Community Ment Health J DOI 10.1007/s10597-014-9824-6
ORIGINAL PAPER
The Effects of Maternal Depression on Child Mental Health Problems Based on Gender of the Child Sun-Mi Cho • Eu jin Kim • Ki-Young Lim Ji-Won Lee • Yun-Mi Shin
•
Received: 23 July 2012 / Accepted: 16 December 2014 Ó Springer Science+Business Media New York 2015
Abstract Depression is a common disorder among women with young children. Compared to non-depressed mothers, depressed mothers tend to display less positive affection, provide less emotional support, and inconsistently respond to their child’s every day and emotional needs. We examined the association between maternal depression and child (middle childhood) mental health problems according to the child’s gender. This study was conducted between June and August 2006 on 3,911 subjects aged 7–12 years. The data for this study was collected through a questionnaire that included the Beck Depression Inventory (BDI) and Korean Child Behavior Checklist (K-CBCL). Most of the CBCL scores were higher for children in the depressed mother group. The two way ANOVAs (depressed group by gender) found girls to have significantly higher scores than boys on somatization. Children may experience somatic complaints when they also suffer from emotional disorders, and therefore must be observed closely. Keywords
Mother Depression Child Gender
Introduction The impact of maternal depression on behavioral and emotional problems in children has been the subject of many recent studies (Goodman et al. 2011). Depressed
S.-M. Cho E. j. Kim K.-Y. Lim J.-W. Lee Y.-M. Shin (&) Department of Psychiatry and Behavioral Sciences, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 443-721, Republic of Korea e-mail: [email protected]
mothers tend to display less positive affection, and provide less emotional support and less consistent response to their children, relative to mothers who are not depressed (Webster-Stratton and Hammond 1988). Depressed mothers often feel more incompetent as a parent and experience more helplessness (Goodman et al. 2011). It may also be that some depressed mothers may be less patient and more direct, harsh and critical in their comments to their children. It has been documented that children of depressed mothers have more problems in three domains compared to controls. First, children of depressed mothers have been found to have abnormalities in neurobiological functioning, with higher heart rate and lower vagal tone, as well as higher cortisol level. Second, in the area of cognition and self-concept, children of depressed mothers show vulnerability to to poor self esteem. They are more likely to blame themselves for negative outcomes, having a more negative self- attribution style, and being less likely to recall positive self-descriptive adjectives. Third, with respect to interpersonal functioning, these children are more likely to display poor social skills, difficulties with impulse control and lack of motivation (Goodman and Gotlib 1999). Furthermore, it has been shown that in comparison to the children of the control parent group, children of the parents with depression or anxiety disorders are at greater risk (two- to threefold) for an early onset of major depressive disorder (Beardslee et al. 1998; Weissman et al. 2006). Many studies have shown that depressed maternal states have variable impact on the child based on the child’s gender (Rutter and Quinton 1984). While some studies found no differences based on gender, others found that girls, especially relatively older ones, were more emotionally affected by their depressed mothers. For instance,
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Fergusson et al. (1995) reported a significant correlation between maternal depressive symptoms and depressive symptoms in their adolescent daughters but not in the sons. Davies and Windle 1997 found that maternal depression was related to adolescent girls’ depressive symptoms, conduct problems and academic difficulties. Also, they found that family discord mediated the effect of maternal depression on the girls’ social and emotional adjustment. Most of the studies has only been focused on two developmental stages; infancy up to the first 3 years of life (Egeland and Farber 1984), and adolescence. The former is the period during which critical events in brain development and human relationship occur and the later is when bio-behavioral transformations into adulthood are dramatically engaged. There is limited research on the impact of maternal depression on children of grade school age. Grade school age children focus their energies on attending school, making new friends, and gaining new skills, all part of expected social and mental development. In this study, we examined the association between maternal depression and the mental health problems of the children in their grade school years, based on the child’s gender.
