence, increase the likelihood of developing depression. The more risk factors present, the more likely an individual will experience depression. Clinical depression can cause impairment in many functional areas, such as marital and family relationships, interpersonal relationships, physical health, occupational functioning, and recreational activities. Of all the mental illnesses, depression is most frequently associated with suicide.12
IMPACT OF MATERNAL DEPRESSION ON CHILDREN
Children of depressed mothers are at risk for a multitude of negative outcomes, depending on their developmental level.13 Clearly, children of depressed mothers are vulnerable themselves to developing depression and related maladaptive emotional functioning. They may have difficulty adjusting to new situations and Stressors, evidence decreased self worth, are more prone to viewing their world as a fearful place, and have memories of an unhappy childhood. They have difficulty focusing on positive aspects of their lives and developing secure interpersonal relationships. Some children of depressed mothers present with oppositional and aggressive behaviors.14 Finally, these children are at risk for less than optimal cognitive development and academic progress.
Multiple factors increase the degree of impact maternal depression has on a child.1 These include parental chronic medical conditions, marital discord, low socio-economic status, existence of other family psychopathology, exposure to a traumatic event, poor social support networks, and child vulnerabilities such as low intelligence or difficult temperament (see Sidebar 2, page 199).
Just as family, personal, and environmental risk factors can exacerbate the negative impact of maternal depression, protective factors can mitigate these negative effects.1 The impact on children is less if paternal depression is present as opposed to maternal depression or if both parents being depressed.15 Apparently, because of differential child rearing roles, children are less likely to be exposed to the negative aspects of a father's depression than their mother's depression. A good relationship with at least one parent, or another important adult figure, can offset the negative effects of maternal depression. Beardslee has described children who are resistant to the negative effects of maternal depression as being "realistic about what they were dealing with, aware of strategies and actions they could take to offset the effects, and they believed their actions made a difference."16 Thus, personal resiliency factors, which might include a positive coping style and feelings of self-efficacy (the belief that one can influence one's environment and accomplish personal goals) appear to play a protective role on the effects of maternal depression. In families where support is high and stress is low, the impact of maternal depression is decreased. Additional protective factors include good marital and family relationships, strong peer/sibling influences, adequate financial resources, and early intervention of maternal depression (see Sidebar 2).
A child's developmental stage determines how the negative effects of maternal depression are manifested. The impact of maternal depression on the parent-child relationship and home environment vary during development. Because a large number of children are raised by mothers with depression, it is important to understand the age specific features of children exposed to maternal depression.
INFLUENCE OF MATERNAL DEPRESSION ON DEVELOPMENT
Numerous studies have documented changes in the home environment and negative characteristics of the parentchild relationship between depressed mothers and their infants. Depressed mothers are less vocal, less positive, and more distant when playing with their t children.17 Depressed mothers tend to respond more slowly and have a blunt affect. Additionally, depressed mothers get frustrated more easily, are more irritable, misread infant cues, and are more ambivalent to infant needs, responding to their infants with less emotional reciprocity and synchrony. At times, these mothers inappropriately withdraw from their infants; at other times they are overly intrusive and stimulating. They also tend to make negative attributions about their infant's behavior (ie, infer negative intent to typical behavior such as crying). All of these observed patterns in the mother-child relationship tend to negatively influence early child development.
As early as the first few months of life, newborns of depressed mothers demonstrate more perinatal problems, including a decreased response to stimulation evidenced by fewer smiles, less playfulness, more irritability, and fussiness. Psychobiological changes, such as higher heart rates, increased cortisol levels, and changes in prefrontal lobe EEG activity, have been observed in infants of depressed mothers.18,20 In one study, 3-month-oId infants responded to a stranger in the same passive style they did when interacting with then depressed mother.21 Theoretically, the infant has mirrored his style of relating to the environment to match the depressed mother. Decreased motor development, decreased social responsiveness, and even delayed growth have also been observed during infancy.22'23 An impaired mother-infant relationship appears to contribute to older children experiencing impaired social and emotional relationships as they continue to develop.24
During the toddler and preschool years, depressed mothers are more likely to engage in negative interactions with their children, with lower tolerance for challenging, yet normal, toddler behaviors.25'27 Negative attributions become particularly salient (eg, mother infers her child has a tantrum purposefully to upset her). Depressed mothers may doubt their own ability to parent effectively. They are more likely to adopt ineffective and harsh parenting strategies. Instead of the needed structure, depressed mothers tend to provide a home environment that is persistently negative, more chaotic, less predictable, and less nurturing than then non-depressed counterparts.28 As toddlers and preschoolers have few alternative opportunities to learn about relationships and the world, they are particularly susceptible to the negative consequences of this parenting style and home environment.
