Puediutric and Pm’nntul Epidemiology 1992, 6, 254-264

The contribution of maternal depressive symptoms and life events to child behaviour problems

Patricia O’ConnoPt and Richard Neugebauertt *Sage Graduate School of The Sage CoIleges,t Gertrude H . Sergievsky Center, Columbia University, SEpidemiology of Developmeh tal Brain Disorders Department, New York State Psychiatric Institute, New York, U S A

Summary. The effect of maternal depressive symptoms and stressful life events on child behaviour problems has been the focus of clinical and epidemiological research for some years. We interviewed 80 women drawn from the New York City area regarding their life events in the preceding 6 months, current levels of depressive symptoms and behav- iour problems in their children. For each woman, one child between the ages of 3 to 8 was selected for study analysis. Maternal depressive symptoms and maternal life events in general, as well as undesirable events in particular, contributed independently to child behaviour problems in mu1 tivariable analyses controlling for maternal education. This association did not vary by maternal marital status, or gender or age of the child. Events judged on _common sense grounds to be especially disruptive of the child’s routine did not contribute to child behaviour problems, independently of maternal depressive symptoms. Future re- search should devote more attention to specification of the life events under study and of factors that may buffer both the mother and the child from their pathogenic effects.

Introduction The influence of environmental stress and maternal depression on dysfunctional child behaviour has been the focus of research interest over the past decade. A

Address for correspondence: Dr P. OConnor, Sage Graduate School, The Sage Colleges, Troy, New York 12180, USA.

254

Maternal life events 255

direct association between maternal depression and behaviour problems in chil- dren is well and consistently documented.14 Also, a number of studies report an increase in childhood psychiatric disorders and specific behaviour problems in the presence of life events generally9 and in particular of negative

Understanding the relative contribution of life events and maternal de- pression to child behaviour problems has proved to be more difficult. Hall and FareP reported that life events together with maternal everyday stressors were the best predictors of behaviour problems, a relationship not mediated by ma- ternal depressive symptoms. By contrast, Fergusson and colleagues found that recent family life events exerted no independent effect on child behaviour after controlling for maternal depressive symptoms among children aged 4 to 5;16

However, in the same group at age 6, life events and maternal depressive symptoms each contributed independently to child behav io~r .~ Similarly, Rose and colleagues reported, first, independent effects of recent life events and maternal depression in children at age 4 and then, in the same cohort a year later, an effect for maternal depression only.I7 These inconsistent findings within the same study cohorts over time underscore the importance of further research in this area.

The current paper reports preliminary results from an investigation of the association of life events and maternal depressive symptoms with child behaviour problems in a sample of urban women and their children. Such community samples have the advantage over those with children in treatment of being free of certain selection biases that may be associated with help-seeking per se. We hypothesised that maternal depressive symptoms and life events would each be associated with child behaviour problems in separate analyses and, further, that life events would affect child behaviour, independent of maternal symptoms. In addition, we examined whether the association of life events with child behaviour vaned with subtypes of events, maternal marital status and the gender and age of the child.

Methods

Sample

The study sample was drawn from one of two comparison groups in a larger epidemiological investigation of depression in women attending Columbia Pres- byterian Medical Center following a miscarriage.18 Criteria for inclusion in the miscamage cohort were that the women be English or Spanish speaking, over age 17, and accessible by telephone. The women in the community sample were located by dialling four random digit telephone numbers, linked to the area codes and telephone exchanges of miscarrying subjects. Respondents were frequency

256

matched to the miscarrying women on language and season of interview, age (in 5-year intervals above age 17) and education (less than high school, high school graduate, college graduate and postgraduate training). Women pregnant in the preceding 12 months were ineligible for study participation. Eligibility status of potential participants was established for 92% of working telephone numbers; 82% (n = 318) of eligible women were interviewed. Overall, interviewed and uninterviewed subjects were similar on sododemographic characteristics and on a single-item measure of depressed mood.*9

Women with one or more resident children between 3 and 8 years of age (n = 84) were administered a scale designed to assess child behaviour problems. Four women provided incomplete study information and are excluded,,:leaving 80 women and their children as the subject of this report. Since most women (n = 74) had only one child between 3 and 8, we restricted these analyses to only one child per woman. The youngest child was always selected since the measure of child behaviour had been developed initially for 3 year olds.