The K-CBCL was used to obtain standardized maternal reports of the child’s behavior over the 6 months prior to the beginning of the study. The Child Behavior Checklist (CBCL), a tool for assessing the child’s behavioral problems, consists of 118 items rating behavior on a 3-point scale (not true, somewhat or sometimes true, or very true or often true). The CBCL factor structure consists of eight narrow-band problem scales and two broadband scales, internalizing problems and externalizing problems and also gives a total problem score. The basic tool was shown to be reliable and to possess the discriminative validity established by Achenbach (1991). The Korean version (K-CBCL) is also considered to be a reliable and valid tool (Oh et al. 1997). Finally, the questionnaire included sections concerning family structure, the child’s age and gender, parental education level and economic status. The educational backgrounds of the parents were divided into two categories: completion of 12 years of schooling and others. Economic status was divided into three categories on a 5-point scale based on family income. Statistical Methods and Analysis
Methods Sample and Setting This study was conducted between June and August 2006 on 3,911 subjects aged 7–12 years residing in the city of Osan, (population 120,000) Republic of Korea, located southeast of Seoul. The investigators of this study visited local schools, explained the study to teachers, and sent questionnaires to the students’ parents along with letters that included a description of the study’s objectives and benefits, confidentiality guarantee, a consent form and contact information. Mothers of the participants answered the questionnaires and returned them to the school in sealed envelopes. Assessments and Measurement The data for this study was collected through a questionnaire that included the Beck Depression Inventory (BDI), Korean Child Behavior Checklist (K-CBCL), and questions concerning the family’s socio-demographic backgrounds. The BDI was used to determine depression in the mothers. The BDI, a self-administered questionnaire designed to measure the severity of depressive symptoms, is comprised of 14 cognitive/affective items and 7 somatic/ performance items that assess symptoms within the previous week, including the day it is administered. A Cronbach’s a of 0.92 was reported for the Korean version of the BDI (Lee and Song 1991).
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After the mothers were divided based on depressive state, their children were divided based on their gender. The sociodemographic and clinical characteristics were then compared. The questionnaire data was then analyzed using the Statistical Package for Social Science (SPSS). A two-by-two analysis of variance was performed using the mother’s depressed state (mother is depressed or control) as the first factor and gender as the second factor. Then, the effects of the mother’s depressed status, gender, and gender by depressed status (interaction) term variables were analyzed. A P value less than 0.05 was interpreted as significant.
Results Of the 4,012 children that were approached, 3,911 completed the study. There were no significant differences in gender or schools between the participants and non-participants. The group of children included 1,970 boys (50.4 %) and 1,941 girls(49.6 %). Characteristics of the study sample (n = 3,911) are shown in Table 1. To determine gender differences related to the impact of a mother’s depression, two-way analysis of variances with the depressed mother group by gender were computed, allowing for interactions (Table 2). Most of the CBCL scores were higher for children in the depressed mother group. The two-way analysis of variances (depressed group by gender) found girls to have significantly higher scores than boys on somatization.
Community Ment Health J
Discussion
Table 1 Demographic data Non-depressed mother N (%)
Depressed mother N (%)
Total (%)
Chisquare test
Boys
1,807 (50.1)
163 (53.6)
1,970 (50.4)
0.67
Girls Age
1,800 (49.9)
141 (46.4)
1,941 (49.6)
8–10
2,429 (67.3)
213 (70.1)
2,642 (67.6)
11–13
1,178 (32.7)
91 (29.1)
1,269 (32.4)
Gender
Family structure Living with both parents
3,601 (95.4)
218 (88.6)
171 (4.5)
28 (11.4)
others
Education of father [12 year 1,694 (44.9) B12 years
2,036 (54.1)
96 (39) 146 (59.3)
Education of mother [12 years
978 (25.9)
52 (21.1)
B12 years
2,715 (72.0)
191 (77.6)
Economic status Upper Middle Low
562 (14.9)
24 (9.8)
2,185 (57.9)
108 (43.9)
921 (24.4)
105 (42.7)
Total
3,911 (100)
0.58
