Poverty and adolescent depressive symptoms.

American Journal of Orthopsychiatry 2014, Vol. 84, No. 1, 82–94

© 2014 American Orthopsychiatric Association DOI: 10.1037/h0098735

Poverty and Adolescent Depressive Symptoms Amy C. Butler

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Iowa

Longitudinal data on non-Hispanic White children from the Panel Study of Income Dynamics (N ⫽ 1,056) were used to examine whether the relationship between poverty (early childhood poverty, poverty persistence, and current poverty) and adolescent depressive symptoms (measured by the Children’s Depression Inventory and the Internalizing Index) can be explained by the mother’s own childhood depression and family characteristics measured during the child’s first year of life. Associations between poverty and depressive symptoms among adolescents were explained by mother’s childhood depression and whether the adolescent had lived with both parents during the first year of life. The findings highlight the need for appropriate treatment of childhood depression so as to reduce the adverse consequences in adulthood and for the next generation.

P

search has also established an association between the persistence of poverty and depressive symptoms among young children (Bolger, Patterson, Thompson, & Kupersmidt, 1995; Duncan, Brooks-Gunn, & Klebanov, 1994; McLeod & Shanahan, 1993, 1996). Associations between economic hardship and symptoms of depression or internalizing behavior have been documented among older children in nationally representative U.S. samples (Goosby, 2007; Rushton, Forcler, & Schectman, 2002), among Australian youth (Spence, Najman, Bor, O’Callaghan, & Williams, 2002), and among adolescents in rural North Carolina (Costello, Keeler, & Angold, 2001) and rural Vermont (Wadsworth, Raviv, Compas, & Connor-Smith, 2005). Conger and his colleagues, however, found no association between economic hardship and internalizing behavior among adolescents in a sample of two-parent families living in rural Iowa (Conger, Conger, & Elder, 1997; Conger, Ge, Elder, Lorenz, & Simons, 1994). This exception to the rule raises the question of whether the presence of both parents acted as a buffer against poverty-produced stress, or whether by limiting the sample to two-parent families, the researchers selected the more psychologically healthy families. Whereas low income is associated with depressive symptoms among children in many, if not all, studies, increases in family income have not been found to reduce children’s depressive symptoms. At least three studies have found that increases in family income tend to reduce poor children’s externalizing behavior (e.g., conduct and oppositional defiant disorders) but do not lead to much, if any, decrease in poor children’s depressive symptoms (Costello, Compton, Keeler, & Angold, 2003; Gennetian & Miller, 2002; McLeod & Shanahan, 1993, 1996). This could be the case if the income-related childhood depressive symptoms had been caused by earlier traumatic childhood experiences and are difficult to reverse. Alternatively, both the poverty and the children’s depressive symptoms may have been caused by common antecedent factors.

overty has been linked to a variety of health, learning, and behavioral problems, including depressive symptoms, for both adults and children (Bradley & Corwyn, 2002; Duncan, Yeung, Brooks-Gunn, & Smith, 1998). There is considerable interest in the extent to which insufficient family income is responsible for these adverse child outcomes. A variety of possible pathways exists for how living in poverty might lead to elevated symptoms of depression among children. Lack of income may prevent the purchase of goods and services that promote healthy emotional development. Living in poverty may expose children to traumatic events that have lasting deleterious effects on their mental health. Insufficient resources may create pressure on parents that, in turn, leads to counterproductive parenting behaviors. However, to demonstrate that living in poverty increases the likelihood that childhood depressive symptoms develop through any of these pathways, researchers must first establish that the child’s poverty and depressive symptoms are not both the products of the parents’ prior behaviors or mental health problems. This study examines the degree to which factors present during a child’s first year of life and earlier can explain both subsequent poverty and depressive symptoms during the adolescent years. The experience of poverty likely differs across race and ethnic groups in complex ways. This study limits its scope to non-Hispanic White adolescents.

The Relationship Between Economic Hardship and Depressive Symptoms The negative association between poverty and mental health is robust. Lorant et al. (2003) conducted a meta-analysis of 51 studies, which indicated that adults with low socioeconomic status (SES) are 80% more likely to be depressed than are higher SES adults. Re-

How Poverty Might Lead to Depressive Symptoms Among Children

Correspondence concerning this article should be addressed to Amy C. Butler, School of Social Work, University of Iowa, 308 North Hall, IA City, IA 52242. E-mail: [email protected]

There are two primary theoretical pathways through which poverty has been proposed to lead to childhood behavioral disorders (Conger 82


POVERTY AND ADOLESCENT DEPRESSION

& Donnellan, 2007). One pathway is referred to as the family investment model: Poor parents cannot afford to live in safe neighborhoods, send their children to schools in which they will thrive, or provide adequate supervision of their children’s activities. Thus, poor children are more likely to be exposed to harsh and potentially traumatic conditions with lasting emotional repercussions. Moreover, poor parents may not be able to afford or obtain needed mental health treatment for their children. In this latter scenario, poverty may not have caused the depressive symptoms, but it prevents the parents from accessing appropriate mental health treatment to reduce those symptoms. A second pathway, the family stress model, proposes that poverty affects children’s mental health primarily through its negative effect on parents. When parents are under financial pressure, the marriage relationship may be strained, and the parents’ interactions with their children may become more harsh, punitive, and inconsistent, which, in turn, may lead to emotional problems among the children (Conger et al., 1993). A number of researchers have used the family stress model to interpret the relationship between economic hardship and depressive symptoms (Conger et al., 2002; Eamon, 2002; Eamon & Zuehl, 2001; Gershoff, Aber, Raver, & Lennon, 2007; Goosby, 2007). None of these studies, however, controlled for preexisting factors and so was unable to rule out the possibility that the association between child’s poverty and depressive symptoms was because of social selection. Research has established a link between childhood trauma and adult depression (Chapman et al., 2004; Kessler, Davis, & Kendler, 1997). There is also evidence that certain potentially traumatic events, including emotional abuse and witnessing the victimization of other people, are more likely to be experienced by low-income children than by higher income children (Finkelhor, Ormrod, Turner, & Hamby, 2005). Taken together, these findings suggest that poor children might be more likely than other children to experience the childhood traumas that may lead to depression in adulthood. If so, this would be consistent with both the family investment and the family stress models. Childhood trauma such as emotional abuse or domestic violence may be perpetrated by economically pressured parents (the family stress model), and the trauma brought about by witnessing of the victimization of other people might be experienced in crime-ridden neighborhoods from which the family cannot afford to escape (the family investment model). To conclude that childhood poverty increases the likelihood of depressive symptoms among adolescents, either through the family investment model, the family stress model, or a combination of the two, causally prior variables must be controlled.

A Question of Causality: Social Selection Poverty does not strike randomly. Education, skills, initiative, good mental and physical health, and stable marriages are some of the factors that reduce the likelihood of poverty in the United States. Some of the factors that lead to a family’s poverty may also be responsible for a child’s depressive symptoms. Two causally prior factors that might account for the relationship between poverty and adolescent depressive symptoms are a family history of depression and the father’s absence from the family. I will discuss these two factors in turn. Depression can lead to downward mobility or failure to climb the socioeconomic ladder, resulting in a greater likelihood of an individ-

83

ual being poor. Using cross-sectional data from the National Comorbidity Survey, Kessler and his colleagues found a retrospective measure of early onset depression to be associated with worse outcomes later in life, including lower educational attainment (Kessler, Foster, Saunders, & Stang, 1995), a greater prevalence of teenage parenthood (Kessler, Berglund, Foster, Saunders, Stang, & Walters, 1997), and lower marital stability (Kessler, Walters, & Forthofer, 1998). Berndt et al. (2000) found an association between early onset depression and later substance abuse, not graduating from college (for women only), and never marrying (for men only). All of these adverse outcomes increase the risk of subsequent poverty. Not all researchers, however, find early onset depression to be associated with adverse outcomes for the individuals (Johnson, Cohen, Dohrenwend, Link, & Brook, 1999; Miech, Caspi, Moffitt, Wright, & Silva, 1999). The social selection thesis that depression increases the risk of economic hardship cannot be applied directly to the association between childhood poverty and adolescent depression, because children’s financial circumstances depend on their parents’, not on their own, income. However, transmission of depression from parent to child can occur genetically (Lau & Eley, 2008; Weissman et al., 1987), through insensitive or unresponsive parenting (Goodman & Gotlib, 1999; Sroufe, Duggal, Weinfield, & Carlson, 2000), and by exposure to stressful life events (Garber, Keiley, & Martin, 2002; Goodman & Gotlib, 1999). Because early onset depression may reduce subsequent earnings in adulthood and may be passed on to one’s children via genetic and other avenues, early onset depression experienced by one of the child’s parents might be at least partially responsible for both the family’s subsequent poverty and the child’s own depressive symptoms. Children with a genetic tendency toward depression may not develop depression unless it is triggered by a traumatic event, an event that would not lead to depression for a child who was not genetically inclined (Tsuang, Bar, Stone, & Faraone, 2004). If the experience of poverty can lead to depressive symptoms in children, therefore, the effect may be more pronounced among children with a genetic tendency toward depression. The father’s absence from the family is a second factor that may lead to subsequent child poverty and depressive symptoms. Singlemother families have lower incomes than do two-parent families, because women tend to earn less than men, and because there is often only one adult with paid employment in single-parent families (SigleRushton & McLanahan, 2004). The absence of the father is associated with worse psychological outcomes among children (Cherlin, Chase-Lansdale, & McRae, 1998), in part because of his lower involvement with his children, and because the single mother has less time to spend with the children (Carlson, 2006). Therefore, father absence may precipitate both children’s poverty and children’s depressive symptoms.

