Journal of Child & Adolescent Mental Health
ISSN: 1728-0583 (Print) 1728-0591 (Online) Journal homepage: http://www.tandfonline.com/loi/rcmh20
Maternal depression and anxiety among children with mental health problems Anthony L Pillay To cite this article: Anthony L Pillay (2008) Maternal depression and anxiety among children with mental health problems, Journal of Child & Adolescent Mental Health, 20:1, 13-20 To link to this article: http://dx.doi.org/10.2989/JCAMH.2008.20.1.4.489
Published online: 12 Nov 2009.
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Date: 04 June 2016, At: 07:35
Journal of Child and Adolescent Mental Health 2008, 20(1): 13–20 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH EISSN 1728–0591 DOI: 10.2989/JCAMH.2008.20.1.4.489
Maternal depression and anxiety among children with mental health problems Anthony L Pillay
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Department of Behavioural Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Midlands Hospital, PO Box 370, Pietermaritzburg 3200, South Africa e-mail: [email protected] Objective: The investigation sought to examine depression and anxiety levels in mothers of children with mental health problems. Method: A case control design was employed and self-reports of depressive and anxiety symptoms were measured in a group of women whose children were receiving mental health care, as well as a community control group and a group of women receiving outpatient psychiatric care. Results: No significant differences were noted in depressive and anxiety symptoms between the mothers of children with mental health problems and the community controls, although both of these groups showed significantly lower levels of depression and anxiety than the psychiatric patient group. These findings were not influenced by demographic variables Conclusions: The findings are contrary to those of high income countries where mothers of children with mental health problems show higher levels of depression and anxiety. This disparity may be due to the sampling and mental health service usage patterns in low-income countries where mothers who seek mental health care for their children probably constitute a specific group of people who have awareness of mental health problems and available services. As a result their own mental health is likely to be better.
Introduction The coexistence of, or interplay between, maternal and children’s mental health problems is a significant concern. This is related to many factors, inter alia, the fact that in most cases mothers are the primary caregivers, and closer to the child than anyone else in the early years. The child’s growth and development from birth and during the infancy years is highly influenced by the maternal mental health symptoms (Stewart 2007). Children of depressed parents have long been identified as having a higher risk than average for the development of psychological difficulties (Beardslee, Gladstone, Wright and Cooper 2003). While some of these symptoms may be reactive to the child’s emotional or behavioural problems, in other cases they may be more etiologically linked to the child’s presentation. Still another possibility is that both mother and child may manifest psychological responses to wider family disturbances, including patriarchal behaviour and psychopathology. However, recent research is also emphasising the significance of genetic factors. For example, maternal depression has been implicated in increasing the risk for the development of childhood antisocial behaviour (Kim-Cohen, Moffitt, Taylor, Pawlby and Caspi 2006). The value of research in this area lies in its impact on treatment and prevention. Recent research has shown that the treatment and remission of maternal depressive symptoms is associated with positive changes in children’s mental health status (Weissman et al. 2006). However, an examination of the research in the area shows that not as much work has been done on mothers of children with mental health problems. Conversely, relatively more work has been undertaken on mentally ill women, their parenting styles, and effects on their children. While a number of psychological
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symptoms and mental disorders have relevance, more of the focus appears to have been on anxiety and depressive conditions. This is obviously due to the fact that these disorders are considerably more common among women. The World Health Report 2001 noted that anxiety and depressive disorders are more commonly diagnosed in women than men, with the trend being evident in both high- and low-income countries (World Health Organization 2001). According to the American Psychiatric Association (2000) women have a lifetime risk of up to 25% for the development of a Major Depressive Disorder. Among the research findings has been one showing that mothers with affective symptoms were more negative and critical in their parenting styles than control mothers (Hamilton, Jones and Hammen 1993). The effects are that children reared under such circumstances are more vulnerable to the development of psychological problems, than children without such critical parents. Further research has demonstrated that the level of depressive symptoms in mothers correlates significantly with their children’s frustration levels in problem-solving tasks (Nolen-Hoeksema, Wolfson, Mumme and Guskin 1995). This, of course, is likely to have behavioural and scholastic sequelae in the children. Other researchers examining depressed women found them more likely to report anxiety or depressive symptomatology in their children (Goodman, Adamson, Riniti and Cole 1994). It has also been demonstrated that the severity and chronicity of maternal depression correlate significantly with the presence of externalising and internalising symptoms in young adolescents (Frye and Garber 2005). Evidently the interactional style of depressive mothers is a further factor that may aggravate the mental health vulnerabilities of children reared in homes with parental psychopathology. Lundy, Field, McBride, Abrams and Carraway (1997) reported that school-aged children with externalising disorders were found to exhibit deficient levels of affect and interaction with their mothers when the mothers had depressive symptoms. Research on children with Attention Deficit Hyperactivity Disorder (ADHD), for example, noted higher rates of depressive symptoms in mothers (Whalen and Henker 1999). Subsequent research has shown that maternal depressive symptoms are linked to the development of conduct disorder in children with ADHD (Johnston, Murray, Hinshaw, Pelham and Hoza 2002). The authors argued that depressive mothers’ symptoms and affective dysfunction interfered with their ability to respond appropriately to their child’s behaviour, which has the effect of exacerbating