Child Psychiatry Hum Dev DOI 10.1007/s10578-014-0462-6
ORIGINAL ARTICLE
Mothers with Depression, Anxiety or Eating Disorders: Outcomes on Their Children and the Role of Paternal Psychological Profiles Silvia Cimino • Luca Cerniglia • Marinella Paciello
Springer Science+Business Media New York 2014
Abstract The present paper aims to longitudinally assess the emotional functioning of children of mothers with depression, anxiety, or eating disorders and of mothers with no psychological disorders and to evaluate the possible mediating role of fathers’ psychological profiles on children’s internalizing/externalizing functioning using SCID I, SCL-90/R and CBCL/1-5. The results showed maternal psychopathology to be strongly related to children’s maladaptive profiles. Children of mothers with depression and anxiety showed higher internalizing scores than children of other groups. These scores increased from T1 to T2. Children of mothers with eating disorders showed higher and increasing externalizing scores than children of other groups. The data showed that fathers’ interpersonal sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of the children. Moreover, interpersonal sensitivity and psychoticism significantly predicted externalizing problems. Our results confirmed the impact of maternal psychopathology on maladaptive outcomes in their children, which suggests the importance of considering paternal psychological profiles. Keywords Infancy Maladaptive functioning Paternal psychological profile S. Cimino Department of Dynamic and Clinical Psychology, ‘‘Sapienza’’ University of Rome, Rome, Italy e-mail: [email protected] L. Cerniglia (&) M. Paciello Department of Psychology, International Telematic University Uninettuno of Rome, Rome, Italy e-mail: [email protected] M. Paciello e-mail: [email protected]
Introduction The international scientific literature points to parental psychopathology as a crucial risk factor for the development and maintenance of emotional and behavioral problems in children in the first years of life [1]. Douglas [2] states that the more severe mothers’ and fathers’ mental issues are, the faster the child will develop behavioral problems. Additionally, Riahi Amini and Salehi Veisi [3] found a positive correlation between maternal symptoms and children’s behavioral problems. An intensification in maternal symptoms increases their children’s behavioral problems, especially when their fathers’ psychological profiles are at risk and the paternal involvement in child rearing is scarce. In particular, many studies have focused on the influence of maternal depression on internalizing problems in children, on the impact of maternal eating disorders (EDs) on children’s mental health [4, 5], and have considered the possible role of paternal psychopathology as a mediating variable [6]. Some studies have found that mothers afflicted by major depression or panic disorder most likely have children who suffer from emotional behavioral problems. Moreover, maternal depression is associated with depressive disorder, social phobia, disruptive behavior, separation anxiety, multiple anxiety disorder and compromised social function in children; maternal panic disorder is associated with panic disorder, acrophobia, separation anxiety and multiple anxiety disorder in children [7, 8]. It is suggested that these results are mediated by protective or risk factors related to paternal psychological functioning and/or the quality of father–infant attachment [9]. Murray et al. [10] demonstrated that maternal depression in the early postpartum months was the best predictor of child behavioral problems, which were not influenced by
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current maternal depression but mediated by fathers’ involvement. Moreover, Luoma et al. [11] conducted a longitudinal analysis in Finland, and the results showed that prenatal maternal depression was associated with higher levels of child behavioral problems and that prenatal and recurrent maternal depressive symptoms led to the most negative child outcomes in absence of protective factors provided by the fathers. By the preschool years, children exposed to chronic maternal depression had higher levels of parent-reported internalizing and externalizing behavioral problems. A meta-analysis demonstrated that the relationship between maternal depression and conduct problems extends to adolescence. In addition, maternal depression has been shown to mediate the relationship between exposure to community violence and adolescent behavioral problems, which highlights its powerful effect on longterm child outcomes [12–17]. Regarding studies of maternal eating disorders, an increased incidence of early feeding disorders has been shown in children whose mothers were more intrusive and controlling in the feeding context and had difficulties recognizing the child’s signals of hunger and satiety and regulation of the affective states of the child [18–23]. These results proved to be particularly severe in the presence of psychopathological symptoms in the partners of women with EDs because they appear to facilitate the onset of emotional disorders in their children [24]. Indeed, Maldonado-Dura`n [25] found that caregivers (both mothers and fathers) had more difficulties in expressing positive affect in families with children with feeding disorders. These caregivers showed more negative affect and a lower ability to read the communication signals of the child. Furthermore, the children revealed problematic characteristics in their feeding patterns, difficulty regulating their state during meals, temperamental difficulties, and behavioral problems such as opposition, negativity, and stubbornness. Although some researchers have found that children of depressed or anxious parents are themselves at a substantially increased risk (twofold to fivefold) of psychiatric disorders [26–29], there are currently few studies that focus on maternal anxiety disorder (not otherwise specified). Moreover, there are few longitudinal studies that examine the emotional-adaptive development of children with mothers and/or fathers with psychopathological difficulties. As shown above, the research that has examined paternal psychopathology has suggested that it may play a crucial role in the quality of caregiving by modulating and integrating with interactional mother–infant patterns. In particular, Elgar, Mills and McGrath [30] note that a father with psychopathologic symptoms who shows a low level of responsiveness to his children may be a risk factor for the
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onset of children’s maladaptive behavior. Indeed, Pinquart and Teubert [31] state that a combination of maternal and paternal psychopathologies may create a style of co-parenting dominated by negative interactive cycles with the children. On the other hand, adaptive paternal psychological functioning may be a protective factor against the development of psychopathologies in children by facilitating mothers’ understanding of their children’s needs [32]. However, although the role of fathers have been increasingly considered in recent years, it seems useful to deepen the study of paternal psychopathological risk as a possible mediating variable in the onset of impaired adjustment in children, especially in the presence of specific maternal psychological difficulties [33]. Based on these theoretical premises, a longitudinal study is proposed here to assess the impact of specific maternal psychopathology on specific frameworks of child functioning that deepens the role of paternal psychopathological risk over time. In particular, the present prospective study has set the following specific objective: •
to assess the adaptive emotional functioning (internalizing, externalizing) of children of mothers with depression, anxiety, and eating disorders and of mothers with no psychological disorder considering the possible impact of the fathers’ psychological profiles over time on children’s internalizing/externalizing functioning.