Controlling for Antecedent Factors To tease out the causal connections between poverty and childhood depressive symptoms, researchers have attempted to control for aspects of the parents’ background that might have contributed to the family’s subsequent poverty and the children’s depressive symptoms. In the absence of measures of the parents’ early mental health (i.e., before they made decisions that affected the course of their lives), some researchers have controlled for factors that might be considered rough proxies for the mother’s early mental health. McLeod and

BUTLER


84

Nonnemaker (2000) controlled for mother’s delinquency and illegal activity measured before the birth of her child. This decreased the size of the relationship between poverty and the child’s score on the Behavior Problem Index (internalizing and externalizing behavior combined). Using the same National Longitudinal Survey of Youth data set, Blau (1999) controlled for the education of the mother’s parents and her household structure when she was 14 years old, as well as the mother’s mental aptitude (measured by the Armed Forces Qualification Test score), assessed when she was between the ages of 15 and 22. The inverse association between family income and children’s depressive symptoms declined with these controls in place. These findings suggest that children’s behavioral health can be predicted, to some extent, by factors present before the child was born. This study will control for the two factors hypothesized to lead to childhood poverty and adolescent depressive symptoms. Mothers’ early onset depression is controlled using a retrospective measure of the mother’s childhood depression. Retrospective measures tend to underestimate actual prevalence, especially if the depression was less severe, the episodes less frequent, or the illness untreated (Simon & VonKorff, 1995). But these errors in recall can be minimized with the strategic use of probes (Knäuper, Cannell, Schwarz, Bruce, & Kessler, 1999). In addition to serving as a rough proxy for genetics, mothers diagnosed with depression as children are likely to experience depressive episodes as adults, which could cause depressive symptoms in their children (Joormann, Eugene, & Gotlib, 2008). Ideally, the study would also control for the biological father’s depression, which has also been found to be associated with depressive symptoms in children (Joormann et al., 2008). Inadequate measurement of the parents’ early depression can be expected to result in an underestimate of parental transmission of depression to their children, and the study findings must be viewed with this in mind. To determine whether the father’s absence preceded the child’s experience of poverty, the study controls for whether both parents lived with the child during the first year of the child’s life. In addition, the effect of poverty on adolescent depressive symptoms is examined separately for single-parent and for two-parent families to assess whether the link between poverty and adolescent depressive symptoms exists in families in which both biological parents are present. Other factors that affect poverty status, such as the mother’s age and educational attainment and the number of children in the family at the time of the child’s birth, can also affect the child’s early experiences and so are controlled.

Measuring Poverty If poverty leads to depressive symptoms among children, it may be that certain times in the developmental process are most critical. For example, the experience of poverty might have the strongest impact during early childhood when important developmental tasks, such as attachment, must be negotiated (Bowlby, 1980; Mash & Dozois, 2003). A number of researchers have examined the length of time or the proportion of a child’s life spent in poverty, based on the idea that the more persistent the poverty, the more harmful its effects (Bolger et al., 1995; Duncan et al., 1994; McLeod & Shanahan, 1993). It has also been proposed that sudden drops in income may be more harmful for children than persistent poverty because of the shock of dislocation and the stress placed on the parents (Elder & Caspi, 1988). In addition, current poverty may have an impact on an

adolescent’s present emotional state, even if its effect is transient. Depression can be conceptualized as having both trait and state dimensions. A trait is relatively stable over time, whereas a state dimension of depression is a response to current circumstances and will change as circumstances change. Current poverty may have the strongest effect on state depression, whereas earlier experiences of poverty may produce trait depression. A study of 4- to 8-year-old children found that poverty persistence, but not current poverty, was associated with internalizing behavior among children (McLeod & Shanahan, 1993), suggesting that if poverty leads to depressive symptoms, the effect is longer lasting (i.e., trait producing) rather than transient. The study uses several indicators of poverty. The persistence of poverty during early childhood (age 0 through 2 years), controlling for poverty persistence in subsequent years (age 3 through 12), allows us to examine whether poverty during early childhood is especially critical in the development of depressive symptoms that are evident during adolescence. The persistence of poverty over the first 12 years of the child’s life will allow us to explore the importance of the accumulation of economic hardship on subsequent depressive symptoms in adolescence. Currently poor children are more likely than other children to have been poor in the past. Examining the effect of current poverty, while controlling for poverty persistence, explores the potentially transitory effect of poverty on adolescent depressive symptoms.

Research Questions The study addresses the following research questions: 1. Is poverty (i.e., early childhood poverty, poverty persistence, and current poverty) associated with depressive symptoms among White adolescents? 2. Is the mother’s childhood depression associated with adverse outcomes for her adolescent child (e.g., childhood poverty, father absence, caregiver distress, and adolescent depressive symptoms)? 3. Do factors that precede the child’s experience with poverty explain (i.e., account for) the relationship between poverty and adolescent depressive symptoms? 4. Is the association of poverty with adolescent depressive symptoms greater if the youth’s mother was depressed as a child (i.e., an interaction effect) than if she was not depressed as a child? 5. Does the relationship between poverty and depressive symptoms differ depending on whether the adolescent is currently living with both biological parents?

Method Sample and Data The sample consisted of 1,056 non-Hispanic White adolescents, of whom 578 were age 12 to 17 in 2002, and 493 were age 12 to 16 in 2007. The data came from the Panel Study of Income Dynamics (PSID). The PSID initially surveyed a nationally representative sample of approximately 5,000 English-speaking families in 1968. The household heads were reinterviewed annually until 1997 and bienni-



ally thereafter. The 2002 and 2007 waves of the Child Development Supplement (CDS) included interviews with the primary caregivers (PCGs) of PSID children and interviews with the children themselves. The annual and biennial PSID interviews provided data on family income and other family background variables for the current study. The PCG interviews provided information on the caregiver’s assessment of the adolescent’s internalizing behavior and the caregivers’ own psychological distress. The child interviews provide information on the adolescent’s depressive symptoms. The PSID provides sample weights to adjust analyses for attrition and the disproportionate sampling of low-income families. Additional information about the PSID can be found on their Web site (http://psidonline.isr.umich.edu/).

Measures Adolescent depressive symptoms. The study employed two indicators of adolescent depressive symptoms. The first measure is the short form of the Children’s Depression Inventory (CDI). The CDI is a widely used assessment with good reliability and validity (see Sitarenios & Stein, 2004, for a review of research on the psychometric properties of the CDI). No reliability and validity checks have been established for the short form, but the correlation between scores on the short and long forms is high (r ⫽ .89), and the two versions are generally seen as comparable (Sitarenios & Stein, 2004). Adolescents were given 10 sets of three statements and were asked to select one statement from each set to indicate how they had felt over the past 2 weeks. Measured symptoms included being bothered by things; having no

85

friends; hating oneself; disliking how one looks; and feeling sad, alone, like crying, unloved, that things never work out, and that they do things wrong. Responses were totaled, resulting in possible scores that range from a low of 0 (no depressive symptoms) to a high of 20. The second indicator of adolescents’ depressive symptoms is based on the PCG’s assessment of the adolescent’s behavior using a 13-item Internalizing Index, based on work by Peterson and Zill (1986) using items derived from Achenbach’s Behavioral Problem Index. Caregivers were asked, “For the next set of statements, decide whether they are not true, sometimes true, or often true, of (CHILD)’s behavior.” The statements included feels or complains that no one loves (him or her); is too fearful or anxious; is easily confused, seems to be in a fog; has trouble getting along with other children; feels worthless or inferior; is not liked by other children; has difficulty getting (his or her) mind off certain thoughts; is unhappy, sad, or depressed; is withdrawn, does not get involved with others; is too dependent on others; feels others are out to get (him or her); is secretive, keeps things to (himself or herself); and worries too much. Responses of not true were coded 0, sometimes true were coded 1, and often true were coded 2. The responses were summed, creating an Internalizing Index that ranged from 0 (low) to 26 (high). The internal reliability is .82 (PSID, 2010). The distributions for the adolescent-assessed CDI and the caregiver-assessed Internalizing Index, along with the other study variables, are shown in Table 1. Poverty. Family income was calculated by adding income from all sources, including, but not limited to, regular and irregular