problematic behaviour. Of relevance to clinical service settings has been the finding that mothers with depressive pathology report more severe ADHD symptoms, compared to school teacher reports on their children’s presentations (Chi and Hinshaw 2002). In addition to mood disorders, anxiety spectrum conditions in women have also been empirically linked to their children’s mental health problems. Maternal anxiety disorders have been found to significantly predict the presence of anxiety disorders in children, with the risk doubling in the case of a lifetime history of maternal anxiety disorder, and tripling if the maternal anxiety is co-morbid with depression (McClure, Brennan, Hammen and Le Brocque 2001). Interestingly these authors found no significant association between paternal anxiety disorder and child anxiety. More recent research has linked high levels of maternal anxiety, more so in the antenatal stages, to the development of anxiety, externalising symptoms and ADHD symptoms in children (Van den Bergh and Marcoen 2004). Corroborative evidence has come from a more recent investigation, which found that mothers of children with anxiety disorders reported significantly more symptoms of anxiety and depression in themselves, than mothers of non-clinical child samples (Suveg, Zeman, Flannery-Schroeder and Cassano 2005). These researchers have also noted that such children may perceive their mothers as less of an emotional support, and even anticipate negative responses to discussions of their emotional experiences. Clearly there is evidence that anxiety and depressive symptoms in mothers is associated with mental health problems in children. However, the studies showing these trends are all based on samples in Western, high income countries, and it is important that local studies test these relationships, rather than accept them as universal. To this end the present study was formulated. The major hypothesis was that mothers of children with mental health problems would show higher
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levels of depression and anxiety than community control mothers. Considering depressive and anxiety conditions are frequently co-morbid (American Psychiatric Association 2000), it was further hypothesised that a positive correlation would be found between scores on these variables. The models available to understand the association between maternal mental health problems and children’s mental disturbances implicate different lines of transmission. In some cases the mental health problems of the mother may result in disturbances in her children, due to genetic influences or impaired parenting (Kim-Cohen, Moffitt, Taylor, Pawlby and Caspi 2006). Maternal mental illness constitutes a significant risk factor for childhood problems, not least of all through the quality of the mother-child interactions (Tomlinson, Swartz, Cooper and Molteno 2004). On the other hand, it is likely that children’s mental health problems can invoke mental health symptoms in mothers as a result of the stresses endured by the mother having to cope with a seriously disturbed child. The disproportionate responsibilities of child care and family well-being poses significant stresses on women, especially those in traditional and lower socioeconomic communities (Kisekka 1990). It must be remembered that the traditional roles of women in society exposes them to greater stresses, and at the same time makes them less able to change their stressful environments (World Health Organisation 2001). A third scenario is that mothers and their children develop mental health problems as a response to an abusive patriarch. Of course, the distress experienced by women in such contexts must serve to highlight the problem of woman abuse, and not be obscured by the use of a psychiatric label (Wilson and Strebel 2004). Research has shown that in most cases children witness intimate partner violence against their mothers, and as a result they are at higher risk for mental health problems (O’Conner 1995; Ellsberg, Pena, Herrera, Liljestrand and Winkvist 2000). Of course, the present study was not designed to determine causation or the route of transmission between the mental health problems in mothers (if depressive or anxiety symptoms are present) and the disturbances in the children. Instead the study has been designed to detect only correlational presence; that is, the co-existence of mental health problems in children and their mothers. Method Subjects A multiple control group design was employed, which included a group of women whose children attended a mental health care facility, a group of women currently being treated for psychiatric problems and a community control group. The first group (n = 50) was sampled through the Child Outpatient Department at a psychiatric hospital in Pietermaritzburg. The mothers of child attenders under 14 years of age were approached for participation at the child’s first appointment. All but three of the mothers who were approached agreed to participate. No other exclusion criteria were applied. Being a state facility serving poor socioeconomic communities from the surrounding area, the women in this group were all of low socioeconomic status. The second group (n = 30) was drawn from women who were currently attending a mental health clinic in the area for their own treatment. Women who were overtly psychotic were excluded due to the obvious difficulty they would experience in responding to the instruments. The third group (n = 30) comprised nonclinical subjects and sampled women involved in community groupings such as women’s groups, volunteer societies, the unemployed and other representative groups. Both control groups were sampled from the same low socioeconomic area as the mothers of disturbed children. In constituting both these groups, simple random sampling was used after first pooling women who were mothers and within two years of the ages of subjects in the first group (i.e. mothers of children with mental health problems). This strategy was used to avoid large age differences between the groups, which could introduce confounding and, thereby, contamination of the results. The author’s concern in this regard was the widely recognised prominence of depressive and anxiety disorders in women in the general population (World Health Organisation 2001). The use of controls that differed substantially from the cases could bring into play many other confounding factors, thereby putting the results into question. It is known that age influences the prevalence of depressive and anxiety disorders in women (American Psychiatric Association