This study is significant for several reasons. First, while most previous studies were conducted on clinical samples referred from mental health services, this study was conducted on a community sample. Second, this study targeted grade school children, which is relatively unique compared to previous studies which mostly focused on infancy to age 3 or adolescence. Third, this study examined the association between maternal depression and children’s psychological problems according to the child’s gender. The CBCL scores for daughters of depressed mothers were significantly higher for somatic complaints. The issue of differential effects of maternal depression on child gender is of special importance because during adolescence, the sex ratio of clinical depression for girls and boys evolves from 1:1 to approximately 2:1 (NolenHoeksema et al. 1999). Studies have reported similar results, finding greater association between maternal depressive problems and behavioral and emotional difficulties with daughters more so than sons (Boyle and Pickles 1997; Davies and Windle 1997; Krain and Kendall 2000). In a study conducted by Krain and Kendall (2000) maternal, but not paternal, depressive symptoms correlated with the parental report of child’s anxiety. When examined by gender, both parents’ depressive symptoms correlated with the parental report of their child’s anxiety in daughters
Table 2 Comparison of means and standard deviations for the CBCL based on their gender with depressed and nondepressed mother group CBCL
Non depressed mother
Depressed mother
Boys Mean (SD)
Boys Mean (SD)
Girls Mean (SD)
Girls Mean (SD)
Mother’s depression
Gender
Mother’s depression 9 Gender
Withdrawn
1.17 (± 1.64)
1.14 (±1.51)
2.53 (±2.45)
2.78 (±2.58)
NS
NS
NS
Somatization
0.96 (±1.53)
0.96 (±1.51)
1.95 (±2.21)
2.58 (±2.92)
NS
NS
0.001*
Depressive/anxious Immaturity
1.98 (±2.57) 1.68 (±1.82)
1.98 (±2.41) 1.58 (±1.73)
4.35 (±3.85) 3.14 (±2.25)
4.55 (±4.21) 3.02 (±2.21)
0.026* 0.006**
NS NS
NS NS
Thought problem
0.36 (±0.80)
0.27 (±0.67)
0.74 (±1.31)
0.70 (±1.28)
0.034*
NS
NS
Attention problem
2.55 (±2.45)
2.00 (±2.20)
4.65 (±3.35)
4.14 (±3.17)
0.007**
0.026*
NS
Conduct problem
0.89 (±1.97)
0.62 (±1.04)
1.55 (±1.67)
1.26 (±1.40)
0.009**
0.022*
NS
Aggressive behavior
4.84 (±4.30)
4.37 (±3.76)
8.19 (±5.47)
8.20 (±5.49)
0.043*
NS
NS
Emotional problem
2.38 (±2.37)
2.59 (±2.37)
4.34 (±3.06)
4.82 (±3.20)
0.040*
NS
NS
Internalization
45.03 (±8.97)
44.7 (±8.60)
53.13 (±9.82)
53.10 (±9.65)
0.012*
NS
NS
Externalization
46.41 (±8.74)
46.10 (±8.81)
52.45 (±9.28)
53.95 (±8.71)
NS
NS
NS
Total problem
44.76 (±9.01)
44.32 (±9.11)
52.69 (±9.63)
53.86 (±9.48)
NS
NS
NS
Social skills
7.47 (±1.19)
7.57 (±1.16)
6.78 (±1.41)
6.93 (±1.39)
0.027*
NS
NS
Academic achievements
2.14 (±0.47)
2.18 (±0.46)
1.95 (±0.48)
2.1 (±0.48)
0.047*
NS
NS
Social competence
9.61 (±1.37)
9.75 (±1.36)
8.73 (±1.59)
9.04 (±1.62)
NS
NS
NS
*p \ 0.05; **p \ 0.01
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Community Ment Health J
rather than sons. A review by Sheeber et al. (2001) proposed several explanations for gender-specific vulnerability to the effects of maternal depression. These include the maternal modeling of depressive interpersonal behaviors and lack of effective coping strategies for girls and more conflictual mother–daughter relationships (Hops et al. 1987). Girls that are at a higher risk of depression are also often those that have been subjected to taking responsibility for the family and the depressed mother (Davies and Lindsay 2004; Klimes-Dougan and Bolger 1998). Finally, girls tend to be more sensitive to the conflicts between parents. Therefore the development of internalizing symptoms likely increases in girls (Langrock et al. 2002). The prevalence of somatic complaints in children is high, especially in grade school children and adolescence. (Roth-Isigkeit et al. 2004) Recurrent complaints of somatic symptoms are common among children and adolescents, more so in girls than boys. In a general population survey, Offord et al. (1987) found recurrent distressing somatic symptoms in 11 % of girls and 4 % of boys aged 12–16 years. The literature supports that negative moods are related to more somatic complaints. In epidemiological studies, depressive and anxiety disorders have been associated with recurrent headaches and stomach aches more in girls than boys (Egger et al. 1999). Children may complain of somatic symptoms when they suffer from emotional disorders (Reinherz et al. 1993). Since eliciting depressive symptoms from children is somewhat difficult, as some may not be sufficiently cognitively developed or capable enough of expressing emotional experiences, assessing somatic symptoms may be a useful screen for depression in children (McCauley et al. 1991). Parents are better able to recognize externalized behaviours in their children than internalized symptoms, and are not the most accurate reporters of internalizing problems in their children (Poli et al. 2003). Children are better at recognizing and reporting their internalized symptoms than their parents. It has become increasingly evident that children 8 years and older are reliable reporters of their internal mood states (Frigerio et al. 2001). This could explain our finding that higher scores were noted only on somatization in girls in the depressed mother group compared to the control group. Negative findings in other items from the K-CBCL might be due to the lack of children’s self-reports in this study rather than internalized symptoms not existing. This study has several limitations. First, it is impossible to determine from the data alone the causality between a child’s illness and the mother’s psychiatric disorder or vice versa. Second, fathers did not complete the K-CBCL, thus the assessment of the mental-health problems of the child relied solely upon the maternal report which may have been biased by the mood state of the mother. Some studies