Table 1. Descriptive Statistics Variables

M

SD

Children’s Depression Inventory Internalizing Index Current poverty (yes ⫽ 1; no ⫽ 0) Poverty persistence (age 0–2) Lived in poverty for at least one of the first 3 years Proportion of first 3 years in poverty for children whose poverty lasted at least 1 year (n ⫽ 141) Poverty persistence (age 3–12) Lived in poverty for at least one of the subsequent 9 years Proportion of subsequent 9 years in poverty for children whose poverty lasted at least 1 year (n ⫽ 261) Poverty persistence (age 0–12) Lived in poverty for at least one of the first 12 years Proportion of first 12 years in poverty for children whose poverty lasted at least 1 year (n ⫽ 326) Mother diagnosed with depression before age 17 PCG’s current distress Both parents present during child’s first year (T1) Both parents present during adolescence (T2) Mother’s age at child’s birth Mother’s education (in years) at child’s birth Number of children in family at child’s birth Female 1991–95 birth cohort

2.95 3.08 7.3% .075 13.9%

(3.32) (3.19)

Note.

N ⫽ 1,056; PCG ⫽ primary caregiver; T1 ⫽ Time 1; T2 ⫽ Time 2.

(.211)

.540 .079 25.0%

(.264) (.185)

.317 .079 29.6%

(.250) (.176)

.270 4.5% 3.72 82.3% 64.7% 29.1 13.6 1.8 49.2% 44.2%

(.232) (3.42)

(5.4) (2.1) (0.9)


86

BUTLER

employment, overtime pay, interest and dividends on investments, child support, social security benefits, cash welfare benefits, and unemployment compensation. Current poverty is a dichotomous variable indicating whether family income was below the federal poverty threshold (yes ⫽ 1; no ⫽ 0). The 2002 family income was used for cases in which the adolescent’s behavioral health was measured in 2002; 2006 family income (the most recent year for which income data were available) was used for cases in which the adolescents’ behavioral health was measured in 2007. Poverty persistence (0 –2) is the proportion of the child’s first 3 years (through age 2) that the family income was below the poverty threshold; poverty persistence (3–12) is the proportion of the child’s subsequent 9 years (age 3 through age 12) during which the family income was below the poverty threshold; and poverty persistence (0 –12) is the proportion of the child’s first 12 years that the family income was below the poverty threshold. For cases with missing poverty data for some of the years, the base for the proportion was the number of nonmissing years. A minimum of 2 years of nonmissing data was set for poverty persistence (0 –2), 4 years for poverty persistence (3–12), and 5 years for poverty persistence (0 –12). As shown in Table 1, 7.3% of the adolescents were poor at the time their depressive symptoms were assessed. Thirty percent of the adolescents had been poor for at least 1 year during their first 12 years of life and, on average, they were poor for 27% of those first 12 years. Thirteen percent of the adolescents had been poor for at least 1 of their first 3 years of life. Mother’s childhood depression. The biological mother’s childhood depression (yes ⫽ 1; no ⫽ 0) was obtained from the 2007 and 2009 family interviews, when the PSID collected data on childhood health conditions for heads of household and “wives” (i.e., spouse or cohabiting partner). Respondents were asked a series of questions about their health and mental health histories, including depression: “Before you were 17 years old, did you have depression?” If respondents responded in the affirmative, they were asked, “At what age were you first diagnosed with depression?” To engage the respondent in an active memory search, as suggested by Knäuper et al. (1999) as a means of increasing measurement reliability, interviewers filled in a grid of dates during childhood when important events occurred, including separation of the parents, residential moves, and the starting and switching of schools. If respondents could not remember the age at which the depression was diagnosed, interviewers probed using landmarks (e.g., “Was that before or after your parents separated?”). Data are missing for cases (n ⫽ 86) in which the mother was a nonresponse in 2007 and 2009, was neither head nor “wife” in a responding household (e.g., living with a parent or sibling who was the household head), or responded “don’t know.” Missing cases were coded ⫺1 and a dummy variable was included in the analyses to indicate missing cases. The percentage of mothers who reported having been diagnosed with depression prior to age 17 was 4.5% (see Table 1). This variable is probably an underestimate of the mother’s childhood depression, because of recall error and the likelihood that some women experienced depression in childhood but were not diagnosed as such (Aneshensel, Estrada, Hansell, & Clark, 1987). Based on a metaanalysis of 26 epidemiologic studies of children born between 1965 and 1996, Costello, Erkanli, and Angold (2006) estimated depression prevalence rates to be 5.9% for adolescent girls age 13 to 18. It is likely, therefore, that mothers’ childhood depression is underreported, and the results should be viewed with this in mind.

The PCG’s level of psychological distress was measured the same year as the adolescent’s depressive symptoms (2002 or 2007) with the K6 scale (Kessler et al., 2003). PCGs were asked, “During the past 4 weeks, how much of the time did you feel so sad nothing could cheer you up? Nervous? Restless or fidgety? Hopeless? That everything was an effort? Worthless?” PCGs answered each question on a 5-point scale. Responses were summed, resulting in a scale that ranged from a low of 0 to a possible high of 24. Living with both parents during the first year of the child’s life (both parents present Time 1 [T1]) is a dichotomous variable (yes ⫽ 1; no ⫽ 0). Children were counted as living with both parents if both parents were in the child’s household for the first two family interviews of the child’s life. This ensured that the child was living with both parents for at least one full year. Three additional early family characteristics were controlled. Number of children in the household is a continuous variable measured during the child’s first year of life. Mother’s age at the birth of the child ranged from 14 to 44. Mother’s education was assessed as the number of years of school the mother had completed at the time the child was born. Each of the variables representing early family characteristics contained some missing data: living with both parents (n ⫽ 13), number of children (n ⫽ 51), mother’s age at birth (n ⫽ 12), and mother’s educational attainment (n ⫽ 15). These are cases in which the mother was not available to be interviewed during the first 2 years of the child’s life, although she may have returned to the PSID study in subsequent waves of the survey. Missing cases were coded ⫺1 for the variable in question, and dummy variables (missing yes ⫽ 1; no ⫽ 0) were included in the analyses to indicate missing cases. A dummy variable was included to indicate whether the adolescent was in the 1991–1995 birth cohort (yes ⫽ 1; no ⫽ 0) and whose depressive symptoms were therefore measured in 2007, or in the 1985–1990 cohort and whose depressive symptoms were measured in 2002. The gender of the youth was coded female (yes ⫽ 1; no ⫽ 0). Living with both biological parents during adolescence (both parents present Time 2 [T2]) was measured at the time depressive symptoms were measured and was coded yes (1) and no (0).

Data Analysis Cross-tabulations (␹2) and comparisons of means (t test) were conducted to examine the relationship between mother’s childhood depression and adolescent outcomes. Statistical significance was set at .05; all significance tests were two-tailed. All analyses were weighted to adjust for attrition and nonproportional probability sampling. The dependent variables (the CDI and Internalizing Index) are discrete and were treated as count data. The data were analyzed using generalized linear regression. The dependent variables both have a pronounced positive skew, making a Poisson model (which forces the mean and the variance to be equal) inappropriate (Afifi, Kotlerman, Ettner, & Cowan, 2007). A negative binomial model fit the data better than either a Poisson model or a zero-inflated Poisson model. Vuong tests comparing the negative binomial with the zero-inflated binomial indicate that including zero inflation was unnecessary. Control variables were added in causal order to the multivariate analyses of poverty and depressive symptoms: first, the truly exogenous variables (race, gender, and year of interview); next, mother’s childhood depression; then the family characteristics measured during the child’s first year of life; and finally, factors measured the



same year as adolescent depressive symptoms (i.e., father presence and PCGs’ psychological distress). Two sets of interaction terms were introduced in turn: the first between poverty and mothers’ childhood depression; the second between poverty and living with both biological parents during adolescence (T2). Finally, analyses were run separately for youth who were living with both biological parents and youth who were not living with both biological parents during adolescence (T2). Missing data for the control variables were represented with dummies. The coefficients for missing data dummies were omitted from the tables to simplify the presentation of results.