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2000). The sampling involved a simple procedure of approaching every second woman identified as a potential subject. The rationale for this method was to allow every woman the biggest possible chance of being recruited as a subject. In the psychiatric patient group five of the patients approached for participation declined, while in the community control group there were no refusals. Instruments A brief biographical questionnaire was used to gain basic demographic information. Two questionnaires were also used to obtain self-reports of depression and anxiety. The Beck Anxiety Inventory (BAI) (Beck and Steer 1993) is a 21-item self-report inventory designed to measure the presence of anxiety symptoms in adults. Although developed with adult psychiatric patients, the BAI has been used successfully with nonclinical samples as well (Dent and Salkovskis 1986). According to the developers the BAI was constructed to measure symptoms of anxiety that are minimally shared with those of depression. The BAI provides a total score between zero and 63, and has cutting points indicating different severities of anxiety. The Beck Depression Inventory (BDI) (Beck and Steer 1988) was used to measure depressive symptoms. It is a 21-item self-report instrument that has been widely used for many years. The BDI has a similar scoring system to the BAI. The BAI and the BDI assess symptom manifestation specifically over the week before the testing. Both these instruments have been used effectively in the South African context (Pillay and Schoubben-Hesk 2001). However, like all foreign-developed psychometric techniques, they should be used with caution, and the inclusion of control groups in the design serves to improve the rigour of the study. In addition to the basic demographic information elicited, the psychologists attending to the children with mental health problems were requested to give their assessment of whether the child’s problem appeared ‘’reactive’‘ to some obvious stressor (e.g. sexual abuse, death of a significant other) or not. While this is a rather crude measure, it was included as a way of controlling for the psychological effects of trauma on the maternal presentation. For example, it would not be unexpected to find higher rates of depression or anxiety in a mother who has lost a significant other, or whose child has been abused. It was felt that this would be a more useful (broader) variable, for comparative purposes, than the narrow focus on children’s diagnoses. Also, with the relatively small sample and the established diagnostic profile of children presenting at this specific facility, it was clear that the wide range of diagnoses would contribute little (if anything) to statistical analyses. The simple two-fold distribution was deemed capable of permitting some meaningful statistical computations. Procedure The mothers of mentally disturbed children were asked if they would be interested in providing information regarding their own psychological state over the past week through a questionnaire format, in the hope that this information would help provide a better understanding of the mental health of mothers (who are usually the primary caregivers) of children with mental health problems. They were informed that participation was voluntary, and should they choose not to be involved their children’s treatment would not be affected in any way. Almost all the mothers agreed to participate and were given the instruments for self-report. The subjects in the psychiatric patient group and the community control group were advised of the purpose of the project and issues relating to informed consent were handled in a similar way to the first group. The subjects in the psychiatric patient group were assured that their participation or non-participation would not influence their treatment in any way. Most subjects understood and spoke English at a reasonable level, but in a few cases (two mothers of disturbed children, four psychiatric patients and two community controls) the instruments were read out and translated to them in IsiZulu . The data was analysed using the Statistical Package for the Social Sciences. The major analytical procedures involved tests of difference among the three groups with respect to the measures of depression and anxiety. Analyses of Variance were performed on the three groups, and post-hoc
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Tukey tests were employed to identify between group differences. Pearson Product Moment Correlation Coefficients were also computed to examine the strength of associations between the two dependant variables (i.e. depression and anxiety). The study was conducted with the support of the University of KwaZulu-Natal.
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Results The mean ages of the subjects in the three groups were as follows: mothers of disturbed children (mean = 36.28 years, SD = 5.75); psychiatric patients (mean = 38.57 years, SD = 5.5), and community controls (mean = 36.67 years, SD = 6.71). Within the group of mothers with disturbed children, 29 (58%) had children whose referral problems appeared ‘‘reactive’ to an obvious stressor. The mean BAI and BDI scores for the three groups are presented in Table 1. The Analysis of Variance (ANOVA) conducted on the BAI scores showed that the three groups differed significantly (F = 7.75, p < 0.001). The post-hoc Tukey test revealed that the mothers of disturbed children scored significantly lower than the psychiatric patients (p < 0.01), but not significantly different to the community controls (p = 0.39). The psychiatric patients scored significantly higher than the community controls (p < 0.001). The ANOVA performed on the BDI scores showed significant between group differences (F = 28.78, p < 0.0005). The post-hoc Tukey test showed that the mothers of disturbed children scored significantly lower than psychiatric patients (p < 0.0005), but not significantly different from the community controls (p = 0.29). The psychiatric patient group scored significantly higher than the community controls (p < 0.0005). Pearson correlation coefficients computed within the group of disturbed mothers revealed that the BAI and BDI scores were highly correlated (r = 0.82). The BDI was also correlated significantly with education (r = –0.31), indicating lower levels of depression in individuals with higher levels of education. Education and BAI scores were not significantly correlated (r = -0.16). Age was also not significantly correlated with the BAI (r = 0.08) and BDI scores (r = 0.19). The type of problem in the child (i.e. reactive vs not reactive) was not significantly different between those mothers who had less than three children and those who had three or more children (Chi square = 0.19, p = 0.67). The type of problem in the child was also not significantly different between those mothers who were married (or cohabiting) and those who were single parents (Chi square = 0.38, p = 0.54). The mean maternal anxiety (t = 1.21, p = 0.23) and depression (t = 0.60, p = 0.56) levels were also not significantly different between the ‘reactive’ and ‘not reactive’ groups. No significant correlation was found between the age of the child receiving mental health care and either maternal anxiety (r = 0.16) or maternal depression (r = 0.24). Discussion The finding that over half the mothers of disturbed children had children whose referral problems appeared reactive to an obvious stressor is not unexpected, considering the frequency of stressors (e.g. traumatic, violent and criminal) affecting children in South Africa. Recent research on attenders at a child mental health facility noted that 72% of the children were from fractured families, while over 40% of the girls had recent histories of sexual abuse (Pillay and Mkhonza 2004). Table 1: BAI and BDI Scores