Methods Sample To recruit the sample for our study, we planned two subsequent sessions of assessment. In a period of 1 year (T1), N = 251 families were recruited through nurseries, primary schools (N = 146) and mental health clinics (N = 105) in Central Italy. Families with children in the first 3 years of life were contacted by a group of trained psychologists who described the purposes and methods of the study, gave explanations about the questionnaires to be administered and gathered an informant consent from all the participants. Thanks to the collaboration of teachers and mental health workers, all the parents in schools and clinics were informed of the possibility of participating in the research. We administered all the sections of the SCID I (Non-Patient Edition) [34] to the mothers. The SCID II, which assesses personality disorders, was not administered. Our sample is divided into four subgroups: (a) three clinical subgroups were composed by families in which the mothers suffered from Anxiety Disorder (N = 42),
Child Psychiatry Hum Dev
Depression Disorder (N = 39) or Eating Disorder (N = 44) without a comorbidity disorder and (b) families in which the mothers received no diagnosis (N = 126). We chose not to include mothers who were pursuing treatment to avoid the bias of the effect of a psychotherapeutic intervention over time on the families’ dynamics (N = 9). Consistent with several perspective studies [35], the drop-off rate in the sample at the second time point (T2, 3 years after) was *45 % of the original number of subjects. We excluded the families with missing data in their administered questionnaires (N = 54). Thus, at T2 we assessed N = 80 families. The four groups have been then paired by age of the children, age of the mothers and the families’ socio-economic status. The sample presented for the present study is composed of N = 80 families with firstborn children with a mean age of T1 = 2.3 years (SD = 1.1) and T2 = 5.1 (SD = .08). Most of the parents (87 %) were of middle socio-economic status (SES) [36]. Sixty-eight percent of the parents lived together; 88 % of the fathers and 71 % of the mothers worked; 83 % of the children went to nursery or kindergarten; 88 % of the children have been breast-fed. All the partners of the mothers recruited for the present study were the biological fathers of the children, and all parents were Caucasian. The mean age of the fathers at T1 was 35.3 years of age (SD = 2.5), and the mean age of the mothers at T1 was 33.2 years of age (SD = 3.1).
Tools and Procedures The assessment was administered face-to-face by a group of trained psychologists who visited the families at their home or at mental health clinics. During these visits, a set of self-report and report-form tools were administered, and all the parents signed an informed consent for all the procedures. At the evaluation times (T1 and T2), the parents of both the Clinical Groups and the Non Clinical Group were administered the following tools: SCL-90-R:
The Symptom Checklist-90-Revised (SCL90-R) is a 90-item self-report symptom inventory aimed to measure psychological symptoms and psychological distress [37]. The main symptom dimensions are Somatization, Obsessive–Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation and Psychoticism. The internal coherence tested within a sample of adolescent and adults is satisfying (alpha between .70 and .96), and the clinical cut-off =1 [38]
CBCL:
The Child Behavior Checklist (CBCL) is a questionnaire filled out by parents and caregivers to assess a child’s abilities and his/her specific behavioral/emotional characteristics. The CBCL/1-5 [39] is composed of 100 items. The Internalizing Problem Scale consists of the Emotionally Reactive, Anxious/Depressed, Somatic Complaints and Withdrawn Subscales. The Externalizing Problem Scale is composed of the Attention Problems and Aggressive Behavior subscales. The CBCL/1-5 has a high test–retest reliability and a high internal consistency [39] (Italian validated version and Italian cut-offs, 40). Each parent independently completed the questionnaires at T1 and T2
Analyses Before performing the analyses, the variables’ normality and the congruence between the mothers’ and fathers’ evaluations of the child’s internalizing and externalizing problems were preliminarily ascertained. All the variables were normally distributed, and the correlations among the mothers’ and fathers’ evaluations on the children’s CBCL dimensions were highly and significantly correlated ([.30). Thus, we decided to aggregate the mothers’ and fathers’ scores on the CBCL using mean scores. We began the analyses by examining the stability and change of the children’s internalizing and externalizing problems over time for each group of mothers with a specific disorder (anxiety, depression and eating disorders) and without diagnosis (normative group). Specifically, we examined the mean score differences from Time 1 to Time 2 on the children’s problems by performing repeated measure analyses of variance using time as a within-subject factor and group as a between subject factor. Moreover, a one-way ANOVA was used to test the differences among the groups on internalizing and externalizing dimensions separately for each time. Then, we examined how the fathers’ psychological profiles at T1 were associated with the children’s internalizing and externalizing problems by performing correlation analyses and standard regressions with the fathers’ variables as predictors. Moreover, we examined whether and how the fathers’ SCL-90-R subscales were associated with the mothers’ disorders at Time 1 by analyzing the point-biserial correlation coefficients. Finally, to test the influence of the mothers’ disorders and the fathers’ psychological risk on internalizing and externalizing children’s problems, four hierarchical regression analyses were performed separately for the two assessment
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The significant differences are that (a) the children of mothers of the three clinical groups showed higher internalizing scores than did those of the normative group that (b) the children of mothers with depression and eating disorders showed higher externalizing scores than did those of the normative group or anxiety group. More specifically, at Time 2, the children of mothers with depression showed higher internalizing scores than did other children, but the children of mothers with an eating disorder showed higher externalizing scores than did other children. The normative group showed the lowest internalizing and externalizing problems at both time points.
points (T1 and T2). In all the regression models, the presence/absence of each specific disorder of the mother was entered at step 1 and the fathers’ scores on the SCL-90-R subscales were entered at step 2. We also evaluated the influence of the interaction of the mothers’ and fathers’ characteristics on the children’s internalizing and externalizing problems by entering the product of each mothers’ disorders and each fathers’ SCL-90-R subscale at T1 at step 3. These analyses revealed no statistically significant interactions.
Results Fathers’ Psychological Profile and Their Child’s Problems
Mothers’ Disorders and Children’s Internalizing and Externalizing Problems
Regarding the possible associations between the fathers’ psychopathological risk and their children’s psychological problems at both T1 and T2, correlational analyses attested that (a) interpersonal sensitivity and depression dimensions were significantly and positively associated with both internalizing and externalizing problems, that (b) obsessive–compulsive and anxiety dimensions were significantly and positively associated with internalizing problems and negatively associated with externalizing problems, and that (c) psychoticism and hostility dimensions were particularly associated with externalizing problems (Table 2). The results of the regression analyses also attested to the influence of the fathers’ psychological scores on their child’s problems, which confirmed some associations. The fathers’ interpersonal sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of their child at both Time 1 (45 % of explained variance) and Time 2 (48 % of explained variance). Moreover, at T1, interpersonal sensitivity and psychoticism significantly predicted externalizing problems (51 % of explained variance), and hostility and psychoticism significantly predicted externalizing problems at Time 2.
The repeated analyses results indicated that the children’s internalizing and externalizing scores were not stable over time [F(1,80) = 74,42; p= at p \ .001 with an eta square of .48 and F(1,80) = 9,87; p= at p \ .01 with an eta square of .11, respectively] and that there were significant interaction between time and group [F(1,80) = 12,31; p= at p \ .001 with eta square .32 and F(1,80) = 11,81; p= at p \ .001 with eta square .31, respectively]. More specifically, the multiple comparison tests indicated that the internalizing problems tended to increase over time for all the children. This result was particularly strong in the group of mothers with depression, but the children’s externalizing problems tended to increase over time only in the group of mothers with an eating disorder (Table 1). Analyses on the children’s psychological profile showed significant differences on both internalizing [Time 1: F(3,80) = 26,65; p= at p \ .001 with an eta square of .50; Time 2: F(3,80) = 30; p= at p \ .001 with an eta square of .53] and externalizing problems [Time 1: F(3,80) = 37,43; p= at p \ .001 with an eta square of .58; Time 2: F(3,80) = 34,27; p= at p \ .001 with an eta square of .56].