Results A key variable that can assess the extent to which social selection accounts for the association between poverty and adolescent depressive symptoms is mothers childhood depression. Table 2 shows the bivariate associations between the mother’s childhood depression and relevant outcomes for their children. Youth fared consistently worse if their mothers had been diagnosed with depression in childhood. Compared with youth whose mothers had not been diagnosed with childhood depression, these adolescents were less likely to have lived with both parents during their first year of life (T1) and during adolescence (T2), they spent a greater proportion of their childhoods in poverty, they were more likely to be poor the year their depressive symptoms were assessed, their PCG rated them higher on internalizing symptoms, they scored higher on the CDI, and their PCGs had higher levels of psychological distress. Outcomes for youth for whom information on mother’s childhood depression was missing tended to fall between outcomes for youth whose mothers were depressed in childhood and those whose mothers were not depressed, indicating that these cases were missing for a variety of reasons and do not represent a clear bias.

87

We examined the association between poverty and adolescent depressive symptoms. As shown in Table 3, poverty persistence (0 –12) was positively associated with adolescents’ CDI scores (Model 1). The effect of early childhood poverty (poverty persistence [0 –2]) was not significant when subsequent poverty persistence (3–12) was controlled (Model 2). Current poverty was not associated with the CDI when poverty persistence (0 –12) was controlled (Model 3), nor was it associated with the CDI when poverty persistence (0 –12) was not included as a control (not shown). Next we examined the associations between the poverty variables and youths’ internalizing behavior and found the same pattern (see Table 4). Poverty persistence (0 –12) was positively associated with internalizing behavior (Model 1). Early childhood poverty (poverty persistence [0 –2]) did not have significant effect on internalizing behavior when subsequent poverty persistence (3–12) was controlled (Model 2). Current poverty was not significantly associated with internalizing behavior when poverty persistence (0 –12) was controlled (Model 3), nor was it associated with internalizing behavior when poverty persistence (0 –12) was not controlled (not shown). Subsequent analyses included poverty persistence (0 –12) and not the other poverty measures. Analyses (not shown) indicated that the other poverty measures behave similarly to poverty persistence (0 –12) when subsequent controls were added. We examined how the coefficients for poverty persistence (0 –12) changed as mother’s childhood depression and early family characteristics were added to the model. As shown in Table 3, the coefficient for poverty persistence (0 –12) declined in size and lost statistical significance when mother’s childhood depression was added to the analysis of the CDI (compare Models 1 and 4) and then disappeared when early family characteristics were added (Model 5). Mother’s childhood depression was positively associated with adolescents’ CDI scores. The presence of both parents during the first year of life (T1) was associated with lower CDI scores.

Table 2. Selected Adolescent Outcomes by Whether Mother Was Diagnosed With Depression Before Age 17 Mother depressed as child No Both parents present (T1) n Both parents present (T2) n Poverty persistence (age 0–3) n Poverty persistence (age 3–12) n Poverty persistence (age 0–12) n Current poverty n Children’s Depression Inventory n Internalizing Index n PCG’s current distress n

84.3% 922 70.6% 922 .058 888 .067 922 .067 922 5.3% 922 2.9 792 2.9 921 3.6 922

Yes

p

Missing

45.2% 48 24.4% 48 .323 42 .311 48 .318 48 21.4% 48 5.2 44 5.9 48 7.5 48

ⴱ

77.8% 72 23.1% 86 .100 77 .093 86 .093 86 22.2% 86 2.2 73 3.7 86 3.7 84

Note. PCG ⫽ primary caregiver; T1 ⫽ Time 1; T2 ⫽ Time 2. p ⬍ .001.

ⴱ

ⴱ

ⴱ

ⴱ

ⴱ

ⴱ

ⴱ

ⴱ

ⴱ

Total 1,042 1,056 1,007 1,056 1,056 1,056 909 1,055 1,054

.58 (.21) .32 (.20) .23 (.23)

2

3

.03 (.15)

.57 (.23)

ⴱ

.47ⴱⴱ (.17)

.35 (.22)

4

.40ⴱ (.17) ⫺.51ⴱⴱⴱ (.10) .01 (.01) ⫺.02 (.02) .05 (.04)

.00 (.24)

5

.39ⴱ (.17) ⫺.31ⴱⴱ (.12) .01 (.01) ⫺.02 (.02) .03 (.04) ⫺.33ⴱⴱⴱ (.09)

⫺.13 (.24)

6

.57ⴱⴱⴱ (.16)

7

.41ⴱ (.16) ⫺.43ⴱⴱⴱ (.09)

8

.38ⴱ (.17) ⫺.42ⴱⴱⴱ (.09)

.11 (.22)

9

.30 (.17) ⫺.36ⴱⴱⴱ (.12) .01 (.01) ⫺.02 (.02) .03 (.04) ⫺.30ⴱⴱⴱ (.09) .03ⴱ (.01)

⫺.20 (.24)

10

.41ⴱ (.19) .33 (.18) .29 (.27)

2

.13 (.14)

.32 (.21)

3

.67ⴱⴱⴱ (.16)

.13 (.20)

4

.62ⴱⴱⴱ (.16) ⫺.19 (.10) .00 (.01) ⫺.09 (.02) ⫺.00 (.04)

.00 (.21)

5

.59ⴱⴱⴱ (.16) ⫺.01 (.11) .01 (.01) ⫺.01 (.02) ⫺.09 (.04) ⫺.40ⴱⴱⴱ (.08)

⫺.21 (.22)

6

Models

.70ⴱⴱⴱ (.15)

7

.64ⴱⴱⴱ (.16) ⫺.16 (.09)

8

.62ⴱⴱⴱ (.16) ⫺.15 (.09)

.06 (.20)

9

.37ⴱ (.16) ⫺.09 (.10) .01 (.01) ⫺.01 (.02) ⫺.05 (.04) ⫺.37ⴱⴱⴱ (.08) .08ⴱⴱⴱ (.01)

⫺.45ⴱ (.21)

10

Note. Standard errors in parentheses. Coefficients for female, 1991–95 cohort, missing data dummies, intercept, and negative binomial not shown; N ⫽ 1,055. PCG ⫽ primary caregiver; T1 ⫽ Time 1; T2 ⫽ Time 2. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

Poverty persistence (0–12) Poverty persistence (0–2) Poverty persistence (3–12) Current poverty Mother depressed as child Both parents present (T1) Mother’s age Mother’s education # children Both parents present (T2) PCG’s current distress

1

Table 4. Negative Binomial Regressions of the Internalizing Index on Childhood Poverty, Controlling for Early Family Characteristics

Note. Standard errors in parentheses. Coefficients for female, 1991–95 cohort, missing data dummies, intercept, and negative binomial not shown; N ⫽ 909. PCG ⫽ primary caregiver; T1 ⫽ Time 1; T2 ⫽ Time 2. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

Poverty persistence (0–12) Poverty persistence (0–2) Poverty persistence (3–12) Current poverty Mother depressed as child Both parents present (T1) Mother’s age Mother’s education # children Both parents present (T2) PCG’s current distress

1 ⴱⴱ

Models

Table 3. Negative Binomial Regressions of the Children’s Depression Inventory (CDI) on Childhood Poverty, Controlling for Early Family Characteristics