Group Mothers of disturbed children Psychiatric patients Community controls Total
n 50 30 30 110
BAI scores Mean 15.02 18.43 13.50 15.54
SD 3.68 6.21 5.59 5.31
BDI scores Mean SD 14.92 7.74 26.93 10.85 12.07 5.50 17.42 10.10
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The significantly higher levels of anxiety and depressive symptoms in the psychiatric patient group compared to the community controls is expected. Although the mothers of disturbed children had slightly higher mean scores than the community controls for anxiety and depressive symptoms, they were not significantly different. This finding is interesting, considering the overseas research evidence suggesting higher levels of mental health symptoms in mothers of children with mental health problems (Frye and Garber 2005; Suveg et al. 2005). The present result may be influenced by the sampling and other pertinent issues that characterise mental health service usage in low-income countries. In a country such as South Africa where (1) mental health services are few, and (2) the awareness of mental health problems and appropriate resources is generally low, it is fairly obvious that not all mothers of disturbed children are going to seek such care. Only a select group of mothers will access this type of care for their children. This variable (i.e. the decision to seek help) may therefore reflect more positively on the mental health status of these mothers. In other words, the question of whether the presence of poor mental health status in mothers interferes with their ability and motivation to seek help for their disturbed children must be raised. Unlike high-income countries, where most cited research is conducted, poorer countries are still characterised by the many barriers that limit the provision of effective mental health services (World Health Organisation 2001). Women with less awareness of these problems and services are obviously less likely to take their children to mental health facilities, and those with mental health problems themselves may lack the insight and motivation to seek help for their children (and themselves). It is also very likely that women with greater social awareness also have greater personal resources to help them cope with their own mental health issues. Of course, it can be argued that the mean scores of 13.5 on the BAI and 12.07 on the BDI achieved by the community control group are indicative of ‘mild anxiety’ and ‘mild depression’, according to the test developers (Beck and Steer 1993; Beck and Steer 1988), and that this clinical description applies to the mothers of disturbed children as well. However, this is one of the difficulties inherent in using instruments developed and standardised in Western (high income) countries, where the norms and standardisation procedures have been conducted with different national groups, thus rendering the prescribed cutting points less accurate on local samples. The use of control groups are, therefore, designed to provide a local normative score for the specific investigation. The high correlation between anxiety and depressive symptoms in the mothers of disturbed children is consistent with the findings of Dent and Salkovskis (1986) and the general clinical trend of depressive symptoms frequently reported in patients with anxiety symptoms (Beck and Steer 1993). The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) also points out that individuals with anxiety conditions commonly manifest depressive symptoms. The negative correlation between education and BDI scores suggests that more educated mothers of disturbed children had fewer depressive symptoms than less educated ones. This finding is consistent with those of Patel (2001); showing that the lack of schooling, especially at the secondary level, is a considerable risk factor for the development of mental health problems. Of course the relevance of the type of education offered in schools is also seen as a critical issue (World Health Organisation 2001). The lack of significant differences found between mothers of disturbed children whose problems were considered ‘reactive’ or ‘not reactive’ may reflect on the crude distinction that was used, and on the likelihood that both sets of mothers manifested similar levels of distress regardless of the nature or perceived etiology of their children’s problems. The type of childhood problem (i.e. ‘reactive’ or ‘not reactive’) was also not influenced by the number of children in the family or the marital status of the mother. These findings are meaningful in that they lend support to the idea that stressful and traumatic life events can occur in any type of family. Conclusion The finding that the mothers of the disturbed children presenting for mental health care showed no significant difference in depression and anxiety levels compared to community controls is probably
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better understood in the context of their decisions to seek mental health care for their children. Local research examining these variables in non-clinical (i.e. the general population) contexts would provide an interesting comparison. Also, it is equally important to investigate mental health presentations in the fathers of children with mental health problems. Of course, in clinical practice, clinicians have contact mainly with the mothers of children with mental health problems. This is another issue that warrants exploration, considering there are often no substantive reasons why fathers cannot be involved in their children’s healthcare. Acknowledgements — The support of the University of KwaZulu-Natal is gratefully acknowledged, and the assistance of Ms Carol-Ann Sargent is appreciated.