P. O’Connor and R. Neugebauer

Instruments

Maternal depressive symptoms

Maternal depressive symptoms were measured with the Center for Epidemi- ologic Studies-Depression Scale (CES-D).20 This 20-item scale assesses the pres- ence and persistence over a week of depressed mood, feelings of guilt, worthlessness, helplessness, hopelessness, psychomotor retardation, appetite loss and sleep disturbance. Items are scored 0 (indicating symptom present rarely or none of the time) to 3 (symptom present most or all of the time). Its adequate internal consistency reliability (generally above 0.85) and validity are well-docu- men ted. 20,21

Children’s behaviour

The Behaviour Checklist (BCL) developed by Richman and was used to assess problem behaviour in childhood. Coverage of 12 domains of child behaviour includes eating and sleeping habits, bowel training, activity and con- centration level, autonomy, womes and sociability. Each item has three response choices (typically, none, occasionally/some, frequentlyhp to three times per week). The mother selects the response that most closely applies to her child’s behaviour. Items are summed to produce a total score ranging from 0 to 24. Test-retest reliability of the BCL is satisfactory (0.81).24 Use of the BCL in several studies has yielded consistent prevalence rates (from 11-14% with a cutpoint of 10) of disturbance among ~ h i l d r e n . ~ , ~ ~ ~

Maternal life events 257

Life events Life events in the 6 months preceding the interview were assessed with an inventory comprising events and event magnitude ratings generated in part from multi-ethnic New York City community samples by the Dohrenwends and col- leagues. Event valences (desirable, undesirable, uncertain) resulted from consen- sus ratings by the original investigators.m Events of low magnitude, or of moderate magnitude but reported by less than 5% of community women of reproductive age (Dohrenwend and Shrout, unpublished data) were excluded a priori. To enhance the comparability of this study with other investigations, we further restricted the analysis to events happening to the mother herself or to her household.

Three non-mutually exclusive classifications of these maternal and household events are employed: all events (n = 59); events rated as undesirable ( n = 29); events, irrespective of valence, that altered the child’s daily environment or routine and hence, that the child was nearly certain to know about ( n = 30) (Table 1). This last grouping, based on consensus ratings by the authors, is labelled ‘change events’, which we expected to have a stronger association with child behavioural problems than life events generally. These three event categories, all events combined, undesirable events and ‘change events’, correspond to classifi- cations that have been deployed and debated widely in the literature on stress and adult psychopathology.2931 Life event scores represent a simple sum of reported events.

Table 1. Life event inventory: frequency and classification of events by desirability for the mother and amount of change for the child

Undesirable events No. of events reported

Moderatelsevere change Laid off Family memberlclose friend died Moved to a worse residencelneighbourhood Physically assaultedlattacked Physical illness startedgot worse Injury occurredlgot worse Relations worsened with husbandhoyfriend Separated Divorced Fired Arrested Sent to jail Not released from jail when expected Child died

SlighVno change Changed jobs for a worse one Had trouble with a boss Promotion fell through

1 14 1 2 2

0 3 2

258 P. O'Connor and R . Neugebauer

Undesirable events (continued) No. of events reported

Broke up with a friend Involved in a law suit Accused of something for which one could go to jail Got involved in a court case Convictedlfound guilty of a crime Engagement broken Husbandhoyfriend unfaithful Took a cut in wage or salary Suffered finanaal lossfloss of property Went on welfare Did not get an expected wage increase Found out could not have children

4 2 0 4 0 0 3 1 2 3 1 1

Desirable and othef events- No. of events reported

Moderatelsevere change Started work for the first time Returned to work* Started a business/professional practice Stopped working (not laid off or fired)* Person moved into the household* Person moved out of the household* Moved to better residencelneighbourhood Took hip other than a vacation* Remodelled a home Released from jail Started schooYtraining programme Birth of second or later child* Adopted a child Got married Got together again with husbandboyfriend after separation

1 4 2 4 5

10 3 4

16 0 7 0 0 0 2

Slightlno change Changed jobs for a better one 5 Promoted 2 Significant success at work 15 Expanded business/professional practice 2 Reduced work load' 2 Acquittedlfound innocent of a crime 0 Physical health improved 4 Became engaged 1

Took out mortgage* 1 Started buying a car, or other large purchase on the

Financial improvement, unrelated to work Graduated from schooYtraining programme 2 Started menopause* 0 Increase in pay without a promotion

Relations with husbandhoyfriend changed for better 15

4

3 plan

3

* Events rated as of uncertain valence.