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have reported that parents that are more distressed or depressed have a lower tolerance for frustration and regard their children as having more externalizing problems (Richters 1992). Also, researchers with well-designed studies have found supporting evidence for an association between higher maternal depression and mothers’ tendency to over-report children’s behavior problems, relative to a latent criterion variable (Boyle and Pickles 1997; Fergusson et al. 1995). By obtaining and then comparing both parents’ responses, the contribution of the mother’s depression to the perception of somatic complaints in daughters might be better elucidated. Other vulnerabilities of their children more recognizable to fathers might also have been identified although such a result might also in turn reflect father’s perceptions and sensitivities be they accurate or not. Third, the survey has several methodological limitations. Assessment of maternal depression relied on self-reporting. At present, no independent measures are available for the range, severity or persistence of depression. The result of our study supports targeting somatic symptoms for screening depression in children of depressive mothers, especially in girls. In future studies, inclusion of children’s self-reports and father’s self-reports would be helpful in evaluating internalized symptoms of the children more accurately. Also, future studies might also include multiple informants’ assessments i.e. father and teachers to address potential rater bias. In addition, future studies need to be replicated with a more comprehensive instrument to support our findings.
References Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/418 and 1991 Profile. Burlington: University of Vermont Department of Psychiatry. Beardslee, W. R., Versage, E. M., & Gladstone, T. R. (1998). Children of affectively ill parents: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 37(11), 1134–1141. Boyle, M. H., & Pickles, A. (1997). Maternal depressive symptoms and ratings of emotional disorder symptoms in children and adolescents. Journal of Child Psychology and Psychiatry, 38(8), 981–992. Davies, P. T., & Lindsay, L. L. (2004). Interparental conflict and adolescent adjustment: Why does gender moderate early adolescent vulnerability? Journal of Family Psychology, 18(1), 160. Davies, P. T., & Windle, M. (1997). Gender-specific pathways between maternal depressive symptoms, family discord, and adolescent adjustment. Developmental Psychology, 33(4), 657–668. Egeland, B., & Farber, E. A. (1984). Infant–mother attachment: factors related to its development and changes over time. Child Development, 55(3), 753–771. Egger, H. L., Costello, E. J., Erkanli, A., & Angold, A. (1999). Somatic complaints and psychopathology in children and
Community Ment Health J adolescents: stomach aches, musculoskeletal pains, and headaches. Journal of the American Academy of Child and Adolescent Psychiatry, 38(7), 852–860. Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1995). Maternal depressive symptoms and depressive symptoms in adolescents. Journal of Child Psychology and Psychiatry, 36(7), 1161–1178. Frigerio, A., Pesenti, S., Molteni, M., Snider, J., & Battaglia, M. (2001). Depressive symptoms as measured by the CDI in a population of northern Italian children. European Psychiatry, 16(1), 33–37. 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(3), 458–490. Goodman, S. H., Rouse, M. H., Connell, A. M., Broth, M. R., Hall, C. M., & Heyward, D. (2011). Maternal depression and child psychopathology: A meta-analytic review. Clinical Child and Family Psychology Review, 14(1), 1–27. Hops, H., Biglan, A., Sherman, L., Arthur, J., Friedman, L., & Osteen, V. (1987). Home observations of family interactions of depressed women. Journal of Consulting and Clinical Psychology, 55(3), 341–346. Klimes-Dougan, B., & Bolger, A. K. (1998). Coping with maternal depressed affect and depression: Adolescent children of depressed and well mothers. Journal of Youth and Adolescence, 27(1), 1–15. Krain, A. L., & Kendall, P. C. (2000). The role of parental emotional distress in parent report of child anxiety. Journal of Clinical Child Psychology, 29(3), 328–335. Langrock, A. M., Compas, B. E., Keller, G., Merchant, M. J., & Copeland, M. E. (2002). Coping with the stress of parental depression: Parents’ reports of children’s coping, emotional, and behavioral problems. Journal of Clinical Child and Adolescent Psychology, 31(3), 312–324. Lee, Y. H., & Song, J. Y. (1991). A study of the reliability and the validity of the BDI, SDS, and MMPI-D scales. Journal of Korean Neuropsychiatric Association, 10, 98–113. McCauley, E., Carlson, G. A., & Calderon, R. (1991). The role of somatic complaints in the diagnosis of depression in children and
adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 30(4), 631–635. Nolen-Hoeksema, S., Larson, J., & Grayson, C. (1999). Explaining the gender difference in depressive symptoms. Journal of Personality and Social Psychology, 77(5), 1061–1072. Offord, D. R., Boyle, M. H., Szatmari, P., Rae-Grant, N. I., Links, P. S., Cadman, D. T., et al. (1987). Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization. Archives of General Psychiatry, 44(9), 832–836. Oh, K., Hong, K. M., Lee, H., & Ha, E. (1997). K-CBCL. seoul, Korea: Chung Ang Aptitude Publishing Co. Poli, P., Sbrana, B., Marcheschi, M., & Masi, G. (2003). Self-reported depressive symptoms in a school sample of Italian children and adolescents. Child Psychiatry and Human Development, 33(3), 209–226. Reinherz, H. Z., Giaconia, R. M., Pakiz, B., Silverman, A. B., Frost, A. K., & Lefkowitz, E. S. (1993). Psychosocial risks for major depression in late adolescence: A longitudinal community study. Journal of the American Academy of Child and Adolescent Psychiatry, 32(6), 1155–1163. Richters, J. E. (1992). Depressed mothers as informants about their children: A critical review of the evidence for distortion. Psychological Bulletin, 112(3), 485–499. Roth-Isigkeit, A., Thyen, U., Raspe, H. H., Stoven, H., & Schmucker, P. (2004). Reports of pain among German children and adolescents: An epidemiological study. Acta Paediatrica, 93(2), 258–263. Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: Effects on children. Psychological Medicine, 14(4), 853–880. Sheeber, L., Hops, H., & Davis, B. (2001). Family processes in adolescent depression. Clinical Child and Family Psychology Review, 4(1), 19–35. Webster-Stratton, C., & Hammond, M. (1988). Maternal depression and its relationship to life stress, perceptions of child behavior problems, parenting behaviors, and child conduct problems. Journal of Abnormal Child Psychology, 16(3), 299–315. Weissman, M. M., Pilowsky, D. J., Wickramaratne, P. J., Talati, A., Wisniewski, S. R., & Rush, A. J. (2006). Remissions in maternal depression and child psychopathology: A STAR*D-child report. JAMA, 295(12), 1389–1398.
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ORIGINAL PAPER
The Effects of Maternal Depression on Child Mental Health Problems Based on Gender of the Child Sun-Mi Cho • Eu jin Kim • Ki-Young Lim Ji-Won Lee • Yun-Mi Shin
•
Received: 23 July 2012 / Accepted: 16 December 2014 Ó Springer Science+Business Media New York 2015
Abstract Depression is a common disorder among women with young children. Compared to non-depressed mothers, depressed mothers tend to display less positive affection, provide less emotional support, and inconsistently respond to their child’s every day and emotional needs. We examined the association between maternal depression and child (middle childhood) mental health problems according to the child’s gender. This study was conducted between June and August 2006 on 3,911 subjects aged 7–12 years. The data for this study was collected through a questionnaire that included the Beck Depression Inventory (BDI) and Korean Child Behavior Checklist (K-CBCL). Most of the CBCL scores were higher for children in the depressed mother group. The two way ANOVAs (depressed group by gender) found girls to have significantly higher scores than boys on somatization. Children may experience somatic complaints when they also suffer from emotional disorders, and therefore must be observed closely. Keywords
Mother Depression Child Gender
Introduction The impact of maternal depression on behavioral and emotional problems in children has been the subject of many recent studies (Goodman et al. 2011). Depressed
S.-M. Cho E. j. Kim K.-Y. Lim J.-W. Lee Y.-M. Shin (&) Department of Psychiatry and Behavioral Sciences, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtong-gu, Suwon 443-721, Republic of Korea e-mail: [email protected]
mothers tend to display less positive affection, and provide less emotional support and less consistent response to their children, relative to mothers who are not depressed (Webster-Stratton and Hammond 1988). Depressed mothers often feel more incompetent as a parent and experience more helplessness (Goodman et al. 2011). It may also be that some depressed mothers may be less patient and more direct, harsh and critical in their comments to their children. It has been documented that children of depressed mothers have more problems in three domains compared to controls. First, children of depressed mothers have been found to have abnormalities in neurobiological functioning, with higher heart rate and lower vagal tone, as well as higher cortisol level. Second, in the area of cognition and self-concept, children of depressed mothers show vulnerability to to poor self esteem. They are more likely to blame themselves for negative outcomes, having a more negative self- attribution style, and being less likely to recall positive self-descriptive adjectives. Third, with respect to interpersonal functioning, these