88 BUTLER



Turning to Table 4, we find that the association between poverty persistence (0 –12) and adolescent internalizing scores declined and lost statistical significance when mother’s childhood depression was controlled (compare Models 1 and 4) and declined in size still further when early family characteristics were controlled (Model 5). Mother’s childhood depression was positively associated with internalizing scores. None of the early family characteristics was significantly associated with internalizing behavior. Several variables included in the analyses are not shown in the tables for purposes of brevity: female, birth cohort, and dummy variables representing missing data. Girls scored higher than boys on both the CDI and the Internalizing Index. The coefficient for birth cohort was negative for all models regardless of whether the dependent variable was the CDI or the Internalizing Index. This indicates that the adolescents born between 1991 and 1995, and whose depressive symptoms were measured in 2007, had lower symptom scores than did the adolescents born between 1985 and 1990, whose depressive symptoms were measured in 2002. This effect was unexpected, yet is consistent with the results of a study of 91,748 children enrolled in managed care plans, which found that the number of children age 5 to 18 who were diagnosed with depression increased from 1999 to 2004 and then decreased between 2004 and 2007 (Libby, Orton, & Valuck, 2009). Regardless of the reason for the cohort effect, the birth cohort variable was unrelated to the other variables in the models, and therefore its inclusion in the analyses had no effect on the relationships between poverty and adolescent depressive symptoms. Interaction terms between poverty (current and persistent) and mothers’ childhood depression were added to the analyses of the CDI and Internalizing Index (not shown). This allowed for the examination of whether the association between poverty and depressive symptoms was stronger for cases in which the mother had been diagnosed with depression as a child. The resulting coefficients for these interaction terms were not statistically significant, nor did they even reach the p ⫽ .50 level of significance. Controlling for the presence of both biological parents allowed us to examine how father presence during infancy influenced the CDI in ways not entirely captured by current family circumstances. As shown in Table 3, for Models 5 and 6, the coefficient for the presence of both parents (T1) declined in magnitude but remained statistically significant when the presence of both parents during adolescence (T2) was controlled, indicating that the absence of the father during infancy was associated with CDI-measured adolescent depressive symptoms for reasons not entirely captured by the father’s absence later during childhood. Mother’s childhood depression is an important predictor of adolescent depressive symptoms, and it is therefore instructive to examine how the effect is mediated through the other variables. Model 7 in Tables 3 and 4 regresses adolescent depressive symptoms on mothers’ childhood depression, female, and birth cohort. By comparing Models 7 and 8 in Table 3, we see that approximately 28% (1 minus .407/.568) of the effect of mother’s childhood depression on the CDI was mediated through the presence of both parents during the child’s infancy. Another 5% of the effect was mediated through persistent poverty (0 –12) (Model 9) and additional 15% was accounted for by current factors: father presence and caregiver distress (Model 10). The remaining 52% of the effect of mothers’ childhood depression influenced the CDI through paths not measured here. A similar examination of how mothers’ childhood depression affected

89

the adolescents’ internalizing behavior found 9% (1 minus .638/.698) of the effect was mediated through the presence of both parents during the child’s infancy (compare Models 7 and 8 in Table 4); another 2% was accounted for by persistent poverty (0 –12), and 36% was mediated through the fathers’ presence during adolescence and caregivers’ current distress. Forty-seven percent of the effect of mothers’ childhood depression on adolescent internalizing behavior remained unexplained. The proportion of the effect of mothers’ childhood depression that was accounted for by caregivers’ current distress was considerably greater for the caregiver-assessed Internalizing Index than for the adolescent-assessed CDI, which raises questions regarding the extent to which caregivers’ own distress affected their assessment of adolescent depressive symptoms. Note that the PCG was the mother in almost all (93%) cases. When cases in which the PCG was not the mother were omitted and the analyses rerun, the results were similar. Interaction terms between poverty and living with both parents (T2) were added to Model 5 in Tables 3 and 4 to determine whether the association between poverty and adolescent depressive symptoms differed for children in single-parent and two-parent families. The results (not shown) indicated that the effect of poverty on depressive symptoms did not vary by family structure at T2. Next, Models 1, 4, 5, and 10 from Tables 3 and 4 were run separately for single-parent and two-parent families at T2. The results, summarized on the left side of Table 5, indicated that poverty persistence (0 –12) was not associated with either measure of depressive symptoms for adolescents who were not living with both biological parents. Moreover, neither mother’s childhood depression nor the PCG’s current distress was associated with the adolescent-assessed CDI in these families. The presence of the father during infancy was associated with lower CDI scores for the adolescents in currently single-parent families. Adolescents in single-parent families scored higher on the PCGassessed Internalizing Index if their mother had been diagnosed with depression as a child (Models 4 and 5), or if the PCG had elevated levels of distress (Model 10). Poverty persistence (0 –12) was also not associated with depressive symptoms for adolescents living with both biological parents. As summarized on the right side of Table 5, mothers’ childhood depression was positively associated with scores on both the CDI and the Internalizing Index for adolescents in two-parent families (Models 4 and 5), and remained so when the PCGs’ current psychological distress was controlled (Model 10). Depressive symptoms were not affected by whether the father had been present in the house when the child was an infant. The PCG’s current distress was associated with higher scores for adolescents on both the CDI and Internalizing Index. It should be noted that adolescents living with both of their biological parents were better off than other adolescents on all the criteria measured (data not shown): Their mothers were less likely to have been diagnosed with depression as children, their fathers were more likely to have been present during their first year of life, they were less likely to have experienced poverty throughout childhood, they were less likely to be currently poor, their PCG had lower levels of psychological distress, and they had lower scores on the CDI and the Internalizing Index. Thus, two-parent families differed from single-parent families in a number of ways in addition to the presence of both parents, at least in the non-Hispanic White population.

BUTLER

90

Table 5. Summary of Negative Binomial Regressions of Adolescent Depressive Symptoms, by Whether Both Biological Parents Were Present During Adolescence (T2) Both parents present (T2) No


Models

1

4

Yes 5

10

1

4

5

10

Children’s Depression Inventory n ⫽ 306 n ⫽ 603 Poverty persistence (0–12) .181 (.248) .070 (.256) ⫺.011 (.253) ⫺.066 (.258) .332 (.426) ⫺.064 (.434) ⫺.097 (.438) ⫺.187 (.431) Mother depressed as child .133 (.183) .088 (.182) .035 (.195) .953ⴱⴱ (.339) .944ⴱⴱ (.339) .892ⴱⴱ (.337) ⴱ ⴱ Both parents present (T1) ⫺.290 (.114) ⫺.291 (.122) .100 (.201) ⫺.065 (.200) PCGs’ current distress .012 (.015) .043ⴱⴱ (.015) Internalizing Index n ⫽ 368 n ⫽ 687 Poverty persistence (0–12) ⫺.078 (.210) ⫺.265 (.214) ⫺.220 (.241) ⫺.421 (.219) .235 (.434) ⫺.106 (.447) ⫺.135 (.452) ⫺.406 (.433) Mother depressed as child .509ⴱⴱ (.168) .516ⴱⴱ (.168) .314 (.172) .763ⴱ (.355) .758ⴱ (.355) .698ⴱ (.345) Both parents present (T1) .060 (.103) .008 (.102) ⫺.078 (.194) .086 (.191) PCGs’ current distress .051ⴱⴱⴱ (.014) .096ⴱⴱⴱ (.016) Note. Standard errors in parentheses. Coefficients for the control variables have been omitted from the table. PCG ⫽ primary caregiver; T1 ⫽ Time 1; T2 ⫽ Time 2. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

Discussion The association between poverty and depressive symptoms found by a number of previous studies was replicated in this sample of non-Hispanic White youth. The more persistent the poverty during childhood (i.e., birth through age 12), the higher adolescents scored on the CDI and the higher their PCGs rated them on the Internalizing Index. The adolescents’ depressive symptoms were not associated with current poverty, indicating that cause of the depressive symptoms—whether poverty or something correlated with it— dated back to at least an earlier point in their childhoods. However, poverty in early childhood (birth through age 2) did not have a stronger association with adolescent depressive symptoms than did poverty experienced during the later childhood years. The positive relationships between poverty persistence and adolescent depressive symptoms were largely explained once the mother’s childhood depression was controlled. The relationships were further reduced in size when the presence of both parents during the child’s infancy was factored in. This pattern of findings suggests that the more persistent the poverty adolescents had experienced during childhood, the greater their risk for depressive symptoms, not because of the economic hardships they had endured, but because of the greater likelihood that their mothers were prone to depression and that they had been born into unstable parental unions. A retrospective measure of mothers’ childhood depression was associated with adverse outcomes for their children many years later: more persistent family poverty throughout childhood; a greater likelihood of current poverty; a lower likelihood of having lived with both parents as an infant and during adolescence; and more depressive symptoms during adolescence. In addition, when mothers reported having been diagnosed with childhood depression, the PCG (who was almost always the mother) tended to report higher current levels of psychological distress. These findings are consistent with those of Kessler and colleagues, who found a retrospective measure of childhood depression to be associated with a number of adverse conditions during adulthood (Kessler, Berglund, et al., 1997; Kessler et al., 1995; Kessler et al., 1998). The measure of mother’s childhood depression is probably an underestimate of the actual prevalence of