Maternal life events 259

Procedure

All interviews were administered by telephone and conducted by trained, bi- lingual interviewers using a structured questionnaire. The general interview contained information about sociodemographic characteristics, reproductive his- tory and maternal psychological status. Interviews with community women were conducted from 1986 to 1987.

Data analysis

Ordinary least sqtlares multiple regression procedures were used to determine the proportion of variance in children’s behaviour (BCL) accounted for by ma- ternal depressive symptoms (CES-D) and life events. Covariates for the multiva- riate models were selected following examination of the univariable associations of sociodemographic characteristics with BCL scores. Variables associated with BCL at P < 0.05 were retained for inclusion in the multivariate model. Only maternal education met this criterion. Unless stated otherwise, statistical signifi- cance was set at P C 0.05.

Results

The mean age of subjects was 31 and the majority had a high school education or less. Most were mamed or cohabitating (Table 2); 61% described themselves as Hispanic; 65% reported incomes of less than $20 000; 80% had one or two children; 41 of the children were girls.

Mean maternal CES-D score was 17.1 (range 1-45). Mean number of life events was 2.2 (range 0-18) with a quarter of the women reporting no events, and 40% reporting three or more. Maternal depressive symptoms were associated with change events ( P c0.06) but not with general life events nor with undesirable events.

The mean of BCL scores was 7.0 (range 0-19) with 14% of children receiving scores above 9. BCL scores were not associated with language of interview, ethnicity, marital status, family income, gender or age of the child or number of siblings. BCL was significantly inversely associated with maternal education (P < 0.002).

Maternal depressive symptoms exhibited a strong, direct association with child behavour both in an unadjusted analysis and after controlling for maternal education (Table 3). By contrast, all events were associated with child behaviour only after controlling for education. When maternal depressive symptoms and all events were entered into the same regression equation, each made a separate contribution to child behaviour, with (Table 3) or without (not shown) education controlled.

260 P. O'Connor and R. Neugebauer Table 2. Characteristics of women and their children

Characteristic Percentage

Ethnicity Hispanic Black White

Mamedkohabitating

Education Less than high school High school Some college College or more

Y

Income Less than $10 OOO $10 000-$19 OOO $20 000-$39 000 $4OOOO or more

Number of children One Two Three or more

Female

Age of child 3-5 years 6-8 years

61 20 19

55

34 36 18 12

40 25 26 9

39 41 20

51

54 46

Next, we examined the relative contribution of undesirable events and of other, predominantly desirable events (identified in Table 1) to child behaviour. When these two conceptually distinct classes of events are entered into the same re- gression equation, together with maternal depressive symptoms and maternal education, undesirable events but not other events contributed substantially and significantly to child behaviour scores (Table 3). Using a statistical procedure developed by R i n d s k ~ p f , ~ ~ we determined that this suggestion of a differentially greater effect of undesirable events did not achieve formal statistical significance. Change events did not predict child behaviour once maternal education and depressive symptoms had been controlled.

These patterns of results did not vary significantly by marital status, or gender or age of the child.

Maternal life events 261 Table 3. Association of maternal depressive symptoms (CES-D) and categories of maternal life events with child behaviour problems

~

Unadjusted model Adjusted for education Full model

Predictors Beta P Beta P Beta P ~

CES-D Education

R2

0.47 0.001

0.22

0.40 -0.19

0.001 NS

0.26

General life events Education CESD

R2

Undesirable events Other events Education CES-D

R2

Change events Education CES-D

R2

0.15 NS

0.02

0.24 0.04 0.01 NS

0.06

0.25 0.03

0.06

0.24 0.40

0.26 0.09

-0.39

0.24 -0.34

0.03 0.001

0.18

0.02 NS

0.001

0.20

0.02 0.001

0.18

0.20 -0.25

0.39

0.22 0.07

-0.24 0.37

0.17 -0.21

0.36

0.04 0.02

0.001 0.29

0.03 NS

0.03 0.001 0.31

NS 0.05

0.001 0.28

Discussion

In this study of a community sample of multi-ethnic women, we found that maternal life events influenced children’s behaviour beyond the expected contri- bution of maternal depressive symptoms. The effect of life events on child behaviour, in controlled analyses, appeared to be greater for undesirable events. Events that were selected based on their expected degree of impact on the child’s environment, irrespective of valence, did not contribute to child behaviour problems.