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References American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders (4th edn, text revision). Washington, DC: American Psychiatric Association Beardslee WR, Gladstone TRG, Wright EJ and Cooper AB (2003) A family-based approach to the prevention of depressive symptoms in children at risk: Evidence of parental and child change. Pediatrics 112: 119–131 Beck AT and Steer RA (1988) Manual for the Revised Beck Depression Inventory. San Antonio: Psychological Corporation Beck AT and Steer RA (1993) Beck Anxiety Inventory: Manual. San Antonio: Psychological Corporation Chi TC and Hinshaw SP (2002) Mother-child relationships of children with ADHD. Journal of Abnormal Child Psychology 30: 387–400 Dent HR and Salkovskis PM (1986) Clinical measures of depression, anxiety and obsessionality in nonclinical populations. Behavioural Research and Therapy 24: 689–691 Ellsberg M, Pena R, Herrera A, Liljestrand J and Winkvist A (2000) Candies in hell: Women’s experiences of violence in Nicaragua. Social Science & Medicine 51: 1595–1610 Frye AA and Garber J (2005) The relationship among maternal depression, maternal criticism, and adolescents’ externalizing and internalizing symptoms. Journal of Abnormal Child Psychology 33: 1–11 Goodman S, Adamson L, Riniti J and Cole S (1994) Mothers’ expressed attitudes: Associations with maternal depression and children’s self-esteem and psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry 33: 1265–1274 Johnston C, Murray C, Hinshaw SP, Pelham WE and Hoza B (2002) Responsiveness in interactions of mothers and sons with ADHD. Journal of Abnormal Child Psychology 30: 77–88 Hamilton EB, Jones M and Hammen C (1993) Maternal interaction style in affective disordered, physically ill, and normal women. Family Process 32: 329–340 Kim-Cohen J, Moffitt TE, Taylor A, Pawlby SJ and Caspi A (2006) Maternal depression and children’s antisocial behaviour. Archives of General Psychiatry 62: 173–181 Kisekka MN (1990) Gender and mental health in Africa. In: Rothblum ED and Cole E (eds), Women’s Mental Health in Africa. London: Harrington Park. pp 1–14 Lundy B, Field T, McBride C, Abrams S and Carraway K (1997) Child psychiatric patients’ interactions with their mothers. Child Psychiatry and Human Development 27: 231–240 McClure EB, Brennan PA, Hammen C and Le Brocque RM (2001) Parental anxiety disorders and the perceived parent-child relationship in an Australian high-risk sample. Journal of Abnormal Child Psychology 29: 1–10 Nolen-Hoeksema S, Wolfson A, Mumme D and Guskin K (1995) Helplessness in children of depressed mothers. Developmental Psychology 31: 377–387 O’Conner M (1995) Making the links: Towards an integrated strategy for the elimination of violence against women in intimate relationships with men. Dublin: Women’s Aid Patel V (2001) Poverty, inequality, and mental health in developing countries. In: Leon D and Walt G (eds), Poverty, Inequality, and Health: An International Perspective. Oxford: Oxford University Press. pp 247–261 Pillay AL and Mkhonza ZK (2004) A broader perspective on childhood maltreatment and mental health care. Journal of Child and Adolescent Mental Health 16: 87–92 Pillay AL and Schoubben-Hesk S (2001) Depression, anxiety and hopelessness in sexually abused adolescent girls. Psychological Reports 88: 727–733 Stewart RC (2007) Maternal depression and infant growth: A review of recent evidence. Maternal and Child Nutrition 3: 94–107 Suveg C, Zeman J, Flannery-Schroeder E and Cassano M (2005) Emotion socialization in families of children with an anxiety disorder. Journal of Abnormal Child Psychology 33: 145–155
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Tomlinson M, Swartz, L, Cooper, PJ and Molteno C (2004) Social factors and postpartum depression in Khayelitsha, Cape Town. South African Journal of Psychology 34: 409–420 Van den Bergh BRH and Marcoen A (2004) High antenatal maternal anxiety is related to ADHD symptoms, externalizing problems, and anxiety in 8-and 9-year-olds. Child Development 75: 1085–1097 Weissman MM, Pilowsky DJ, Wickramaratne PJ, Talati A, Wisniewski SR, Fava M, Hughes CW, Garber J, Malloy E, King CA, Cerda G, Sood AB, Alpert JE, Trivedi MH and Rush AJ (2006) Remissions in Maternal Depression and Child Psychopathology. Journal of the American Medical Association 295: 1389–1398 Whalen CK and Henker B (1999) The child with attention deficit hyperactivity disorder in family contexts. In: Quay HC and Hogan AE (eds), Handbook of Disruptive Behaviour Disorders. New York: Plenum. pp 139–155 Wilson T and Strebel A (2004) Psychiatric discourses of woman abuse. South African Journal of Psychology 34: 421–442 World Health Organization (2001) The World Health Report 2001. Geneva: World Health Organization
ISSN: 1728-0583 (Print) 1728-0591 (Online) Journal homepage: http://www.tandfonline.com/loi/rcmh20
Maternal depression and anxiety among children with mental health problems Anthony L Pillay To cite this article: Anthony L Pillay (2008) Maternal depression and anxiety among children with mental health problems, Journal of Child & Adolescent Mental Health, 20:1, 13-20 To link to this article: http://dx.doi.org/10.2989/JCAMH.2008.20.1.4.489
Published online: 12 Nov 2009.
Submit your article to this journal
Article views: 124
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rcmh20 Download by: [Northwestern University]
Date: 04 June 2016, At: 07:35
Journal of Child and Adolescent Mental Health 2008, 20(1): 13–20 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH EISSN 1728–0591 DOI: 10.2989/JCAMH.2008.20.1.4.489
Maternal depression and anxiety among children with mental health problems Anthony L Pillay
Downloaded by [Northwestern University] at 07:35 04 June 2016
Department of Behavioural Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal and Midlands Hospital, PO Box 370, Pietermaritzburg 3200, South Africa e-mail: [email protected] Objective: The investigation sought to examine depression and anxiety levels in mothers of children with mental health problems. Method: A case control design was employed and self-reports of depressive and anxiety symptoms were measured in a group of women whose children were receiving mental health care, as well as a community control group and a group of women receiving outpatient psychiatric care. Results: No significant differences were noted in depressive and anxiety symptoms between the mothers of children with mental health problems and the community controls, although both of these groups showed significantly lower levels of depression and anxiety than the psychiatric patient group. These findings were not influenced by demographic variables Conclusions: The findings are contrary to those of high income countries where mothers of children with mental health problems show higher levels of depression and anxiety. This disparity may be due to the sampling and mental health service usage patterns in low-income countries where mothers who seek mental health care for their children probably constitute a specific group of people who have awareness of mental health problems and available services. As a result their own mental health is likely to be better.