Table 1 Means (SD) of child’s internalizing and externalizing problems by mother’s group at Time 1 and Time 2 Internalizing problems (clinical cut off [16)
Externalizing problems (clinical cut off [21)
T1
T2
T1–T2
T1
T2
T1–T2
Anxiety disorder
19.6 (6.2) a
21.2 (5.6) a
**
6.31 (5.7) a
5.71 (3.5) a
ns.
Depression disorder
17.7 (5.5) a
23.1 (6.9) a
***
27.29 (13.0) b
26.54 (14.3) b
ns.
Eating disorder
17.93 (8.0) a
19.1 (8.0) a
*
25.57 (12.5) b
30.20 (15.2) b
***
Normative
5.24 (2.7) b
6.9 (3.1) b
**
2.98 (1.7) a
4.21 (2.1) a
ns.
Total sample
15.12 (8.18)
17.61 (8.8)
15.55 (14.47)
16.62 (15.73)
The letters indicate significant differences among the group T1 Time 1, T2 Time 2, T1–T2 difference from Time 1 to Time 2, Fisher F ANOVA at each time, g2 eta square *** p \ .001; ** p \ .01; * p \ .05; ns not significant
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Child Psychiatry Hum Dev Table 2 Regressions and point-biserial correlations on fathers’ dimensions, child’s problems and mothers’ disorders Mean (SD)
Internalizing problems
Externalizing problems
Mother disorder
T1
T1
Anxiety
Depression
Eating
b
r
R
r
-.04
T2
R
b
r
b
Somatization (F)
.48 (29)
.28**
Ns
.26**
Ns
Obsessive– compulsive (F)
1.0 (1.0)
.35***
Ns
.27**
Ns
Interpersonal sensitivity (F)
.86 (1.0)
.24*
.35*
.40***
.36*
T2 b
r .10 -.39*** .44***
Ns -.37? .36*
Depression (F)
.99 (.98)
.28**
.31*
.44***
.43**
.46***
Ns
Anxiety (F)
.88 (.99)
.40***
.57**
.32**
.56**
-.34***
Ns
r .15*
Ns
-.38***
Ns
.37***
Ns
-.33**
Ns
-.25*
.39*** -.33**
Ns
.80***
.79**
Hostility (F)
.88 (.94)
.22*
Ns
.13
Ns
.45***
Ns
.56***
.31*
-.36**
Phobic anxiety (F)
.32 (.37)
.06
Ns
.09
Ns
.16
Ns
.17
Ns
-.16
Paranoid ideation (F)
.53 (.42)
.11
Ns
.15
Ns
.10
Ns
.11
Ns
-.20
Psychoticism (F)
.81 (1.0)
.22*
.38*
.13
.39*
.41***
.51***
.52***
.51**
-.29*
.08
.07
-.25*
-.30*
.88*** .90*** -.24* -.16
-.32* -.32* -.28* .81***
.22*
-.07
.26*
-.09
-.25*
.88***
b regression beta coefficients, F fathers’ dimensions at Time 1, T1 Time 1, T2 Time 2 *** p \ .001; ** p \ .01; * p \ .05;
?
p \ .06
Impact of Mothers’ Disorders and Fathers’ Psychological Profiles on Their Children’s Internalizing and Externalizing Problems The correlation results suggested that there were significant associations between the fathers’ dimensions and the mothers’ disorders. In particular, the fathers’ interpersonal sensitivity and depression were very significantly and positively related to the mothers’ depression disorder. The fathers’ anxiety and obsessive–compulsive symptoms were very significantly and positively related to the mothers’ anxiety disorder. Finally, the fathers’ hostility and psychoticism were very significantly and positively related to the mothers’ eating disorder (Table 2). As shown in Table 3, all the regression models attested that the mothers’ disorder significantly predicts their children’s outcomes, concurrently (51 and 60 % of the explained variance for internalizing and externalizing problems, respectively) and longitudinally (54 and 66 % of the explained variance for internalizing and externalizing problems, respectively). In particular, the mothers’ eating disorders and depression significantly and positively influence their children’s externalizing and internalizing problems; instead, the mothers’ anxiety significantly and positively influences only their child’s internalizing problems. Moreover, after controlling the mothers’ disorders, the fathers’ psychological profiles significantly predicted their children’s outcomes (explaining between 09 and 12 % of the variance) with the only exception of externalizing problems at Time 2. In particular, the fathers’ interpersonal sensitivity and anxiety are significantly and positively associated with their child’s internalizing problems and mediate the influence of the mothers’ depression
disorder, but the fathers’ obsessive–compulsive dimension is significantly and negatively related to their child’s externalizing problems at Time 1.
Discussion The present paper aimed to assess the impact of specific maternal psychopathology on particular frameworks of their children’s functioning by considering the role of paternal psychopathological risk over time. Our results are in line with the international scientific literature that suggests that mothers’ psychopathology can foster their children’s emotional and behavioral problems, which increase in their severity during development [3]. In fact, in our study, the children of mothers with a diagnosis showed significantly higher scores on all internalizing and externalizing dimensions than did the healthy group children at both Time 1 and Time 2. In particular, the data show that specific diagnoses in the mothers are related to precise maladaptive emotional and behavioral patterns in their children. In Figs. 1, 2 and 3, we present a graphical representation of our main findings from regression analyses: As shown in Fig. 1, we did not find a significant and direct effect of maternal depression on their child’s emotional/behavioral functioning if considered together with the paternal psychopathological risk. Rather, our results show that the fathers’ interpersonal sensitivity predicts their children’s internalizing problems. This result is consistent with Lovejoy and colleagues’ work [41] that suggested that, in specific family configurations, fathers’ psychopathological risk could have an even more severe
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Child Psychiatry Hum Dev Table 3 Parents’ impact on their child’s internalizing and externalizing problems at Time 1 and Time 2 Internalizing problems Time 1
Externalizing problems Time 2
Time 1
Time 2
b1
b2
R Ch.
b1
b2
R Ch.
b1
b2
RCh.
b1
b2
R Ch.
Anxiety disorder (M)
.67***
.49***
.51***
.59***
.45**
.54***
Ns
.52***
.60***
Ns
Ns
.66***
Depression disorder (M) Eating disorder
.76*** .68***
Ns. .66***
.87*** .57***
Ns .59***
.75*** .73***
.67*** .51**
.49*** .87***
Ns .51***
Step 1
Step 2 Somatization (F)
Ns.
Obsessive–compulsive (F)
Ns.
.12*
Ns. Ns.
.10*
Ns -.45***
.09*
Ns. Ns.
Interpersonal sensitivity (F)
.40**
.36*
Ns
Ns.