childhood depression among the mothers because some cases may have gone undiagnosed. If so, then the actual relationships between mothers’ childhood depression and adverse outcomes for their children may be stronger than those found in this study. The continued impact of mothers’ childhood depression on their children’s lives many years later raises the troubling issue that even when depression is diagnosed early in life, the individuals and their future children are likely to experience more adverse conditions over the course of their lives. This study did not examine whether the mothers diagnosed with depression in childhood were treated for their depression, or whether treatment would have reduced the likelihood of subsequent poverty, family disruption, and elevated distress in adulthood. However, the finding that women diagnosed with depression as children continue to have difficulties in the decades that follow, including elevated symptoms of distress in adulthood, suggests that their mental health problems have not been adequately and consistently addressed over the years. There are a number of pathways through which mother’s childhood depression may have led to depressive symptoms in the adolescent (Goodman & Gotlib, 1999). First, the association between mother’s and child’s depressive symptoms may be because of a common genetic tendency toward depression in mother and child. Second, mothers who were depressed as children are likely to have experienced depressive symptoms after they became mothers, which may have reduced their ability to meet their children’s emotional needs. Third, depressed mothers may provide a less stable and more stressful environment for their growing children. Finally, there may be unmeasured factors correlated with mothers’ depression that produced depressive symptoms in the children. This study does not examine what those pathways might have been. However, the children of mothers who had been diagnosed with childhood depression were more likely than other children to be born into single-parent families and to end up in a single-parent family later in childhood, to be exposed to poverty as a child, and to have a PCG who has higher than average levels of psychological distress. All of these factors may lead to a lower ability of parents to meet their children’s emotional



needs and would produce a less stable environment for the developing child. It has been suggested that depression may be triggered by hardship among children with a genetic tendency toward depression (Tsuang et al., 2004). The relationships between the indicators of poverty and depressive symptoms found in the study were not stronger among children whose mothers had been diagnosed with childhood depression than among children whose mothers had not been so diagnosed. To the extent that mother’s childhood depression is a reasonable proxy for a genetic tendency for early onset depression in their offspring, this finding indicates that poverty may not be sufficient to set off depression in the genetically inclined child. The findings of Conger et al. (1994, 1997) that economic hardship was not associated with internalizing behavior among adolescents living with both biological parents raised the question of whether two-parent families might provide a protective buffer that shields children from the psychological impact of poverty. If so, then the relationship between poverty and adolescent depression might be stronger among youth in single-parent families than youth in twoparent families. The current study, however, found little or no association between poverty and depressive symptoms among adolescents in either two-parent families or single-parent families. Adolescents who did not live with both of their biological parents had more depression symptoms than did adolescents living with both parents, but their depressive symptoms did not vary by how much of their childhoods they spent in poverty. The apparent relationship between poverty and adolescent depressive symptoms found in the larger sample was explained by those factors that increased the likelihood of father absence during adolescence, specifically mothers’ childhood depression and father absence during the child’s infancy. The finding that the presence of both parents during the first year of life was associated with the child’s scores on the CDI many years later raises interesting questions of interpretation. The association may reflect beneficial and lasting consequences of having both parents present during early childhood for both family income and the children’s emotional well-being. The association remained even after controlling for whether the father was present during adolescence and, therefore, may reflect the critical nature of the early childhood years for healthy child development. Together, mother’s childhood depression and father absence during the child’s first year of life would seem to account for the relationship between poverty persistence and adolescent depressive symptoms. But even with longitudinal data, we must be cautious about causal inferences. Whether the child lived with both parents during its first year may have been influenced by poverty experienced by the preceding generation. The economic hardships experienced by the parents prior to the child’s birth or during the first year of the child’s life may have influenced whether the parents remained a couple, thereby indirectly affecting the youth’s well-being. This would fit what Conger and Donnellan (2007) call the interactionist model of socioeconomic status and human development, in which both social selection and social causation combine in a reciprocal process to influence human development.

Limitations Several limitations of this study are important to note. First, the measure of mother’s childhood depression is based on retrospective

91

data and is subject to recall error. Moreover, the measure probably underreports childhood depression to some extent, because not all children with depression are diagnosed during childhood. Measurement error may also influence the indicators of childhood depressive symptoms. Mothers who themselves have a tendency toward depression may be more prone than other mothers to note depressive symptoms in their adolescent children, but whether they exaggerate symptoms or are simply more sensitive to depressive symptoms in their children is not clear (Blodgett Salafia, Gondoli, & Grundy, 2008; Richters, 1992; Youngstrom, Izard, & Ackerman, 1999). Second, the current study is limited in its scope to non-Hispanic White adolescents, and the findings therefore cannot be generalized to other race and ethnic groups in the United States. Although the PSID includes sufficient numbers of African American youth to support a separate analysis, a key independent variable, mother’s childhood depression, is underreported for African Americans (2% compared with 4.5% for White mothers). The underdiagnosis of African Americans with depression had been noted by other researchers (Das, Olfson, McCurtis, & Weissman, 2006; Fletcher, 2008) and may also be an issue for other racial and ethnic minority groups. This makes it difficult to replicate the study among other race and ethnic groups. A third study limitation is that the measurement of poverty was based on family income adjusted for family size, a method meant to produce a measure of poverty comparable with the official federal poverty threshold. Other measures of poverty might yield other results. For example, a measure proposed by the Panel on Poverty and Family Assistance (Citro & Michael, 1995) would take into account family needs such as high medical costs and work expenses, while adjusting for regional differences in the cost of living. Such a nuanced measure would more accurately reflect the economic hardship experienced by children. Other researchers have suggested that sudden drops in family income, rather than poverty itself, may lead to depressive symptoms among children. This was not explored in the current study. Fourth, not all potentially relevant preexisting factors were controlled. As a consequence, the measures of mother’s childhood depression and father’s absence during the child’s first year may be acting as proxies for other factors. For example, the circumstances that led to the father’s absence during the child’s first year (e.g., father’s mental health problems) may account for some or even all of the apparent effect of father’s absence on the child’s subsequent poverty and depressive symptoms. Although the data indicate that factors that predate the child’s experience with poverty can account for the association between poverty persistence and adolescent depressive symptoms, we cannot conclude with certainty that the relevant factors are mother’s history of depression and father’s early absence, rather than other factors correlated with them or causally prior to them.

Policy Implications The study findings shift the focus for policy intervention from providing income supports as a way to address adolescent depressive symptoms (although income supports may be vital for increasing other aspects of child well-being) and toward interventions that promote well-functioning two-parent families and enhance parental mental health. Strategies to reduce family disruption and to increase father participation in ways that would benefit the child have been the

BUTLER


92

focus of decades of research and limited policy success (see Shore [2009] for a summary). The study finding that childhood depression is associated with many adverse conditions over the course of women’s lives and the lives of their children highlights the need to provide treatment— whether psychosocial, pharmacological, or both—as needed over the life course for children who are diagnosed with depression. Recent policy developments have the potential to make this more likely to occur. The 2009 Health Information Technology for Economic and Clinical Health Act (2012) and the 2010 Patient Protection and Affordable Care Act (2012) are providing the impetus for a move toward the systematic and comprehensive use of electronic health records (Health Information Technology for Economic and Clinical Health Act, 2012; Patient Protection and Affordable Care Act of 2010, 2012). The goal is for patients’ health information to be collected and stored in a manner that can be readily accessed by health providers and patients, and can be used in a meaningful way to improve health outcomes. Electronic health records need to be coordinated across health care providers. This, in theory, will make it possible for childhood diagnoses of depression to be available to subsequent providers over the years. Treatment need not lapse because of lack of provider awareness of earlier diagnoses. Moreover, patient-reported behavioral health could be collected annually, making appropriate diagnosis more likely and allowing treatment to follow (Estabrooks et al., 2012; Glasgow, Kaplan, Ockene, Fisher, & Emmons, 2012). These management information systems are currently being developed. Input from the behavioral health community is essential to ensure that mental health providers have access to these systems, and that the appropriate balance is found between accessibility of mental health information and patients’ privacy concerns. It will also be important to ensure that electronic health records are transferable as children transition to adulthood, switch providers, and move to other parts of the country.