Toddlers and preschoolers of depressed mothers are at risk for manifesting a number of problematic socialemotional, behavioral, and cognitive outcomes.28 These outcomes include decreased social competence, increased withdrawal, anxiety, and temper tantrums. They may have difficulty mastering emotional self-regulatory skills, evidencing more emotional and behavioral extremes. They may manifest distress through physical complaints. One study found that toddlers presenting to pediatricians with stomach aches were more likely to have a mother with depression.29 Children of depressed mothers are also at risk for lower cognitive scores.30,31 Longitudinal studies reveal dysfunctional behavior patterns during toddler years place children at risk for having pervasive social and cognitive difficulties throughout childhood.32
During the school-age years, children continue to need a secure parent-child relationship and a predictable home environment. From this secure base, they learn how to cope with stress, establish and maintain meaningful interpersonal relationships, regulate their own emotions, and persist with the demands of daily life. Unfortunately, mothers who are depressed are less likely to develop the quality of parent-child relationship necessary to optimize children's success with these developmental challenges.28 Maternal responses may be erratic and inconsistent, vacillating between withdrawing from her children to responding in an irritable, explosive, volatile manner. Often ineffective or harsh parental discipline techniques are chosen. In addition, depressed mothers may be less emotionally available to help the child succeed academically and socially. Many of the same aspects of the toddler home environment, specifically being more chaotic and unpredictable, also characterize that of the school-age child who lives with a depressed mother.33
School-age children of depressed mothers are more prone to depression and anxiety, as well as less severe forms of emotional distress.34 They have higher rates of conduct disorder, ADHD, and other disruptive behavior disorders.35 These children tend to experience impaired academic performance, negative self-concept, and negative self-esteem.36 Because of their advanced cognitive development, school-age children are more aware of parental functioning, but are not yet socially or emotionally mature enough to cope effectively with this knowledge. Issues of inappropriate rolereversal and guilt may be prominent: the child may try to provide support to the parent and feel responsible if the parent's functioning does not improve.33 Parent-child interactions that are chronically characterized by criticism, rejection, lack of warmth, and intrusiveness contribute to the child's developing maladaptive behavior patterns and a negative self-concept that can extend into adolescence.37
Although the influence of parental behavior is believed to diminish during the teenage years, the cumulative effect of living with a mother who suffers from depression continues into adolescence. Critical developmental tasks of adolescents include the ability to develop a coherent sense of self, become less dependent upon the family, and establish meaningful, mature interpersonal relationships. Depressed mothers are likely to be poor coping models, provide less monitoring and involvement with their child while utilizing potentially detrimental discipline strategies.33 They may inappropriately depend on their adolescent for emotional support and have difficulty tolerating the adolescent's need for increased independence. These behavioral patterns further alienate depressed mothers, rendering them less available to help the adolescent cope with typical and often turbulent developmental issues.
When adolescents are being raised by mothers with depression, the strained family relationships often negatively influence social competence and peer relationships and may lead to decreased school attendance and academic problems.38 Although depressive disorders become more prevalent during adolescence in general than at earlier developmental stages, teenage youth of depressed mothers are at an even higher risk for developing an affective disorder than their peers without parental psychopathology,39 Consequently, they are also at an increased risk for substance abuse and other psychiatric disturbances.40 Most importantly, depressed youth are at higher risk for suicidal ideation and attempted/completed suicides.41
Because of the potential negative consequences of maternal depression, it is critical for the primary care provider to recognize the signs and symptoms of maternal depression and indicators of its impact upon children at all ages. Adults who are depressed may not seek direct care for themselves; thus, the only health care professional they may encounter is their child's medical provider. In 2002, the U.S. Preventive Services Task Force recommended that all adults be checked for depression by asking them if during the past two weeks: 1) they have felt down, depressed, or hopeless, and 2) they have felt little interest or pleasure in doing things. If the response to either question is positive, then the provider should determine the frequency and intensity of these feelings to decide if a more thorough assessment for depression is warranted.42 Screening questionnaires for adult depression may also prove useful. Alternatively, listening for signs and symptoms that a parent is distressed may help identify a family at risk (see Sidebar 3, page 200). The expectation is not for the pediatrician to diagnose or treat a maternal depressive disorder, but rather to educate the parent about the effect of parental mood upon the parent-child relationship and home environment, the potential impact of maternal depression on child functioning, and to make a mental health referral for diagnosis and treatment, when appropriate. When a mother's depression improves following treatment, studies show the social and emotional functioning of her children also improves.43
Physicians should be aware of child behaviors that might suggest the presence of depression in the mother, risk factors that exacerbate these effects, and potential protective factors (see Sidebar 2, page 199). The complex interplay of these multiple variables determines the child's clinical presentation.