Depression (F)
Ns.
Ns.
Ns
Ns.
Anxiety (F)
.37?
.38*
Ns
Ns. Ns.
Hostility (F)
Ns.
Ns.
Ns
Phobic anxiety (F)
Ns.
Ns.
.15?
Ns.
Paranoid ideation (F)
Ns.
Ns.
Ns
Ns.
Psychoticism (F)
Ns.
Ns.
Ns
.06
Ns.
R2
.62***
.64***
.69***
.73***
AR2
.57
.57
.64
.68
R Ch R change, b1 beta at step 1, b2 beta at step 2, R2 = R square, AR adjusted R2, Ns not significant, M mother’s disorders at Time 1 (1 = presence; 0 = absence), F fathers’ psychological dimensions at Time 1 *** p \ .001; ** p \ .01; * p \ .05;? p \ .06
Fig. 1 Conceptual model—mothers with depression
Fig. 2 Conceptual model—mothers with anxiety
impact on their children’s psychological functioning than does maternal depression. It is possible that the reciprocally influencing relationship we found between the mothers’ depression and the fathers’ interpersonal sensitivity might express a maladjustment in the couple functioning, which in turn could reflect on the fathers’ capacity for quality interactions with his son or daughter; poor caregiving has been widely recognized to be a predictor of infants’ internalizing (and externalizing) problems [42]. Figure 2 shows that the mothers’ and fathers’ anxiety significantly and directly predicts their children’s
internalizing problems. It is important to note that psychological/psychopathological difficulties of mothers and fathers are connected with a bidirectional influence in our sample; thus, we can hypothesize in agreement with the studies of Weissmann et al. [26] that parents often share a specific psychological difficulty whose cumulative weight impairs their child’s emotional and behavioral functioning in the direction of internalizing problems. Figure 3 shows that maternal eating disorders predict externalizing problems in children. Paternal psychoticism does not predict children’s problems, but it is reciprocally
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Fig. 3 Conceptual model—mothers with eating disorders
connected to maternal disorders. In this case, it is possible hypothesize that mothers’ eating disorders have such an intense impact on their children’s psychological functioning that the weight of paternal psychopathological risk is lost. In line with the studies of Sarkadi and colleagues [43], we can suppose that the mother is most likely responsible for feeding the child (with fathers less often involved in the feeding of young children) and that this specific maternal disorder powerfully impacts the child’s emotional and behavioral functioning because the mother–infant dyad interacts every day in supposedly difficult interactions during meals. These results highlight the importance of assessing the whole family (mother, father and children) over time and the significance of an early intervention because our study indicates an increase in children’s maladaptive psychological profiles from T1 to T2 that could be avoided with well-timed clinical work [25]. The interesting bidirectional relationship between maternal and paternal psychopathological symptoms (as discussed above) must be more specifically addressed in a future study because we hypothesize that it influences the general functioning of the family and particularly the parents’ caregiving quality, which in turn is connected to possible maladaptive outcomes in their children. This issue is relevant for the organization of intervention practices that must involve the whole family and assess possible marital maladjustment [44] to better understand how various psychopathological maternal and paternal symptoms can interact and impact the psychological welfare of their children. Our study has several strengths. It considered various maternal diagnostic groups and their effects on their children’s emotional/behavioral functioning over time, but it also measured the possible mediating effect of paternal psychopathology. Both parents completed the CBCL, but many previous studies included self-report questionnaires completed only by the mother. Our study has some limitations. The study has a homogeneous sample, which
included only Caucasians of middle socio-economic status with mainly two traditional working parents. Moreover, we did not administer the SCID-II to assess personality disorders in the mothers, and we did not evaluate the severity of the mothers’ diagnosis with a specific tool. We did not administer the SCID I to fathers but relied on the SCL-90R self-report questionnaire, whose scores were not confirmed by other tools and/or clinical interviews administered by trained psychologists. We did not directly observe the children’s behavior and characteristics but used a widely used and validated report-form questionnaire. We also did not address possible differences in the psychological functioning of the sons or daughters of mothers with eating disorders or of mothers with other diagnoses as the international literature suggests [45]. These limitations constitute a motivation to continue our research and take samples of mothers with comorbidities into consideration.
Summary Several authors suggest that parents’ psychopathology can foster the onset of maladaptive psychological profiles in their children. It has been demonstrated that children’s psychological difficulties tend to increase over time, particularly in families in which the mother suffers from depression, anxiety or eating disorders. It has also been suggested that fathers’ psychopathological risk may be a risk factor for the onset of difficulties in their children. The present study focused on assessing the emotional functioning of the children of mothers with various diagnoses and of mothers with no psychological disorder while considering the possible mediating role of the fathers’ psychological profiles on their children’s internalizing/ externalizing functioning. We used the SCID I [25], SCL90/R [36], and CBCL/1-5 [39]. The analyses showed that the children’s internalizing and externalizing scores tended to increase from T1 to T2. Maternal psychopathology proved to be strongly related to their children’s maladaptive profiles. Specifically, the children of mothers with depression showed higher internalizing scores than did children of other groups, and these scores increased from T1 to T2; the children of mothers with eating disorders showed higher and increasing externalizing scores than did other children. The children of mothers with a diagnosis showed significantly higher scores in all internalizing and externalizing dimensions than did the healthy group children at both Time 1 and Time 2. In particular, the children showed specific maladaptive profiles depending on what diagnosis their mother received. Mothers with depression were more likely to have a withdrawn child, and mothers with eating disorders had a higher probability of having aggressive children. Furthermore, the fathers’ interpersonal
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sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of their children at both T1 and T2. Moreover, at T1, the fathers’ interpersonal sensitivity and psychoticism significantly predicted their child’s externalizing problems, and the fathers’ hostility and psychoticism significantly predicted their child’s externalizing problems at T2.
15.
16. 17.