Introduction The coexistence of, or interplay between, maternal and children’s mental health problems is a significant concern. This is related to many factors, inter alia, the fact that in most cases mothers are the primary caregivers, and closer to the child than anyone else in the early years. The child’s growth and development from birth and during the infancy years is highly influenced by the maternal mental health symptoms (Stewart 2007). Children of depressed parents have long been identified as having a higher risk than average for the development of psychological difficulties (Beardslee, Gladstone, Wright and Cooper 2003). While some of these symptoms may be reactive to the child’s emotional or behavioural problems, in other cases they may be more etiologically linked to the child’s presentation. Still another possibility is that both mother and child may manifest psychological responses to wider family disturbances, including patriarchal behaviour and psychopathology. However, recent research is also emphasising the significance of genetic factors. For example, maternal depression has been implicated in increasing the risk for the development of childhood antisocial behaviour (Kim-Cohen, Moffitt, Taylor, Pawlby and Caspi 2006). The value of research in this area lies in its impact on treatment and prevention. Recent research has shown that the treatment and remission of maternal depressive symptoms is associated with positive changes in children’s mental health status (Weissman et al. 2006). However, an examination of the research in the area shows that not as much work has been done on mothers of children with mental health problems. Conversely, relatively more work has been undertaken on mentally ill women, their parenting styles, and effects on their children. While a number of psychological
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symptoms and mental disorders have relevance, more of the focus appears to have been on anxiety and depressive conditions. This is obviously due to the fact that these disorders are considerably more common among women. The World Health Report 2001 noted that anxiety and depressive disorders are more commonly diagnosed in women than men, with the trend being evident in both high- and low-income countries (World Health Organization 2001). According to the American Psychiatric Association (2000) women have a lifetime risk of up to 25% for the development of a Major Depressive Disorder. Among the research findings has been one showing that mothers with affective symptoms were more negative and critical in their parenting styles than control mothers (Hamilton, Jones and Hammen 1993). The effects are that children reared under such circumstances are more vulnerable to the development of psychological problems, than children without such critical parents. Further research has demonstrated that the level of depressive symptoms in mothers correlates significantly with their children’s frustration levels in problem-solving tasks (Nolen-Hoeksema, Wolfson, Mumme and Guskin 1995). This, of course, is likely to have behavioural and scholastic sequelae in the children. Other researchers examining depressed women found them more likely to report anxiety or depressive symptomatology in their children (Goodman, Adamson, Riniti and Cole 1994). It has also been demonstrated that the severity and chronicity of maternal depression correlate significantly with the presence of externalising and internalising symptoms in young adolescents (Frye and Garber 2005). Evidently the interactional style of depressive mothers is a further factor that may aggravate the mental health vulnerabilities of children reared in homes with parental psychopathology. Lundy, Field, McBride, Abrams and Carraway (1997) reported that school-aged children with externalising disorders were found to exhibit deficient levels of affect and interaction with their mothers when the mothers had depressive symptoms. Research on children with Attention Deficit Hyperactivity Disorder (ADHD), for example, noted higher rates of depressive symptoms in mothers (Whalen and Henker 1999). Subsequent research has shown that maternal depressive symptoms are linked to the development of conduct disorder in children with ADHD (Johnston, Murray, Hinshaw, Pelham and Hoza 2002). The authors argued that depressive mothers’ symptoms and affective dysfunction interfered with their ability to respond appropriately to their child’s behaviour, which has the effect of exacerbating problematic behaviour. Of relevance to clinical service settings has been the finding that mothers with depressive pathology report more severe ADHD symptoms, compared to school teacher reports on their children’s presentations (Chi and Hinshaw 2002). In addition to mood disorders, anxiety spectrum conditions in women have also been empirically linked to their children’s mental health problems. Maternal anxiety disorders have been found to significantly predict the presence of anxiety disorders in children, with the risk doubling in the case of a lifetime history of maternal anxiety disorder, and tripling if the maternal anxiety is co-morbid with depression (McClure, Brennan, Hammen and Le Brocque 2001). Interestingly these authors found no significant association between paternal anxiety disorder and child anxiety. More recent research has linked high levels of maternal anxiety, more so in the antenatal stages, to the development of anxiety, externalising symptoms and ADHD symptoms in children (Van den Bergh and Marcoen 2004). Corroborative evidence has come from a more recent investigation, which found that mothers of children with anxiety disorders reported significantly more symptoms of anxiety and depression in themselves, than mothers of non-clinical child samples (Suveg, Zeman, Flannery-Schroeder and Cassano 2005). These researchers have also noted that such children may perceive their mothers as less of an emotional support, and even anticipate negative responses to discussions of their emotional experiences. Clearly there is evidence that anxiety and depressive symptoms in mothers is associated with mental health problems in children. However, the studies showing these trends are all based on samples in Western, high income countries, and it is important that local studies test these relationships, rather than accept them as universal. To this end the present study was formulated. The major hypothesis was that mothers of children with mental health problems would show higher
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levels of depression and anxiety than community control mothers. Considering depressive and anxiety conditions are frequently co-morbid (American Psychiatric Association 2000), it was further hypothesised that a positive correlation would be found between scores on these variables. The models available to understand the association between maternal mental health problems and children’s mental disturbances implicate different lines of transmission. In some cases the mental health problems of the mother may result in disturbances in her children, due to genetic influences or impaired parenting (Kim-Cohen, Moffitt, Taylor, Pawlby and Caspi 2006). Maternal mental illness constitutes a significant risk factor for childhood problems, not least of all through the quality of the mother-child interactions (Tomlinson, Swartz, Cooper and Molteno 2004). On the other hand, it is likely that children’s mental health problems can invoke mental health symptoms in mothers as a result of the stresses endured by the mother having to cope with a seriously disturbed child. The disproportionate responsibilities of child care and family well-being poses significant stresses on women, especially those in traditional and lower socioeconomic communities (Kisekka 1990). It must be remembered that the traditional roles of women in society exposes them to greater stresses, and at the same time makes them less