children are more likely to display poor social skills, difficulties with impulse control and lack of motivation (Goodman and Gotlib 1999). Furthermore, it has been shown that in comparison to the children of the control parent group, children of the parents with depression or anxiety disorders are at greater risk (two- to threefold) for an early onset of major depressive disorder (Beardslee et al. 1998; Weissman et al. 2006). Many studies have shown that depressed maternal states have variable impact on the child based on the child’s gender (Rutter and Quinton 1984). While some studies found no differences based on gender, others found that girls, especially relatively older ones, were more emotionally affected by their depressed mothers. For instance,
123
Community Ment Health J
Fergusson et al. (1995) reported a significant correlation between maternal depressive symptoms and depressive symptoms in their adolescent daughters but not in the sons. Davies and Windle 1997 found that maternal depression was related to adolescent girls’ depressive symptoms, conduct problems and academic difficulties. Also, they found that family discord mediated the effect of maternal depression on the girls’ social and emotional adjustment. Most of the studies has only been focused on two developmental stages; infancy up to the first 3 years of life (Egeland and Farber 1984), and adolescence. The former is the period during which critical events in brain development and human relationship occur and the later is when bio-behavioral transformations into adulthood are dramatically engaged. There is limited research on the impact of maternal depression on children of grade school age. Grade school age children focus their energies on attending school, making new friends, and gaining new skills, all part of expected social and mental development. In this study, we examined the association between maternal depression and the mental health problems of the children in their grade school years, based on the child’s gender.
The K-CBCL was used to obtain standardized maternal reports of the child’s behavior over the 6 months prior to the beginning of the study. The Child Behavior Checklist (CBCL), a tool for assessing the child’s behavioral problems, consists of 118 items rating behavior on a 3-point scale (not true, somewhat or sometimes true, or very true or often true). The CBCL factor structure consists of eight narrow-band problem scales and two broadband scales, internalizing problems and externalizing problems and also gives a total problem score. The basic tool was shown to be reliable and to possess the discriminative validity established by Achenbach (1991). The Korean version (K-CBCL) is also considered to be a reliable and valid tool (Oh et al. 1997). Finally, the questionnaire included sections concerning family structure, the child’s age and gender, parental education level and economic status. The educational backgrounds of the parents were divided into two categories: completion of 12 years of schooling and others. Economic status was divided into three categories on a 5-point scale based on family income. Statistical Methods and Analysis
Methods Sample and Setting This study was conducted between June and August 2006 on 3,911 subjects aged 7–12 years residing in the city of Osan, (population 120,000) Republic of Korea, located southeast of Seoul. The investigators of this study visited local schools, explained the study to teachers, and sent questionnaires to the students’ parents along with letters that included a description of the study’s objectives and benefits, confidentiality guarantee, a consent form and contact information. Mothers of the participants answered the questionnaires and returned them to the school in sealed envelopes. Assessments and Measurement The data for this study was collected through a questionnaire that included the Beck Depression Inventory (BDI), Korean Child Behavior Checklist (K-CBCL), and questions concerning the family’s socio-demographic backgrounds. The BDI was used to determine depression in the mothers. The BDI, a self-administered questionnaire designed to measure the severity of depressive symptoms, is comprised of 14 cognitive/affective items and 7 somatic/ performance items that assess symptoms within the previous week, including the day it is administered. A Cronbach’s a of 0.92 was reported for the Korean version of the BDI (Lee and Song 1991).
123
After the mothers were divided based on depressive state, their children were divided based on their gender. The sociodemographic and clinical characteristics were then compared. The questionnaire data was then analyzed using the Statistical Package for Social Science (SPSS). A two-by-two analysis of variance was performed using the mother’s depressed state (mother is depressed or control) as the first factor and gender as the second factor. Then, the effects of the mother’s depressed status, gender, and gender by depressed status (interaction) term variables were analyzed. A P value less than 0.05 was interpreted as significant.