Ideally, physicians should view depression as an impairing family illness similar to other chronic medical illnesses. Pediatricians can tailor their intervention depending on the severity of the maternal depression and the effects upon the child. If the depression is relatively mild and/or the impact on the family is minimal, a prevention/ early intervention approach is appropriate. Educating parents and providing information within the primary care setting can be very useful. This might simply include discussing the benefits of positive parenting practices and a healthy parent-child relationship upon the well-being of the child. Encouraging daily routines, extracurricular family activities, good sleep hygiene, and discussing realistic expectations for the parent and child can also prove beneficial. By discussing depression in an office setting, a physician can serve as a role model for how parents can talk about depression with their children.
If the depression appears to be moderate and/or there exists a noticeable family impact, more intensive intervention within a primary care setting may be warranted. Helping the mother recognize her own emotional impairment and how it influences her child can help motivate her to seek evaluation and treatment. Referring the mother to her own primary care physician for further evaluation is indicated. Arranging a series of follow-up appointments to monitor and provide more in depth suggestions regarding improving family functioning (ie, targeting specific positive parenting strategies) is recommended.
If the depression is moderate to severe and/or appears to be affecting the child significantly, a mental health referral is warranted, possibly for both the mother and the child. There is clear evidence that a number of treatment approaches are effective in decreasing the negative impact of maternal depression upon child functioning.44 These treatments focus, in part, on treating the family as an interactive system. They strive to increase positive aspects of the home environment, such as family cohesion and stability, as well as improve the quality of the parent-child relationship. Given that effective treatments are available, physicians need to establish appropriate mental health referral resourcfor parents and families.
No single variable determines the social, emotional, and behavioral outcomes of children with a depressed parent. The cumulative results of the nature-nurture interplay are what determine the end effects and functional ability of the child. Consistently encouraging family interaction patterns that promote mental health and responding in a prompt and appropriate manner to children with depressed mothers is critical for child-serving providers.
1 . Goodman SH, Gotlib IH, eds. Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment. Washington, DC: American Psychological Association; 2002.
2. Blehar MC, Oren DA. Women's increased vulnerability to mood disorders: integrating psychobiology and epidemiology. Depression. 1995;3:3-12.
3. Rakel RE. Textbook of Family Predice. 6th ed. Philadelphia; W.B. Saunders Company; 2002.
4. Roland RJ, Keller MB. Course and outcome of depression. In: Gotlib IH, Hammen CL, eds. Handbook of Depression. New York, NY: Guilford Press; 2002.
5. Hirschfeld RM, Keller MB, Panico S, et al. The National Depressive and Manie-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;2774):330-340.
6. Nolen-Hoeksema S. Gender differences in depression. In: Gotlib IH, Hammen CL, eds. Handbook of Depression. New York, NY: Guilford Press; 2002.
7. Campbell SB, Conn JF, Meyer T. Depression in first-time mother: mother-infant interaction and depression chronicity. Developmental Psychology. 1995:31:347-357.
8. Wisner KL, Parry BL, Piontek CM. Clinical practice: postpartum depression. N Engl 3 M«f. 2002;347(3): 194-199.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Menial Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Publishing; 2000.
10. Gotlib IH, Hammen CL Handbook of Depression. New York, NY: Guilford Press; 2002.
11. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry. 2000;157(10):1552-1562.
12. Keitner GI, Miller IW. Family functioning and major depression: An overview. Am J Psychiatry. 1990;147(9):1128-1137.
13. Downey G, Coyne JC. Children of depressed parents: an integrative review. Psychol Bull. 1990;108(1):50-76.
14. McCarty CA, Zimraerman FJ, Digiuseppe DL, Christakis DA. Parental emotional support and subsequent internalizing and externalizing problems among children. J Dev BehavPediatr. 2006;26(4):267-275.
15. Olfson M, Marcus SC, Druss B, Alan Pincus H, Weisman MM. Parental depression, child mental health problems, and health care utilization. Med Care. 2003;416):716-721.
16. Beardslee WR. Out of the Darkened Room: What a Parent is Depressed: Protecting the Children and Strengthening the Family. New York, NY: Houghton Mifflin; 2002:77-78.
17. Sameroff AJ, Seifer R, Zax M. Early development of children at risk for emotional disorder. MonogrSocRes ChildDev. 1982;47(7):l-82.
18. Gunnar MR, Brodersen L, Krueger K, Rigatuso J. Stress reactivity and attachment security. Dev Psychobiol. 1996;29(3}:191-204.