able to change their stressful environments (World Health Organisation 2001). A third scenario is that mothers and their children develop mental health problems as a response to an abusive patriarch. Of course, the distress experienced by women in such contexts must serve to highlight the problem of woman abuse, and not be obscured by the use of a psychiatric label (Wilson and Strebel 2004). Research has shown that in most cases children witness intimate partner violence against their mothers, and as a result they are at higher risk for mental health problems (O’Conner 1995; Ellsberg, Pena, Herrera, Liljestrand and Winkvist 2000). Of course, the present study was not designed to determine causation or the route of transmission between the mental health problems in mothers (if depressive or anxiety symptoms are present) and the disturbances in the children. Instead the study has been designed to detect only correlational presence; that is, the co-existence of mental health problems in children and their mothers. Method Subjects A multiple control group design was employed, which included a group of women whose children attended a mental health care facility, a group of women currently being treated for psychiatric problems and a community control group. The first group (n = 50) was sampled through the Child Outpatient Department at a psychiatric hospital in Pietermaritzburg. The mothers of child attenders under 14 years of age were approached for participation at the child’s first appointment. All but three of the mothers who were approached agreed to participate. No other exclusion criteria were applied. Being a state facility serving poor socioeconomic communities from the surrounding area, the women in this group were all of low socioeconomic status. The second group (n = 30) was drawn from women who were currently attending a mental health clinic in the area for their own treatment. Women who were overtly psychotic were excluded due to the obvious difficulty they would experience in responding to the instruments. The third group (n = 30) comprised nonclinical subjects and sampled women involved in community groupings such as women’s groups, volunteer societies, the unemployed and other representative groups. Both control groups were sampled from the same low socioeconomic area as the mothers of disturbed children. In constituting both these groups, simple random sampling was used after first pooling women who were mothers and within two years of the ages of subjects in the first group (i.e. mothers of children with mental health problems). This strategy was used to avoid large age differences between the groups, which could introduce confounding and, thereby, contamination of the results. The author’s concern in this regard was the widely recognised prominence of depressive and anxiety disorders in women in the general population (World Health Organisation 2001). The use of controls that differed substantially from the cases could bring into play many other confounding factors, thereby putting the results into question. It is known that age influences the prevalence of depressive and anxiety disorders in women (American Psychiatric Association
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2000). The sampling involved a simple procedure of approaching every second woman identified as a potential subject. The rationale for this method was to allow every woman the biggest possible chance of being recruited as a subject. In the psychiatric patient group five of the patients approached for participation declined, while in the community control group there were no refusals. Instruments A brief biographical questionnaire was used to gain basic demographic information. Two questionnaires were also used to obtain self-reports of depression and anxiety. The Beck Anxiety Inventory (BAI) (Beck and Steer 1993) is a 21-item self-report inventory designed to measure the presence of anxiety symptoms in adults. Although developed with adult psychiatric patients, the BAI has been used successfully with nonclinical samples as well (Dent and Salkovskis 1986). According to the developers the BAI was constructed to measure symptoms of anxiety that are minimally shared with those of depression. The BAI provides a total score between zero and 63, and has cutting points indicating different severities of anxiety. The Beck Depression Inventory (BDI) (Beck and Steer 1988) was used to measure depressive symptoms. It is a 21-item self-report instrument that has been widely used for many years. The BDI has a similar scoring system to the BAI. The BAI and the BDI assess symptom manifestation specifically over the week before the testing. Both these instruments have been used effectively in the South African context (Pillay and Schoubben-Hesk 2001). However, like all foreign-developed psychometric techniques, they should be used with caution, and the inclusion of control groups in the design serves to improve the rigour of the study. In addition to the basic demographic information elicited, the psychologists attending to the children with mental health problems were requested to give their assessment of whether the child’s problem appeared ‘’reactive’‘ to some obvious stressor (e.g. sexual abuse, death of a significant other) or not. While this is a rather crude measure, it was included as a way of controlling for the psychological effects of trauma on the maternal presentation. For example, it would not be unexpected to find higher rates of depression or anxiety in a mother who has lost a significant other, or whose child has been abused. It was felt that this would be a more useful (broader) variable, for comparative purposes, than the narrow focus on children’s diagnoses. Also, with the relatively small sample and the established diagnostic profile of children presenting at this specific facility, it was clear that the wide range of diagnoses would contribute little (if anything) to statistical analyses. The simple two-fold distribution was deemed capable of permitting some meaningful statistical computations. Procedure The mothers of mentally disturbed children were asked if they would be interested in providing information regarding their own psychological state over the past week through a questionnaire format, in the hope that this information would help provide a better understanding of the mental health of mothers (who are usually the primary caregivers) of children with mental health problems. They were informed that participation was voluntary, and should they choose not to be involved their children’s treatment would not be affected in any way. Almost all the mothers agreed to participate and were given the instruments for self-report. The subjects in the psychiatric patient group and the community control group were advised of the purpose of the project and issues relating to informed consent were handled in a similar way to the first group. The subjects in the psychiatric patient group were assured that their participation or non-participation would not influence their treatment in any way. Most subjects understood and spoke English at a reasonable level, but in a few cases (two mothers of disturbed children, four psychiatric patients and two community controls) the instruments were read out and translated to them in IsiZulu . The data was analysed using the Statistical Package for the Social Sciences. The major analytical procedures involved tests of difference among the three groups with respect to the measures of depression and anxiety. Analyses of Variance were performed on the three groups, and post-hoc
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Tukey tests were employed to identify between group differences. Pearson Product Moment Correlation Coefficients were also computed to examine the strength of associations between the two dependant variables (i.e. depression and anxiety). The study was conducted with the support of the University of KwaZulu-Natal.