Results Of the 4,012 children that were approached, 3,911 completed the study. There were no significant differences in gender or schools between the participants and non-participants. The group of children included 1,970 boys (50.4 %) and 1,941 girls(49.6 %). Characteristics of the study sample (n = 3,911) are shown in Table 1. To determine gender differences related to the impact of a mother’s depression, two-way analysis of variances with the depressed mother group by gender were computed, allowing for interactions (Table 2). Most of the CBCL scores were higher for children in the depressed mother group. The two-way analysis of variances (depressed group by gender) found girls to have significantly higher scores than boys on somatization.
Community Ment Health J
Discussion
Table 1 Demographic data Non-depressed mother N (%)
Depressed mother N (%)
Total (%)
Chisquare test
Boys
1,807 (50.1)
163 (53.6)
1,970 (50.4)
0.67
Girls Age
1,800 (49.9)
141 (46.4)
1,941 (49.6)
8–10
2,429 (67.3)
213 (70.1)
2,642 (67.6)
11–13
1,178 (32.7)
91 (29.1)
1,269 (32.4)
Gender
Family structure Living with both parents
3,601 (95.4)
218 (88.6)
171 (4.5)
28 (11.4)
others
Education of father [12 year 1,694 (44.9) B12 years
2,036 (54.1)
96 (39) 146 (59.3)
Education of mother [12 years
978 (25.9)
52 (21.1)
B12 years
2,715 (72.0)
191 (77.6)
Economic status Upper Middle Low
562 (14.9)
24 (9.8)
2,185 (57.9)
108 (43.9)
921 (24.4)
105 (42.7)
Total
3,911 (100)
0.58
This study is significant for several reasons. First, while most previous studies were conducted on clinical samples referred from mental health services, this study was conducted on a community sample. Second, this study targeted grade school children, which is relatively unique compared to previous studies which mostly focused on infancy to age 3 or adolescence. Third, this study examined the association between maternal depression and children’s psychological problems according to the child’s gender. The CBCL scores for daughters of depressed mothers were significantly higher for somatic complaints. The issue of differential effects of maternal depression on child gender is of special importance because during adolescence, the sex ratio of clinical depression for girls and boys evolves from 1:1 to approximately 2:1 (NolenHoeksema et al. 1999). Studies have reported similar results, finding greater association between maternal depressive problems and behavioral and emotional difficulties with daughters more so than sons (Boyle and Pickles 1997; Davies and Windle 1997; Krain and Kendall 2000). In a study conducted by Krain and Kendall (2000) maternal, but not paternal, depressive symptoms correlated with the parental report of child’s anxiety. When examined by gender, both parents’ depressive symptoms correlated with the parental report of their child’s anxiety in daughters
Table 2 Comparison of means and standard deviations for the CBCL based on their gender with depressed and nondepressed mother group CBCL
Non depressed mother
Depressed mother
Boys Mean (SD)
Boys Mean (SD)
Girls Mean (SD)
Girls Mean (SD)
Mother’s depression
Gender
Mother’s depression 9 Gender
Withdrawn
1.17 (± 1.64)
1.14 (±1.51)
2.53 (±2.45)
2.78 (±2.58)
NS
NS
NS
Somatization
0.96 (±1.53)
0.96 (±1.51)
1.95 (±2.21)
2.58 (±2.92)
NS
NS
0.001*
Depressive/anxious Immaturity
1.98 (±2.57) 1.68 (±1.82)
1.98 (±2.41) 1.58 (±1.73)
4.35 (±3.85) 3.14 (±2.25)
4.55 (±4.21) 3.02 (±2.21)
0.026* 0.006**
NS NS
NS NS
Thought problem
0.36 (±0.80)
0.27 (±0.67)
0.74 (±1.31)
0.70 (±1.28)
0.034*
NS
NS
Attention problem
2.55 (±2.45)
2.00 (±2.20)
4.65 (±3.35)
4.14 (±3.17)
0.007**
0.026*
NS
Conduct problem
0.89 (±1.97)
0.62 (±1.04)
1.55 (±1.67)
1.26 (±1.40)
0.009**
0.022*
NS
Aggressive behavior
4.84 (±4.30)
4.37 (±3.76)
8.19 (±5.47)
8.20 (±5.49)
0.043*
NS
NS
Emotional problem
2.38 (±2.37)
2.59 (±2.37)
4.34 (±3.06)
4.82 (±3.20)
0.040*
NS
NS
Internalization
45.03 (±8.97)
44.7 (±8.60)
53.13 (±9.82)
53.10 (±9.65)
0.012*
NS
NS
Externalization
46.41 (±8.74)
46.10 (±8.81)
52.45 (±9.28)
53.95 (±8.71)
NS
NS
NS
Total problem
44.76 (±9.01)
44.32 (±9.11)
52.69 (±9.63)
53.86 (±9.48)
NS
NS
NS
Social skills
7.47 (±1.19)
7.57 (±1.16)
6.78 (±1.41)
6.93 (±1.39)
0.027*
NS
NS
Academic achievements
2.14 (±0.47)
2.18 (±0.46)
1.95 (±0.48)
2.1 (±0.48)
0.047*
NS
NS
Social competence
9.61 (±1.37)
9.75 (±1.36)
8.73 (±1.59)
9.04 (±1.62)
NS
NS
NS
*p \ 0.05; **p \ 0.01