There are several limitations in this study which may reduce the generalisabil- ity of our findings. These results are based on a relatively small sample. Also, biases introduced by restricting the sample to women who had not been pregnant in the previous year cannot be ruled out. Since this study is cross-sectional, it is not possible to determine with confidence the causal direction of these relation- ships. Child behaviour may well contribute sustantially both to the likelihood of certain events occurring, e.g. fights with spouse and, independently, to

262 P. O’Connor and R. Neugebauer

maternal symptoms. The assessments of event valence and of event impact on the child’s environment were not based on subjects‘ responses to structured probes but rather on previous research (event valences) and on our ratings (change events). The desirability ratings, in particular, have been shown to contain sub- stantial misclassification errors.33 However, we would generally expect such measurement error to attenuate associations, not produce artifactual ones.

A further limitation may be our reliance solely on maternal report for infor- mation on events, depressive symptoms and child behaviour. Billings and Moos3 have noted the presumed confounding of maternal depression with maternal reporting of both life events and child behaviour, though there is evidence that supports the utility of relying on such reporting. For example, separately obtained maternal and paternal reports of their child’s behaviour have been highly corre- lated.34*35 Further, Billings and Moos3 reported that depressed parents did not rate their children more negatively than non-depressed parents. In our data set, the specificity of the association of maternal depressive symptoms with change events, not with other classes of events, also argues against pervasive response biases in maternal reporting of life events.

Our study findings of independent contributions of maternal depressive symptoms and undesirable life events to child behavioural disturbance concurs with that of two other investigation^.^,^^ However, the inconsistency of this finding across, and especially within, the same samples at different points in time, as reported in prior studies, is intriguing. Two possible related explanations for these contradictory findings are suggested by the current study results.

First, we found that certain classes of life events, here events involving environmental changes, did not contribute to child behaviour over and above the contribution of maternal depressive symptoms. This class of events may predom- inate in some of the checklists deployed in previous studies or, alternatively, these events may be over-represented amongsubjects’ life experiences at the time of a given assessment. The lack of detailed descriptions of item-specific life event frequencies in most prior reports precludes full examination of this possibility.

Second, with the partial exception of Fergusson et d.,* life events appear to contribute significantly to child behavioural problems only when such events are not also associated with maternal depressive symptoms.1517 This pattern is repeated in our sample. Consequently, a proper understanding of the pathogenic effects of life events on child behaviour requires first a greater understanding of factors that buffer women from the impact of these same events.

Acknowledgement

This research was supported in part by a grant from the National Institute of Mental Health (MH39581) to Dr Neugebauer.

Maternal life events 263

References 1 Holahan, C.J., Moos, R.H. Risk, resistance, and psychological distress: a longitudinal analysis with adults and children. Journal of Abnormal Psychology 1987; 963-13. 2 Beardslee, W.R., Bemporad, J., Keller M.B. et al. Children of parents with major affective disorder: a review. American Journal of Psychiatry 1983; 140:825-832. 3 Billings, A., Moos, R.H. Comparisons of children of depressed and nondepressed parents: a social-environmental perspective. Journal of Abnormal Child Psychology 1983; 11:46%485. 4 Fergusson, D.M, Horwood, L.J., Gretton, M.E. et al. Family life events, maternal depression, and maternal and teacher descriptions of child behavior. Pediatrics 1985; 75:30-35. 5 Hammen, C.L., Gordon, D., Burge D. et al. Maternal affective disorder$, illness, and stress: risk for children's psychopathology. American Journal of Psyckiat y 1987; 144:736741. 6 Hammen, C.L., Adrian, C., Gordon, D. et al. Children of depressed mothers: maternal strain and symptom predictors of dysfunction. Journal of Abnormal Psychology 1987; 96: 190-198. 7 Zajicek Colman, E., Ghodsian, M., Wolkind, S.N. Depression in mothers 6 years after the birth of a first child. Social Psychiatry and Psychiatric Epidemiology 1986; 21:76-82. 8 Links, P.S. Community surveys of the prevalence of childhood psychiatric disorders: a review. Child Dmelopment 1983; 54:531-548. 9 Sandler, I.N., Ramirez, R., Reynolds, K.D. Life stress for children of divorce, be- reaved, and asthmatic children. Paper presented at the annual meeting of the American Psychological Association, Washington, DC, August 1986. 10 Goodyer, I.M., Kolvin, I., Gatzanis, S. The impact of recent undesirable life events on psychiatric disorders in childhood and adolescence. British Journal of Psychiatry 1985; 151:179-184. 11 Beck, S., Rosenberg, R. Frequency, quality, and impact of life events in self-rated depressed, behavioral-problem, and normal children. Journal of Consulting and Clinical