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the role of paternal psychological profiles. Eur Eat Disord Rev. doi:10.1002/erv.2218 First MB, Spitzer RL, Gibbon M, Williams JBW (2002) Structured clinical interview for DSM-IV-TR Axis I disorders, research version, non-patient edition (SCID-I/NP). New York State Psychiatric Institute, Biometrics Research, New York Lane P (2008) Handling drop-out in longitudinal clinical trials: a comparison of the LOCF and MMRM approaches. Pharmac Stat 7:93–106 Hollingshead AB (1975) Four factors index of social status. Yale University Department of Sociology, New Haven Derogatis LR (1994) SCL-90-R: administration, scoring and procedures manual. National Computer Systems, Minneapolis Prunas A, Sarno I, Preti E, Madeddu F, Perugini M (2012) Psychometric properties of the Italian version of the SCL-90-R: a study on a large community sample. Eur Psychiat 27(8):591–597. doi:10.1016/j.eurpsy.2010.12.006 Achenbach TM, Rescorla LA (2001) Manual for the ASEBA school-age forms & profiles. Research Center for Children, Youth, & Families, University of Vermont, Burlington Frigerio A, Montirosso R (2002) La valutazione su base empirica dei problemi emotivo-comportamentali in eta` evolutiva. Infanzia e Adolescenza 1:38–48
41. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G (2000) Maternal depression and parenting behaviour: a meta-analytic review. Clin Psych Rev 20:561–592 42. Whisman MA (2001) The association between depression and marital dissatisfaction. In: Beach SRH (ed) Marital and family processes in depression: a scientific foundation for clinical practice. American Psychological Association, Washington, pp 3–24 43. Sarkadi A, Kristiansson R, Oberklaid F, Bremberg S (2008) Fathers’ involvement and children’s developmental outcomes: a systematic review of longitudinal studies. Acta Paediat 97(2):153–158 44. Heinrichs N, Prinz RJ (2012) Families in trouble: bridging the gaps among child, adult, and couple functioning. Clin Child Fam Psych 15(1):1–3 45. Micali N, Stahl D, Treasure J, Simonoff E (2014) Childhood psychopathology in children of women with eating disorders: understanding risk mechanisms. J Child Psychol Psychiat 55(2):124–134. doi:10.1111/jcpp.12112
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ORIGINAL ARTICLE
Mothers with Depression, Anxiety or Eating Disorders: Outcomes on Their Children and the Role of Paternal Psychological Profiles Silvia Cimino • Luca Cerniglia • Marinella Paciello
Springer Science+Business Media New York 2014
Abstract The present paper aims to longitudinally assess the emotional functioning of children of mothers with depression, anxiety, or eating disorders and of mothers with no psychological disorders and to evaluate the possible mediating role of fathers’ psychological profiles on children’s internalizing/externalizing functioning using SCID I, SCL-90/R and CBCL/1-5. The results showed maternal psychopathology to be strongly related to children’s maladaptive profiles. Children of mothers with depression and anxiety showed higher internalizing scores than children of other groups. These scores increased from T1 to T2. Children of mothers with eating disorders showed higher and increasing externalizing scores than children of other groups. The data showed that fathers’ interpersonal sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of the children. Moreover, interpersonal sensitivity and psychoticism significantly predicted externalizing problems. Our results confirmed the impact of maternal psychopathology on maladaptive outcomes in their children, which suggests the importance of considering paternal psychological profiles. Keywords Infancy Maladaptive functioning Paternal psychological profile S. Cimino Department of Dynamic and Clinical Psychology, ‘‘Sapienza’’ University of Rome, Rome, Italy e-mail: [email protected] L. Cerniglia (&) M. Paciello Department of Psychology, International Telematic University Uninettuno of Rome, Rome, Italy e-mail: [email protected] M. Paciello e-mail: [email protected]
Introduction The international scientific literature points to parental psychopathology as a crucial risk factor for the development and maintenance of emotional and behavioral problems in children in the first years of life [1]. Douglas [2] states that the more severe mothers’ and fathers’ mental issues are, the faster the child will develop behavioral problems. Additionally, Riahi Amini and Salehi Veisi [3] found a positive correlation between maternal symptoms and children’s behavioral problems. An intensification in maternal symptoms increases their children’s behavioral problems, especially when their fathers’ psychological profiles are at risk and the paternal involvement in child rearing is scarce. In particular, many studies have focused on the influence of maternal depression on internalizing problems in children, on the impact of maternal eating disorders (EDs) on children’s mental health [4, 5], and have considered the possible role of paternal psychopathology as a mediating variable [6]. Some studies have found that mothers afflicted by major depression or panic disorder most likely have children who suffer from emotional behavioral problems. Moreover, maternal depression is associated with depressive disorder, social phobia, disruptive behavior, separation anxiety, multiple anxiety disorder and compromised social function in children; maternal panic disorder is associated with panic disorder, acrophobia, separation anxiety and multiple anxiety disorder in children [7, 8]. It is suggested that these results are mediated by protective or risk factors related to paternal psychological functioning and/or the quality of father–infant attachment [9]. Murray et al. [10] demonstrated that maternal depression in the early postpartum months was the best predictor of child behavioral problems, which were not influenced by
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current maternal depression but mediated by fathers’ involvement. Moreover, Luoma et al. [11] conducted a longitudinal analysis in Finland, and the results showed that prenatal maternal depression was associated with higher levels of child behavioral problems and that prenatal and recurrent maternal depressive symptoms led to the most negative child outcomes in absence of protective factors provided by the fathers. By the preschool years, children exposed to chronic maternal depression had higher levels of parent-reported internalizing and externalizing behavioral problems. A meta-analysis demonstrated that the relationship between maternal depression and conduct problems extends to adolescence. In addition, maternal depression has been shown to mediate the relationship between exposure to community violence and adolescent behavioral problems, which highlights its powerful effect on longterm child outcomes [12–17]. Regarding studies of maternal eating disorders, an increased incidence of early feeding disorders has been shown in children whose mothers were more intrusive and controlling in the feeding context and had difficulties recognizing the child’s signals of hunger and satiety and regulation of the affective states of the child [18–23]. These results proved to be particularly severe in the presence of psychopathological symptoms in the partners of women with EDs because they appear to facilitate the onset of emotional disorders in their children [24]. Indeed, Maldonado-Dura`n [25] found that caregivers (both mothers and fathers) had more difficulties in expressing positive affect in families with children with feeding disorders. These caregivers showed more negative affect and a lower ability to read the communication signals of the child. Furthermore, the children revealed problematic characteristics in their feeding patterns, difficulty regulating their state during meals, temperamental difficulties, and behavioral problems such as opposition, negativity, and stubbornness. Although some researchers have found that children of depressed or anxious parents are themselves at a substantially increased risk (twofold to fivefold) of psychiatric disorders [26–29], there are currently few studies that focus on maternal anxiety disorder (not otherwise specified). Moreover, there are few longitudinal studies that examine the emotional-adaptive development of children with mothers and/or fathers with psychopathological difficulties. As shown above, the research that has examined paternal psychopathology has suggested that it may play a crucial role in the quality of caregiving by modulating and integrating with interactional mother–infant patterns. In particular, Elgar, Mills and McGrath [30] note that a father with psychopathologic symptoms who shows a low level of responsiveness to his children may be a risk factor for the
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onset of children’s maladaptive behavior. Indeed, Pinquart and Teubert [31] state that a combination of maternal and paternal psychopathologies may create a style of co-parenting dominated by negative interactive cycles with the children. On the other hand, adaptive paternal psychological functioning may be a protective factor against the development of psychopathologies in children by facilitating mothers’ understanding of their children’s needs [32]. However, although the role of fathers have been increasingly considered in recent years, it seems useful to deepen the study of paternal psychopathological risk as a possible mediating variable in the onset of impaired adjustment in children, especially in the presence of specific maternal psychological difficulties [33]. Based on these theoretical premises, a longitudinal study is proposed here to assess the impact of specific maternal psychopathology on specific frameworks of child functioning that deepens the role of paternal psychopathological risk over time. In particular, the present prospective study has set the following specific objective: •
to assess the adaptive emotional functioning (internalizing, externalizing) of children of mothers with depression, anxiety, and eating disorders and of mothers with no psychological disorder considering the possible impact of the fathers’ psychological profiles over time on children’s internalizing/externalizing functioning.