Conclusion Intervention can take place, whether psychosocial, medical, or both, to address depression and stem its life-altering impact on educational attainment, family stability, economic well-being, and consequences for children. Relatively few women were diagnosed with depression as children in this study (4.5%); probably more went undiagnosed. But to the extent that we address depression, we may be able to reduce the likelihood of subsequent poverty and family disruption for children. This is not a solution for poverty, but can address the link between depression and poverty, so that children with depression are not facing a lifetime of disadvantage that they pass on to their own children. Poverty has been linked to many adverse outcomes, and children would surely benefit in numerous ways if their family income were sufficient to meet their needs. This study, however, found no support for the hypothesis that either the persistence of poverty during childhood or current poverty leads to depressive symptoms during adolescence. Regardless of the cause, however, adolescents who were poor during childhood are at greater risk of depressive symptoms than are other youth. Childhood depression has a number of adverse consequences that extend into adulthood and can be transmitted to the next generation. The findings of this study highlight the importance of expanding the availability and extending the outreach

of accessible and affordable child and adolescent mental health services. Keywords: adolescents; depressive symptoms; poverty; parental depression; family stress model

References Afifi, A. A., Kotlerman, J. B., Ettner, S. L., & Cowan, M. (2007). Methods for improving regression analysis for skewed continuous or counted responses. Annual Review of Public Health, 28, 95–111. doi:10.1146/annurev .publhealth.28.082206.094100 Aneshensel, C. S., Estrada, A. L., Hansell, M. J., & Clark, V. A. (1987). Social psychological aspects of reporting behavior: Lifetime depressive episode reports. Journal of Health and Social Behavior, 28, 232–246. doi:10.2307/2136843 Berndt, E. R., Koran, L. M., Finkelstein, S. N., Gelenberg, A. J., Kornstein, S. G., Miller, I. M., . . . Keller, M. B. (2000). Lost human capital from early-onset chronic depression. American Journal of Psychiatry, 157, 940 – 947. Blau, D. M. (1999). The effect of income on child development. The Review of Economics and Statistics, 81, 261–276. doi:10.1162/003465399558067 Blodgett Salafia, E. H., Gondoli, D. M., & Grundy, A. M. (2008). Marital conflict as a mediator of the longitudinal connections between maternal emotional distress and early adolescent maladjustment. Journal of Child and Family Studies, 17, 928 –950. doi:10.1007/s10826-008-9199-9 Bolger, K. E., Patterson, C. J., Thompson, W. W., & Kupersmidt, J. B. (1995). Psychosocial adjustment among children experiencing persistent and intermittent family economic hardship. Child Development, 66, 1107–1129. doi:10.2307/1131802 Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York, NY: Basic Books. Bradley, R. H., & Corwyn, R. F. (2002). Socioeconomic status and child development. Annual Review of Psychology, 53, 371–399. doi:10.1146/ annurev.psych.53.100901.135233 Carlson, M. J. (2006). Family structure, father involvement, and adolescent behavioral outcomes. Journal of Marriage and Family, 68, 137–154. doi:10.1111/j.1741-3737.2006.00239.x Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk depressive disorders in adulthood. Journal of Affective Disorders, 82, 217–225. doi:10.1016/j.jad.2003.12.013 Cherlin, A. J., Chase-Lansdale, P. L., & McRae, C. (1998). Effects of parental divorce on mental health throughout the life course. American Sociological Review, 63, 239 –249. doi:10.2307/2657325 Citro, C. F., & Michael, R. T. (Eds.). (1995). Measuring poverty: A new approach. Washington, DC: National Academy Press. Conger, R. D., Conger, K. J., & Elder, G. H. (1997). Family economic hardship and adolescent adjustment: Mediating and moderating processes. In G. J. Duncan & J. Brooks-Gunn (Eds.), Consequences of growing up poor (pp. 288 –310). New York, NY: Russell Sage Foundation. Conger, R. D., Conger, K. J., Elder, G. H., Lorenz, F. O., Simons, R. L., & Whitbeck, L. B. (1993). Family economic stress and adjustment of early adolescent girls. Developmental Psychology, 29, 206 –219. doi:10.1037/ 0012-1649.29.2.206 Conger, R. D., & Donnellan, M. B. (2007). An interactionist perspective on the socioeconomic context of human development. Annual Review of Psychology, 58, 175–199. doi:10.1146/annurev.psych.58.110405.085551 Conger, R. D., Ge, X., Elder, G. H., Lorenz, F. O., & Simons, R. L. (1994). Economic stress, coercive family process, and developmental problems of adolescents. Child Development, 65, 541–561. doi:10.2307/1131401 Conger, R. D., Wallace, L. E., Sun, Y., Simons, R. L., McLoyd, V. C., & Brody, G. H. (2002). Economic pressure in African American families: A replication and extension of the family stress model. Developmental Psychology, 38, 179 –193. doi:10.1037/0012-1649.38.2.179


POVERTY AND ADOLESCENT DEPRESSION Costello, E. J., Compton, S. N., Keeler, G. P., & Angold, A. (2003). Relationships between poverty and psychopathology: A natural experiment. JAMA: Journal of the American Medical Association, 290, 2023–2029. doi:10.1001/jama.290.15.2023 Costello, E. J., Erkanli, A., & Angold, A. (2006). Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry, 47, 1263–1271. Costello, E. J., Keeler, G. P., & Angold, A. (2001). Poverty, race/ethnicity, and psychiatric disorder: A study of rural children. American Journal of Public Health, 91, 1494 –1498. doi:10.2105/AJPH.91.9.1494 Das, A. K., Olfson, M., McCurtis, H. L., & Weissman, M. M. (2006). Depression in African Americans: Breaking the barriers to detection and treatment. The Journal of Family Practice, 55, 30 –39. Duncan, G. J., Brooks-Gunn, J., & Klebanov, P. K. (1994). Economic deprivation and early childhood development. Child Development, 65, 296 –318. doi:10.2307/1131385 Duncan, G. J., Yeung, W. J., Brooks-Gunn, J., & Smith, J. (1998). How much does child poverty affect the life chances of children? American Sociological Review, 63, 406 – 423. doi:10.2307/2657556 Eamon, M. K. (2002). Influences and mediators of the effect of poverty on young adolescent depressive symptoms. Journal of Youth and Adolescence, 31, 231–242. doi:10.1023/A:1015089304006 Eamon, M. K., & Zuehl, R. M. (2001). Maternal depression and physical punishment as mediators of the effect of poverty on socioemotional problems of children in single-mother families. American Journal of Orthopsychiatry, 71, 218 –226. doi:10.1037/0002-9432.71.2.218 Elder, G. H., & Caspi, A. (1988). Economic stress in lives: Developmental perspectives. Journal of Social Issues, 44, 25– 45. doi:10.1111/j.1540-4560 .1988.tb02090.x Estabrooks, P. A., Boyle, M., Emmons, K. M., Glasgow, R. E., Hesse, B. W., Kaplan, R. M., . . . Taylor, M. V. (2012). Harmonized patient-reported data elements in the electronic heath record: Supporting meaningful use by primary care action on health behaviors and key psychosocial factors. Journal of the American Medical Informatics Association, 19, 575–582. doi:10.1136/amiajnl-2011-000576 Finkelhor, D., Ormrod, R. K., Turner, H., & Hamby, S. L. (2005). The victimization of children and youth: A comprehensive, national survey. Child Maltreatment, 10, 5–25. doi:10.1177/1077559504271287 Fletcher, J. M. (2008). Adolescent depression: Diagnosis, treatment, and educational attainment. Health Economics, 17, 1215–1235. doi:10.1002/ hec.1319 Garber, J., Keiley, M. K., & Martin, N. C. (2002). Developmental trajectories of adolescents’ depressive symptoms: Predictors of change. Journal of Consulting and Clinical Psychology, 70, 79 –95. doi:10.1037/0022-006X .70.1.79 Gennetian, L. A., & Miller, C. (2002). Children and welfare reform: A view from an experimental welfare program in Minnesota. Child Development, 73, 601– 620. doi:10.1111/1467-8624.00426 Gershoff, E. T., Aber, J. L., Raver, C. C., & Lennon, M. C. (2007). Income is not enough: Incorporating material hardship into models of income associations with parenting and child development. Child Development, 78, 70 –95. doi:10.1111/j.1467-8624.2007.00986.x Glasgow, R. E., Kaplan, R. M., Ockene, J. K., Fisher, E. B., & Emmons, K. M. (2012). Patient-reported measures of psychosocial issues and health behavior should be added to electronic health records. Health Affairs, 31, 497–504. doi:10.1377/hlthaff.2010.1295 Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458 – 490. doi: 10.1037/0033-295X.106.3.458 Goosby, B. J. (2007). Poverty duration, maternal psychological resources, and adolescent socioemotional outcomes. Journal of Family Issues, 28, 1113– 1134. doi:10.1177/0192513X07300712 Health Information Technology for Economic and Clinical Health Act, Title