12 Bailey, D., Garralda, M.E. The use of the social stress and support interview in families with deviant children: methodological issues. Social Psychiatry and Psychiatric Epidemiology 1987; 2209-215. 13 Mullins, L.L., Siegel, L.J., Hodges, K. Cognitive problem-solving and life event correlates of depressive symptoms in children. journal of Abnormal Child Psychology 1985; 13:30!5-314. 14 Hodges, K., Kline, J.J., Barbera, G. et al. Life events occurring in families of children with recurrent abdominal pain. Journnl of Psychosomatic Research 1984; 28:185-188. 15 Hall, L.A., Farel, A.M. Maternal stress and depressive symptoms: correlates of behav- ior problems in young children. Nursing Research 1988; 32156.161. 16 Fergusson, D.M., Horwood, L.J., Shannon, F.T. Relationship of family life events, maternal depression, and child-rearing problems. Pediatrics 1984; 73573-776. 17 Rose, S.L., Rose, S.A., Feldman, J.F. Stability of behavior problems in very young children. Development and Psychopathology 1989; 15.19. 18 Neugebauer, R.N., Kline, J., OConnor, P. et al. Depressive symptoms in women in the 6 months after miscarriage. American Journal of Obstetrics and Gynecology 1992; 166:104--109. 19 Folstein, M.R., Luria, R. Reliability, validity and clinical application of the Visual Analogue Mood Scale. Psychological Medicine 1973; 3:479486. 20 Radloff, L.S. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1:385-401.

rsychoiogy 1986; s 4 : w - m .

264 P. O’Connor and R. Neugebauer 21 Weissman, M.M., Sholomskas, D., Pottenger, M. et al. Assessing depressive symp- toms in five psychiatric populations: a validation study. American Journal of Epidemiology 1977; 102203-213. 22 Richman, N., Stevenson, J., Graham, P. Prevalence of behaviour problems in 3-year- old children: an epidemiological study in a London borough. Journal of Child Psychology and Psychiatry 1975; 16:277-287. 23 Richman, N., Stevenson, J., Graham, P. Preschool to School: A Behvioural Study. London: Academic Press, 1982. 24 Nicol, A.R., Stretch, D.D., Fundudis, T. et al. The nature of mother and toddler problems: I. Development of a multiple criterion screen. Journal of Child Psychology and Psychiatry 1987; 28:739-754. 25 Earls, F. The prevalence of behavior problems in three year old children: a cross- national replication. Archives of General Psychiatry 1980; 321153-1157. 26 Cornely, P., Bromet, E. Prevalence of behavior problems in three-year-old children Iiving near Three-Mile Island: a comparative analysis. Journal of Child Psychology and Psychiatry 1986; 22489498. 27 McGuire, J., Richman, N. Screening of behaviour problems in nurseries: the reliability and validity of the Preschool Behaviour Checklist. Journal of Child Psychology and Psychiatry

28 Dohrenwend, B.S., Krasnoff, L., Askenasy, A.R. et al. The Psychiatric Epidemiology Research Interview Life Events Scale. In: Handbook of Stress: Theoretical and Clinciai Aspects. Editors: L. Goldberger, S. Breznitz. New York: The Free Press, 1982. 29 Vinokur, A., Selzer, M.L. Desirable versus undesirable life events: their relationship to stress and mental distress. Journal of Personality and Social Psychology 1975; 32:329-337. 30 Mueller, D.P., Edwards, D.W., Yarvis, R.M. Stressful life events and psychiatric symptomatology: change or undesirability? Journal of Health and Social Behaviour 1977;

31 Tausig, M. Measuring life events. Journal of Heaifh and Social Behaviour 1982; 23.52-64. 32 Rindskipf, D. Linear equality restrictions in regression and loglinear models. Psycho- logical Bulletin 1984; 96:597-603. 33 Dohrenwend, D.P., Link, B.G., Kern, R. et al. Measuring life events: the problem of variability within event category. In: Psychiatric Epjderniology: Progress and Prospects. Editor: 8. Cooper. London: Croom Helm, 1987. 34 Achenbach, T.M., McConaughy, S.H., Howell, C.T. Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychological Bulletin 1987; 101:213-232. 35 Kazdin, A.E., Esveldt-Dawson, K., Unis, AS. et al. Child and parent evaluations of depression and aggression in psychiatric inpatient children. Journal of Abnormal Child Psychology 1983; 11:401413.

1986; 227-32.

18~307-317.