Methods Sample To recruit the sample for our study, we planned two subsequent sessions of assessment. In a period of 1 year (T1), N = 251 families were recruited through nurseries, primary schools (N = 146) and mental health clinics (N = 105) in Central Italy. Families with children in the first 3 years of life were contacted by a group of trained psychologists who described the purposes and methods of the study, gave explanations about the questionnaires to be administered and gathered an informant consent from all the participants. Thanks to the collaboration of teachers and mental health workers, all the parents in schools and clinics were informed of the possibility of participating in the research. We administered all the sections of the SCID I (Non-Patient Edition) [34] to the mothers. The SCID II, which assesses personality disorders, was not administered. Our sample is divided into four subgroups: (a) three clinical subgroups were composed by families in which the mothers suffered from Anxiety Disorder (N = 42),
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Depression Disorder (N = 39) or Eating Disorder (N = 44) without a comorbidity disorder and (b) families in which the mothers received no diagnosis (N = 126). We chose not to include mothers who were pursuing treatment to avoid the bias of the effect of a psychotherapeutic intervention over time on the families’ dynamics (N = 9). Consistent with several perspective studies [35], the drop-off rate in the sample at the second time point (T2, 3 years after) was *45 % of the original number of subjects. We excluded the families with missing data in their administered questionnaires (N = 54). Thus, at T2 we assessed N = 80 families. The four groups have been then paired by age of the children, age of the mothers and the families’ socio-economic status. The sample presented for the present study is composed of N = 80 families with firstborn children with a mean age of T1 = 2.3 years (SD = 1.1) and T2 = 5.1 (SD = .08). Most of the parents (87 %) were of middle socio-economic status (SES) [36]. Sixty-eight percent of the parents lived together; 88 % of the fathers and 71 % of the mothers worked; 83 % of the children went to nursery or kindergarten; 88 % of the children have been breast-fed. All the partners of the mothers recruited for the present study were the biological fathers of the children, and all parents were Caucasian. The mean age of the fathers at T1 was 35.3 years of age (SD = 2.5), and the mean age of the mothers at T1 was 33.2 years of age (SD = 3.1).
Tools and Procedures The assessment was administered face-to-face by a group of trained psychologists who visited the families at their home or at mental health clinics. During these visits, a set of self-report and report-form tools were administered, and all the parents signed an informed consent for all the procedures. At the evaluation times (T1 and T2), the parents of both the Clinical Groups and the Non Clinical Group were administered the following tools: SCL-90-R:
The Symptom Checklist-90-Revised (SCL90-R) is a 90-item self-report symptom inventory aimed to measure psychological symptoms and psychological distress [37]. The main symptom dimensions are Somatization, Obsessive–Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation and Psychoticism. The internal coherence tested within a sample of adolescent and adults is satisfying (alpha between .70 and .96), and the clinical cut-off =1 [38]
CBCL:
The Child Behavior Checklist (CBCL) is a questionnaire filled out by parents and caregivers to assess a child’s abilities and his/her specific behavioral/emotional characteristics. The CBCL/1-5 [39] is composed of 100 items. The Internalizing Problem Scale consists of the Emotionally Reactive, Anxious/Depressed, Somatic Complaints and Withdrawn Subscales. The Externalizing Problem Scale is composed of the Attention Problems and Aggressive Behavior subscales. The CBCL/1-5 has a high test–retest reliability and a high internal consistency [39] (Italian validated version and Italian cut-offs, 40). Each parent independently completed the questionnaires at T1 and T2
Analyses Before performing the analyses, the variables’ normality and the congruence between the mothers’ and fathers’ evaluations of the child’s internalizing and externalizing problems were preliminarily ascertained. All the variables were normally distributed, and the correlations among the mothers’ and fathers’ evaluations on the children’s CBCL dimensions were highly and significantly correlated ([.30). Thus, we decided to aggregate the mothers’ and fathers’ scores on the CBCL using mean scores. We began the analyses by examining the stability and change of the children’s internalizing and externalizing problems over time for each group of mothers with a specific disorder (anxiety, depression and eating disorders) and without diagnosis (normative group). Specifically, we examined the mean score differences from Time 1 to Time 2 on the children’s problems by performing repeated measure analyses of variance using time as a within-subject factor and group as a between subject factor. Moreover, a one-way ANOVA was used to test the differences among the groups on internalizing and externalizing dimensions separately for each time. Then, we examined how the fathers’ psychological profiles at T1 were associated with the children’s internalizing and externalizing problems by performing correlation analyses and standard regressions with the fathers’ variables as predictors. Moreover, we examined whether and how the fathers’ SCL-90-R subscales were associated with the mothers’ disorders at Time 1 by analyzing the point-biserial correlation coefficients. Finally, to test the influence of the mothers’ disorders and the fathers’ psychological risk on internalizing and externalizing children’s problems, four hierarchical regression analyses were performed separately for the two assessment
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The significant differences are that (a) the children of mothers of the three clinical groups showed higher internalizing scores than did those of the normative group that (b) the children of mothers with depression and eating disorders showed higher externalizing scores than did those of the normative group or anxiety group. More specifically, at Time 2, the children of mothers with depression showed higher internalizing scores than did other children, but the children of mothers with an eating disorder showed higher externalizing scores than did other children. The normative group showed the lowest internalizing and externalizing problems at both time points.
points (T1 and T2). In all the regression models, the presence/absence of each specific disorder of the mother was entered at step 1 and the fathers’ scores on the SCL-90-R subscales were entered at step 2. We also evaluated the influence of the interaction of the mothers’ and fathers’ characteristics on the children’s internalizing and externalizing problems by entering the product of each mothers’ disorders and each fathers’ SCL-90-R subscale at T1 at step 3. These analyses revealed no statistically significant interactions.
Results Fathers’ Psychological Profile and Their Child’s Problems
Mothers’ Disorders and Children’s Internalizing and Externalizing Problems
Regarding the possible associations between the fathers’ psychopathological risk and their children’s psychological problems at both T1 and T2, correlational analyses attested that (a) interpersonal sensitivity and depression dimensions were significantly and positively associated with both internalizing and externalizing problems, that (b) obsessive–compulsive and anxiety dimensions were significantly and positively associated with internalizing problems and negatively associated with externalizing problems, and that (c) psychoticism and hostility dimensions were particularly associated with externalizing problems (Table 2). The results of the regression analyses also attested to the influence of the fathers’ psychological scores on their child’s problems, which confirmed some associations. The fathers’ interpersonal sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of their child at both Time 1 (45 % of explained variance) and Time 2 (48 % of explained variance). Moreover, at T1, interpersonal sensitivity and psychoticism significantly predicted externalizing problems (51 % of explained variance), and hostility and psychoticism significantly predicted externalizing problems at Time 2.