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rather than sons. A review by Sheeber et al. (2001) proposed several explanations for gender-specific vulnerability to the effects of maternal depression. These include the maternal modeling of depressive interpersonal behaviors and lack of effective coping strategies for girls and more conflictual mother–daughter relationships (Hops et al. 1987). Girls that are at a higher risk of depression are also often those that have been subjected to taking responsibility for the family and the depressed mother (Davies and Lindsay 2004; Klimes-Dougan and Bolger 1998). Finally, girls tend to be more sensitive to the conflicts between parents. Therefore the development of internalizing symptoms likely increases in girls (Langrock et al. 2002). The prevalence of somatic complaints in children is high, especially in grade school children and adolescence. (Roth-Isigkeit et al. 2004) Recurrent complaints of somatic symptoms are common among children and adolescents, more so in girls than boys. In a general population survey, Offord et al. (1987) found recurrent distressing somatic symptoms in 11 % of girls and 4 % of boys aged 12–16 years. The literature supports that negative moods are related to more somatic complaints. In epidemiological studies, depressive and anxiety disorders have been associated with recurrent headaches and stomach aches more in girls than boys (Egger et al. 1999). Children may complain of somatic symptoms when they suffer from emotional disorders (Reinherz et al. 1993). Since eliciting depressive symptoms from children is somewhat difficult, as some may not be sufficiently cognitively developed or capable enough of expressing emotional experiences, assessing somatic symptoms may be a useful screen for depression in children (McCauley et al. 1991). Parents are better able to recognize externalized behaviours in their children than internalized symptoms, and are not the most accurate reporters of internalizing problems in their children (Poli et al. 2003). Children are better at recognizing and reporting their internalized symptoms than their parents. It has become increasingly evident that children 8 years and older are reliable reporters of their internal mood states (Frigerio et al. 2001). This could explain our finding that higher scores were noted only on somatization in girls in the depressed mother group compared to the control group. Negative findings in other items from the K-CBCL might be due to the lack of children’s self-reports in this study rather than internalized symptoms not existing. This study has several limitations. First, it is impossible to determine from the data alone the causality between a child’s illness and the mother’s psychiatric disorder or vice versa. Second, fathers did not complete the K-CBCL, thus the assessment of the mental-health problems of the child relied solely upon the maternal report which may have been biased by the mood state of the mother. Some studies
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have reported that parents that are more distressed or depressed have a lower tolerance for frustration and regard their children as having more externalizing problems (Richters 1992). Also, researchers with well-designed studies have found supporting evidence for an association between higher maternal depression and mothers’ tendency to over-report children’s behavior problems, relative to a latent criterion variable (Boyle and Pickles 1997; Fergusson et al. 1995). By obtaining and then comparing both parents’ responses, the contribution of the mother’s depression to the perception of somatic complaints in daughters might be better elucidated. Other vulnerabilities of their children more recognizable to fathers might also have been identified although such a result might also in turn reflect father’s perceptions and sensitivities be they accurate or not. Third, the survey has several methodological limitations. Assessment of maternal depression relied on self-reporting. At present, no independent measures are available for the range, severity or persistence of depression. The result of our study supports targeting somatic symptoms for screening depression in children of depressive mothers, especially in girls. In future studies, inclusion of children’s self-reports and father’s self-reports would be helpful in evaluating internalized symptoms of the children more accurately. Also, future studies might also include multiple informants’ assessments i.e. father and teachers to address potential rater bias. In addition, future studies need to be replicated with a more comprehensive instrument to support our findings.
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