19. Kagan J. Behavioral inhibition to the unfamiliar. Child Development. 1984;55:22 12-2225.
20. Dawson G. Infants of mothers with depressive symptoms: Electroencephalogrpahic and behavioral findings related to attachment status. Development and Psychopathology. 1992;4:67-80.
21. Edhborg M1 Ludh W, Seimyr L, Widstrom AM. The long-term impact of postnatal depressed mood on mother child interaction: a preliminary study. Journal of Reproductive Infant Psychology. 2002;41:28-35.
22. Abrams SM, Field T, Scandi F, Prodromidis M. Newborn of depressed mother. Infant Mental Health Journal 1995;16:231-235.
23. Hay DF. Postpartum depression and cognitive development. In: L Murray, PJ Cooper, eds. Postpartum depression and child development New York, NY: Guilford Press; 1997:85-110.
24. Murray L, Cooper P, eds. Post-partum Depression and Child Development. London: Guilford Press; 1997.
25. Goodman SH, Gotlib IH. Risk for psychopathology hi the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychol Rev. 1999;106(3) :458-490.
26. Lovejoy CM, Grazyk PA, O'Hare E, Neuman G. Maternal depression and parenting behavior: a meta analytic review. Clinical Psychology Review. 2000;20:56 1-592.
27. Lyons-Ruth K, Lyubchik A, Wolfe R, Bronfman, E. Parental depression and child attachment: Hostile and helpless profiles of parent and child behavior among families at risk. In: Goodman SH, Gotlib ffl, eds. Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment. Washington, DC: American Psychological Association; 2002:89-120.
28. Radke- Yarrow M, Limes-Dougan B. Parental depression and offspring disorders: a developmental perspective. In: Goodman SH, Gotlib IH, eds. Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment. Washington, DC: American Psychological Association; 2002:155-173.
29. Zuckerman B, Stevenson J, Bailey V. Stomachaches and headaches in a community sample of preschool children. Pediatrics. 1987;79(5):677-682.
30. Bendell D, Field T, Yando R, Lang C, Martinez A, Pickens J. "Depressed" mothers' perceptions of their preschool children's vulnerability. CAiW Psychiatry Hum Dev. 1994;24(3):183-190.
31. Hay DF. Postpartum depression and cognitive development. In: Murray L, Cooper PJ, eds. Postpartum Depression and Child Development. New York, NY: Guilford Press; 1997:85-110.
32. Radke- Yarrow M, Martínez P, Mayfield A, Ronsaville D. Children of Depressed Mothers: From Early Childhood to Maturity. New York, NY: Cambridge University Press; 1998.
33. Hammen C. Context of stress in families of children of depressed parents. In: Goodman SH, Gotlib IH, eds. Children of Depressed Parents: Mechanisms of Risk and Implications for Treatment. Washington, DC: American Psychological Association; 2002:175-199.
34. Gladstone TR, Kaslow NJ. Depression and attributions in children and adolescents: a metaanaiytic review. J Abnorm Child Psychol. 1995;23(5):596-606.
35. Beardslee W, Schultz L, Selman R. Level of social cognitive development, adaptive function, and DSM-tn diagnosis in adolescent offspring of parents with affective disorders: Implications of the development of the capacity form. Developmental Psychology. 1987:23:807-815.
36. Jaenicke C, Hammen C, Zupan B. Cognitive vulnerability in children at risk for depression. J Abnorm Child Psychol. 1987;15(4):559-572.
37. Koestemer R, Zuroff DC, Powers TA. Family origins of adolescent self-criticism and its continuity into adulthood. J Abnorm Psychol. 1991;100(2):191-197.
38. Hammen C, Shin JH, Brennan PA. Intergenerational transmission of depression: test of an interpersonal stress model in a community sample. J Consult Clin Psychol. 2004;72(3):511-522.
39. Beardslee WR, Wheelock I. In: Reynolds WM, Johnston HF, eds. Handbook of Depression in Children and Adolescents. New York, NY: Plenum Press; 1994:463-479.
40. Downey D, Coyne J. Children of depressed parent: an integrative review. Psychol Bull. 1990;108(1):50-76.
41. Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 1996;53( 12): 339-348.
42. Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief matemal depression screening at wellchild visits. Pediatrics. 2006;! 18(1):207-216.
43. Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al. Remissions in maternal depression and child psychopathology a STAR*D child report. JAMA. 2006;295(12):1389-1398.
44. Gladstone TRG, Beardslee WR. Treatment, intervention, and prevention with children of depressed parents: A developmental perspective. In: Goodman SH, Gotlib IH, eds. Children of Depressed Parents: Mechanisms of Risk and Implications far Treatment. Washington, DC: American Psychological Association; 2002:277-305.