The repeated analyses results indicated that the children’s internalizing and externalizing scores were not stable over time [F(1,80) = 74,42; p= at p \ .001 with an eta square of .48 and F(1,80) = 9,87; p= at p \ .01 with an eta square of .11, respectively] and that there were significant interaction between time and group [F(1,80) = 12,31; p= at p \ .001 with eta square .32 and F(1,80) = 11,81; p= at p \ .001 with eta square .31, respectively]. More specifically, the multiple comparison tests indicated that the internalizing problems tended to increase over time for all the children. This result was particularly strong in the group of mothers with depression, but the children’s externalizing problems tended to increase over time only in the group of mothers with an eating disorder (Table 1). Analyses on the children’s psychological profile showed significant differences on both internalizing [Time 1: F(3,80) = 26,65; p= at p \ .001 with an eta square of .50; Time 2: F(3,80) = 30; p= at p \ .001 with an eta square of .53] and externalizing problems [Time 1: F(3,80) = 37,43; p= at p \ .001 with an eta square of .58; Time 2: F(3,80) = 34,27; p= at p \ .001 with an eta square of .56].
Table 1 Means (SD) of child’s internalizing and externalizing problems by mother’s group at Time 1 and Time 2 Internalizing problems (clinical cut off [16)
Externalizing problems (clinical cut off [21)
T1
T2
T1–T2
T1
T2
T1–T2
Anxiety disorder
19.6 (6.2) a
21.2 (5.6) a
**
6.31 (5.7) a
5.71 (3.5) a
ns.
Depression disorder
17.7 (5.5) a
23.1 (6.9) a
***
27.29 (13.0) b
26.54 (14.3) b
ns.
Eating disorder
17.93 (8.0) a
19.1 (8.0) a
*
25.57 (12.5) b
30.20 (15.2) b
***
Normative
5.24 (2.7) b
6.9 (3.1) b
**
2.98 (1.7) a
4.21 (2.1) a
ns.
Total sample
15.12 (8.18)
17.61 (8.8)
15.55 (14.47)
16.62 (15.73)
The letters indicate significant differences among the group T1 Time 1, T2 Time 2, T1–T2 difference from Time 1 to Time 2, Fisher F ANOVA at each time, g2 eta square *** p \ .001; ** p \ .01; * p \ .05; ns not significant
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Child Psychiatry Hum Dev Table 2 Regressions and point-biserial correlations on fathers’ dimensions, child’s problems and mothers’ disorders Mean (SD)
Internalizing problems
Externalizing problems
Mother disorder
T1
T1
Anxiety
Depression
Eating
b
r
R
r
-.04
T2
R
b
r
b
Somatization (F)
.48 (29)
.28**
Ns
.26**
Ns
Obsessive– compulsive (F)
1.0 (1.0)
.35***
Ns
.27**
Ns
Interpersonal sensitivity (F)
.86 (1.0)
.24*
.35*
.40***
.36*
T2 b
r .10 -.39*** .44***
Ns -.37? .36*
Depression (F)
.99 (.98)
.28**
.31*
.44***
.43**
.46***
Ns
Anxiety (F)
.88 (.99)
.40***
.57**
.32**
.56**
-.34***
Ns
r .15*
Ns
-.38***
Ns
.37***
Ns
-.33**
Ns
-.25*
.39*** -.33**
Ns
.80***
.79**
Hostility (F)
.88 (.94)
.22*
Ns
.13
Ns
.45***
Ns
.56***
.31*
-.36**
Phobic anxiety (F)
.32 (.37)
.06
Ns
.09
Ns
.16
Ns
.17
Ns
-.16
Paranoid ideation (F)
.53 (.42)
.11
Ns
.15
Ns
.10
Ns
.11
Ns
-.20
Psychoticism (F)
.81 (1.0)
.22*
.38*
.13
.39*
.41***
.51***
.52***
.51**
-.29*
.08
.07
-.25*
-.30*
.88*** .90*** -.24* -.16
-.32* -.32* -.28* .81***
.22*
-.07
.26*
-.09
-.25*
.88***
b regression beta coefficients, F fathers’ dimensions at Time 1, T1 Time 1, T2 Time 2 *** p \ .001; ** p \ .01; * p \ .05;
?
p \ .06
Impact of Mothers’ Disorders and Fathers’ Psychological Profiles on Their Children’s Internalizing and Externalizing Problems The correlation results suggested that there were significant associations between the fathers’ dimensions and the mothers’ disorders. In particular, the fathers’ interpersonal sensitivity and depression were very significantly and positively related to the mothers’ depression disorder. The fathers’ anxiety and obsessive–compulsive symptoms were very significantly and positively related to the mothers’ anxiety disorder. Finally, the fathers’ hostility and psychoticism were very significantly and positively related to the mothers’ eating disorder (Table 2). As shown in Table 3, all the regression models attested that the mothers’ disorder significantly predicts their children’s outcomes, concurrently (51 and 60 % of the explained variance for internalizing and externalizing problems, respectively) and longitudinally (54 and 66 % of the explained variance for internalizing and externalizing problems, respectively). In particular, the mothers’ eating disorders and depression significantly and positively influence their children’s externalizing and internalizing problems; instead, the mothers’ anxiety significantly and positively influences only their child’s internalizing problems. Moreover, after controlling the mothers’ disorders, the fathers’ psychological profiles significantly predicted their children’s outcomes (explaining between 09 and 12 % of the variance) with the only exception of externalizing problems at Time 2. In particular, the fathers’ interpersonal sensitivity and anxiety are significantly and positively associated with their child’s internalizing problems and mediate the influence of the mothers’ depression
disorder, but the fathers’ obsessive–compulsive dimension is significantly and negatively related to their child’s externalizing problems at Time 1.
Discussion The present paper aimed to assess the impact of specific maternal psychopathology on particular frameworks of their children’s functioning by considering the role of paternal psychopathological risk over time. Our results are in line with the international scientific literature that suggests that mothers’ psychopathology can foster their children’s emotional and behavioral problems, which increase in their severity during development [3]. In fact, in our study, the children of mothers with a diagnosis showed significantly higher scores on all internalizing and externalizing dimensions than did the healthy group children at both Time 1 and Time 2. In particular, the data show that specific diagnoses in the mothers are related to precise maladaptive emotional and behavioral patterns in their children. In Figs. 1, 2 and 3, we present a graphical representation of our main findings from regression analyses: As shown in Fig. 1, we did not find a significant and direct effect of maternal depression on their child’s emotional/behavioral functioning if considered together with the paternal psychopathological risk. Rather, our results show that the fathers’ interpersonal sensitivity predicts their children’s internalizing problems. This result is consistent with Lovejoy and colleagues’ work [41] that suggested that, in specific family configurations, fathers’ psychopathological risk could have an even more severe
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Child Psychiatry Hum Dev Table 3 Parents’ impact on their child’s internalizing and externalizing problems at Time 1 and Time 2 Internalizing problems Time 1
Externalizing problems Time 2
Time 1
Time 2
b1
b2
R Ch.
b1
b2
R Ch.
b1
b2
RCh.
b1
b2
R Ch.