93

XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009, 42 U.S.C. §§300jj et seq.; §§17901 et seq. (2012). Johnson, J. G., Cohen, P., Dohrenwend, B. P., Link, B. G., & Brook, J. S. (1999). A longitudinal investigation of social causation and social selection processes involved in the association between socioeconomic status and psychiatric disorders. Journal of Abnormal Psychology, 108, 490 – 499. doi:10.1037/0021-843X.108.3.490 Joormann, J., Eugene, F., & Gotlib, I. H. (2008). Parental depression: Impact on offspring and mechanisms underlying transmission of risk. In S. H. Nolen-Hoeksema & L. M. Hilt (Eds.), Handbook of depression in adolescents (pp. 441– 472). New York, NY: Routledge. Kessler, R. C., Barker, P. R., Colpe, L. J., Epstein, J. F., Gfroerer, J. C., Hiripi, E., . . . Zaslavsky, A. M. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60, 184 –189. doi: 10.1001/archpsyc.60.2.184 Kessler, R. C., Berglund, P. A., Foster, C. L., Saunders, W. B., Stang, P. E., & Walters, E. E. (1997). Social consequences of psychiatric disorders, II: Teenage parenthood. The American Journal of Psychiatry, 154, 1405– 1411. Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Childhood adversity and adult psychiatric disorder in the U.S. National Comorbidity Survey. Psychological Medicine, 27, 1101–1119. doi:10.1017/ S0033291797005588 Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. The American Journal of Psychiatry, 152, 1026 –1032. Kessler, R. C., Walters, E. E., & Forthofer, M. S. (1998). The social consequences of psychiatric disorders, III: Probability of marital stability. The American Journal of Psychiatry, 155, 1092–1096. Knäuper, B., Cannell, C. F., Schwarz, N., Bruce, M. L., & Kessler, R. C. (1999). Improving accuracy of major depression age-of-onset reports in the U.S. National Comorbidity Survey. International Journal of Methods in Psychiatric Research, 8, 39 – 48. doi:10.1002/mpr.55 Lau, J. Y. F., & Eley, T. C. (2008). The genetics of adolescent depression. In S. Nolen-Hoeksema & L. M. Hilt (Eds.), Handbook of depression in adolescents (pp. 259 –278). New York, NY: Routledge. Libby, A. M., Orton, H. D., & Valuck, R. J. (2009). Persisting decline in depression treatment after FDA warnings. Archives of General Psychiatry, 66, 633– 639. doi:10.1001/archgenpsychiatry.2009.46 Lorant, V., Deliège, D., Eaton, W., Robert, A., Philippot, P., & Ansseau, M. (2003). Socioeconomic inequalities in depression: A meta-analysis. American Journal of Epidemiology, 157, 98 –112. doi:10.1093/aje/kwf182 Mash, E. J., & Dozois, D. J. A. (2003). Child psychopathology: A developmental-systems perspective. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 3–71). New York, NY: Guilford Press. McLeod, J. D., & Nonnemaker, J. M. (2000). Poverty and child emotional and behavioral problems: Racial/ethnic differences in processes and effects. Journal of Health and Social Behavior, 41, 137–161. doi:10.2307/2676302 McLeod, J. D., & Shanahan, M. J. (1993). Poverty, parenting, and children’s mental health. American Sociological Review, 58, 351–366. doi:10.2307/ 2095905 Mcleod, J. D., & Shanahan, M. J. (1996). Trajectories of poverty and children’s behavioral health. Journal of Health and Social Behavior, 37, 207–220. doi:10.2307/2137292 Miech, R. A., Caspi, A., Moffitt, T. E., Wright, B. E., & Silva, P. A. (1999). Low socioeconomic status and mental disorders: A longitudinal study of selection and causation during young adulthood. American Journal of Sociology, 104, 1096 –1131. doi:10.1086/210137 Patient Protection and Affordable Care Act of 2010, 42 U.S.C. § 18001 et seq. (2012). Peterson, J. L., & Zill, N. (1986). Marital disruption, parent-child relationships, and behavioral problems in children. Journal of Marriage and the Family, 48, 295–307. doi:10.2307/352397


94

BUTLER

PSID. (2010). The Panel Study of Income Dynamics Child Development Supplement. User guide supplement for CDS-I. Ann Arbor, MI: The Institute for Social Research. Richters, J. E. (1992). Depressed mothers as informants about their children: A critical review of the evidence for distortion. Psychological Bulletin, 112, 485– 499. doi:10.1037/0033-2909.112.3.485 Rushton, J. L., Forcler, M., & Schectman, R. M. (2002). Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 199 –205. doi:10.1097/00004583-200202000-00014 Shore, R., & Shore, B. (2009). Increasing the percentage of children living in two-parent families. Kids Count Indicator Brief. Baltimore, MD: Annie E. Casey Foundation. Sigle-Rushton, W., & McLanahan, S. (2004). Father absence and child well-being: A critical review. In D. Moynihan, T. Smeeding, & L. Rainwater (Eds.), The future of the family (pp. 116 –155). New York, NY: Russell Sage Foundation. Simon, G. E., & VonKorff, M. (1995). Recall of psychiatric history in cross-sectional surveys: Implications for epidemiologic research. Epidemiological Reviews, 17, 221–227. Sitarenios, G., & Stein, S. (2004). Use of the children’s depression inventory. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Instruments for children and adolescents (3rd ed., Vol. 2, pp. 1–37). Mahwah, NJ: Erlbaum.

Spence, S. H., Najman, J. M., Bor, W., O’Callaghan, M. J., & Williams, G. M. (2002). Maternal anxiety and depression, poverty and marital relationship factors during early childhood as predictors of anxiety and depressive symptoms in adolescence. Journal of Child Psychology and Psychiatry, 43, 457– 469. doi:10.1111/1469-7610.00037 Sroufe, A., Duggal, S., Weinfield, N., & Carlson, E. (2000). Relationships, development, and psychopathology. In A. J. Sameroff, M. Lewis, & S. M. Miller (Eds.), Handbook of Developmental Psychopathology (2nd ed., pp. 75–91). New York, NY: Kluwer Academic/Plenum Press. doi:10.1007/ 978-1-4615-4163-9_5 Tsuang, M. T., Bar, J. L., Stone, W. S., & Faraone, S. V. (2004). Geneenvironment interactions in mental disorders. World Psychiatry, 3, 73– 83. Wadsworth, M. E., Raviv, T., Compas, B. E., & Connor-Smith, J. K. (2005). Parent and adolescent responses to poverty-related stress: Tests of mediated and moderated coping models. Journal of Child and Family Studies, 14, 283–298. doi:10.1007/s10826-005-5056-2 Weissman, M. M., Gammon, G. D., John, K., Merikangas, K. R., Warner, V., Prusoff, B. A., & Sholomskas, D. (1987). Children of depressed parents: Increased psychopathology and early onset of major depression. Archives of General Psychiatry, 44, 847– 853. doi:10.1001/archpsyc.1987 .01800220009002 Youngstrom, E., Izard, C., & Ackerman, B. (1999). Dysphoria-related bias in maternal ratings of children. Journal of Consulting and Clinical Psychology, 67, 905–916. doi:10.1037/0022-006X.67.6.905

Pathways from maternal depressive symptoms to adolescent depressive symptoms: the unique contribution of irritability symptoms.

Longitudinal associations between adolescent psychotic experiences and depressive symptoms.

Trajectories of overweight and their association with adolescent depressive symptoms.

Maternal depressive symptoms during childhood and risky adolescent health behaviors.

The blues of adolescent romance: observed affective interactions in adolescent romantic relationships associated with depressive symptoms.

[Depressive symptoms and sexuality].

Effortful Control Predicts Adolescent Antisocial-Aggressive Behaviors and Depressive Symptoms: Co-Occurrence and Moderation by Impulsivity.

Testing the temporal relationship between maternal and adolescent depressive and anxiety symptoms in a community sample.

Disentangling vulnerabilities from outcomes: Distinctions between trait affect and depressive symptoms in adolescent and adult samples.

Adolescent romance and depressive symptoms: the moderating effects of positive coping and perceived friendship competence.

Role of adolescent and maternal depressive symptoms on transactional emotion recognition: context and state affect matter.

Discrepancies Between Perceptions of the Parent-Adolescent Relationship and Early Adolescent Depressive Symptoms: An Illustration of Polynomial Regression Analysis.

Interdependence of depressive symptoms, school involvement, and academic performance between adolescent friends: A dyadic analysis.

The trajectories of adolescent anxiety and depressive symptoms over the course of a transdiagnostic treatment.

Sex Differences in Genetic and Environmental Influences on Adolescent Depressive Symptoms: A Meta-Analytic Review.

Neural sensitivity to eudaimonic and hedonic rewards differentially predict adolescent depressive symptoms over time.

The relationship between parental depressive symptoms, family type, and adolescent functioning.

Non-suicidal self-injury prospectively predicts interpersonal stressful life events and depressive symptoms among adolescent girls.

Characterizing the longitudinal relations between depressive and menstrual symptoms in adolescent girls.

Association of Adolescent Depressive Symptoms With Health Care Utilization and Payer-Incurred Expenditures.

Stress in romantic relationships and adolescent depressive symptoms: Influence of parental support.

Life course adiposity and adolescent depressive symptoms among Hong Kong adolescents.

Executive functioning and self-reported depressive symptoms within an adolescent inpatient population.

Family and peer social support as specific correlates of adolescent depressive symptoms.