Anxiety disorder (M)
.67***
.49***
.51***
.59***
.45**
.54***
Ns
.52***
.60***
Ns
Ns
.66***
Depression disorder (M) Eating disorder
.76*** .68***
Ns. .66***
.87*** .57***
Ns .59***
.75*** .73***
.67*** .51**
.49*** .87***
Ns .51***
Step 1
Step 2 Somatization (F)
Ns.
Obsessive–compulsive (F)
Ns.
.12*
Ns. Ns.
.10*
Ns -.45***
.09*
Ns. Ns.
Interpersonal sensitivity (F)
.40**
.36*
Ns
Ns.
Depression (F)
Ns.
Ns.
Ns
Ns.
Anxiety (F)
.37?
.38*
Ns
Ns. Ns.
Hostility (F)
Ns.
Ns.
Ns
Phobic anxiety (F)
Ns.
Ns.
.15?
Ns.
Paranoid ideation (F)
Ns.
Ns.
Ns
Ns.
Psychoticism (F)
Ns.
Ns.
Ns
.06
Ns.
R2
.62***
.64***
.69***
.73***
AR2
.57
.57
.64
.68
R Ch R change, b1 beta at step 1, b2 beta at step 2, R2 = R square, AR adjusted R2, Ns not significant, M mother’s disorders at Time 1 (1 = presence; 0 = absence), F fathers’ psychological dimensions at Time 1 *** p \ .001; ** p \ .01; * p \ .05;? p \ .06
Fig. 1 Conceptual model—mothers with depression
Fig. 2 Conceptual model—mothers with anxiety
impact on their children’s psychological functioning than does maternal depression. It is possible that the reciprocally influencing relationship we found between the mothers’ depression and the fathers’ interpersonal sensitivity might express a maladjustment in the couple functioning, which in turn could reflect on the fathers’ capacity for quality interactions with his son or daughter; poor caregiving has been widely recognized to be a predictor of infants’ internalizing (and externalizing) problems [42]. Figure 2 shows that the mothers’ and fathers’ anxiety significantly and directly predicts their children’s
internalizing problems. It is important to note that psychological/psychopathological difficulties of mothers and fathers are connected with a bidirectional influence in our sample; thus, we can hypothesize in agreement with the studies of Weissmann et al. [26] that parents often share a specific psychological difficulty whose cumulative weight impairs their child’s emotional and behavioral functioning in the direction of internalizing problems. Figure 3 shows that maternal eating disorders predict externalizing problems in children. Paternal psychoticism does not predict children’s problems, but it is reciprocally
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Fig. 3 Conceptual model—mothers with eating disorders
connected to maternal disorders. In this case, it is possible hypothesize that mothers’ eating disorders have such an intense impact on their children’s psychological functioning that the weight of paternal psychopathological risk is lost. In line with the studies of Sarkadi and colleagues [43], we can suppose that the mother is most likely responsible for feeding the child (with fathers less often involved in the feeding of young children) and that this specific maternal disorder powerfully impacts the child’s emotional and behavioral functioning because the mother–infant dyad interacts every day in supposedly difficult interactions during meals. These results highlight the importance of assessing the whole family (mother, father and children) over time and the significance of an early intervention because our study indicates an increase in children’s maladaptive psychological profiles from T1 to T2 that could be avoided with well-timed clinical work [25]. The interesting bidirectional relationship between maternal and paternal psychopathological symptoms (as discussed above) must be more specifically addressed in a future study because we hypothesize that it influences the general functioning of the family and particularly the parents’ caregiving quality, which in turn is connected to possible maladaptive outcomes in their children. This issue is relevant for the organization of intervention practices that must involve the whole family and assess possible marital maladjustment [44] to better understand how various psychopathological maternal and paternal symptoms can interact and impact the psychological welfare of their children. Our study has several strengths. It considered various maternal diagnostic groups and their effects on their children’s emotional/behavioral functioning over time, but it also measured the possible mediating effect of paternal psychopathology. Both parents completed the CBCL, but many previous studies included self-report questionnaires completed only by the mother. Our study has some limitations. The study has a homogeneous sample, which
included only Caucasians of middle socio-economic status with mainly two traditional working parents. Moreover, we did not administer the SCID-II to assess personality disorders in the mothers, and we did not evaluate the severity of the mothers’ diagnosis with a specific tool. We did not administer the SCID I to fathers but relied on the SCL-90R self-report questionnaire, whose scores were not confirmed by other tools and/or clinical interviews administered by trained psychologists. We did not directly observe the children’s behavior and characteristics but used a widely used and validated report-form questionnaire. We also did not address possible differences in the psychological functioning of the sons or daughters of mothers with eating disorders or of mothers with other diagnoses as the international literature suggests [45]. These limitations constitute a motivation to continue our research and take samples of mothers with comorbidities into consideration.
Summary Several authors suggest that parents’ psychopathology can foster the onset of maladaptive psychological profiles in their children. It has been demonstrated that children’s psychological difficulties tend to increase over time, particularly in families in which the mother suffers from depression, anxiety or eating disorders. It has also been suggested that fathers’ psychopathological risk may be a risk factor for the onset of difficulties in their children. The present study focused on assessing the emotional functioning of the children of mothers with various diagnoses and of mothers with no psychological disorder while considering the possible mediating role of the fathers’ psychological profiles on their children’s internalizing/ externalizing functioning. We used the SCID I [25], SCL90/R [36], and CBCL/1-5 [39]. The analyses showed that the children’s internalizing and externalizing scores tended to increase from T1 to T2. Maternal psychopathology proved to be strongly related to their children’s maladaptive profiles. Specifically, the children of mothers with depression showed higher internalizing scores than did children of other groups, and these scores increased from T1 to T2; the children of mothers with eating disorders showed higher and increasing externalizing scores than did other children. The children of mothers with a diagnosis showed significantly higher scores in all internalizing and externalizing dimensions than did the healthy group children at both Time 1 and Time 2. In particular, the children showed specific maladaptive profiles depending on what diagnosis their mother received. Mothers with depression were more likely to have a withdrawn child, and mothers with eating disorders had a higher probability of having aggressive children. Furthermore, the fathers’ interpersonal
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sensitivity, depression, anxiety and psychoticism significantly predicted internalizing problems of their children at both T1 and T2. Moreover, at T1, the fathers’ interpersonal sensitivity and psychoticism significantly predicted their child’s externalizing problems, and the fathers’ hostility and psychoticism significantly predicted their child’s externalizing problems at T2.
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