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Results The mean ages of the subjects in the three groups were as follows: mothers of disturbed children (mean = 36.28 years, SD = 5.75); psychiatric patients (mean = 38.57 years, SD = 5.5), and community controls (mean = 36.67 years, SD = 6.71). Within the group of mothers with disturbed children, 29 (58%) had children whose referral problems appeared ‘‘reactive’ to an obvious stressor. The mean BAI and BDI scores for the three groups are presented in Table 1. The Analysis of Variance (ANOVA) conducted on the BAI scores showed that the three groups differed significantly (F = 7.75, p < 0.001). The post-hoc Tukey test revealed that the mothers of disturbed children scored significantly lower than the psychiatric patients (p < 0.01), but not significantly different to the community controls (p = 0.39). The psychiatric patients scored significantly higher than the community controls (p < 0.001). The ANOVA performed on the BDI scores showed significant between group differences (F = 28.78, p < 0.0005). The post-hoc Tukey test showed that the mothers of disturbed children scored significantly lower than psychiatric patients (p < 0.0005), but not significantly different from the community controls (p = 0.29). The psychiatric patient group scored significantly higher than the community controls (p < 0.0005). Pearson correlation coefficients computed within the group of disturbed mothers revealed that the BAI and BDI scores were highly correlated (r = 0.82). The BDI was also correlated significantly with education (r = –0.31), indicating lower levels of depression in individuals with higher levels of education. Education and BAI scores were not significantly correlated (r = -0.16). Age was also not significantly correlated with the BAI (r = 0.08) and BDI scores (r = 0.19). The type of problem in the child (i.e. reactive vs not reactive) was not significantly different between those mothers who had less than three children and those who had three or more children (Chi square = 0.19, p = 0.67). The type of problem in the child was also not significantly different between those mothers who were married (or cohabiting) and those who were single parents (Chi square = 0.38, p = 0.54). The mean maternal anxiety (t = 1.21, p = 0.23) and depression (t = 0.60, p = 0.56) levels were also not significantly different between the ‘reactive’ and ‘not reactive’ groups. No significant correlation was found between the age of the child receiving mental health care and either maternal anxiety (r = 0.16) or maternal depression (r = 0.24). Discussion The finding that over half the mothers of disturbed children had children whose referral problems appeared reactive to an obvious stressor is not unexpected, considering the frequency of stressors (e.g. traumatic, violent and criminal) affecting children in South Africa. Recent research on attenders at a child mental health facility noted that 72% of the children were from fractured families, while over 40% of the girls had recent histories of sexual abuse (Pillay and Mkhonza 2004). Table 1: BAI and BDI Scores
Group Mothers of disturbed children Psychiatric patients Community controls Total
n 50 30 30 110
BAI scores Mean 15.02 18.43 13.50 15.54
SD 3.68 6.21 5.59 5.31
BDI scores Mean SD 14.92 7.74 26.93 10.85 12.07 5.50 17.42 10.10
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The significantly higher levels of anxiety and depressive symptoms in the psychiatric patient group compared to the community controls is expected. Although the mothers of disturbed children had slightly higher mean scores than the community controls for anxiety and depressive symptoms, they were not significantly different. This finding is interesting, considering the overseas research evidence suggesting higher levels of mental health symptoms in mothers of children with mental health problems (Frye and Garber 2005; Suveg et al. 2005). The present result may be influenced by the sampling and other pertinent issues that characterise mental health service usage in low-income countries. In a country such as South Africa where (1) mental health services are few, and (2) the awareness of mental health problems and appropriate resources is generally low, it is fairly obvious that not all mothers of disturbed children are going to seek such care. Only a select group of mothers will access this type of care for their children. This variable (i.e. the decision to seek help) may therefore reflect more positively on the mental health status of these mothers. In other words, the question of whether the presence of poor mental health status in mothers interferes with their ability and motivation to seek help for their disturbed children must be raised. Unlike high-income countries, where most cited research is conducted, poorer countries are still characterised by the many barriers that limit the provision of effective mental health services (World Health Organisation 2001). Women with less awareness of these problems and services are obviously less likely to take their children to mental health facilities, and those with mental health problems themselves may lack the insight and motivation to seek help for their children (and themselves). It is also very likely that women with greater social awareness also have greater personal resources to help them cope with their own mental health issues. Of course, it can be argued that the mean scores of 13.5 on the BAI and 12.07 on the BDI achieved by the community control group are indicative of ‘mild anxiety’ and ‘mild depression’, according to the test developers (Beck and Steer 1993; Beck and Steer 1988), and that this clinical description applies to the mothers of disturbed children as well. However, this is one of the difficulties inherent in using instruments developed and standardised in Western (high income) countries, where the norms and standardisation procedures have been conducted with different national groups, thus rendering the prescribed cutting points less accurate on local samples. The use of control groups are, therefore, designed to provide a local normative score for the specific investigation. The high correlation between anxiety and depressive symptoms in the mothers of disturbed children is consistent with the findings of Dent and Salkovskis (1986) and the general clinical trend of depressive symptoms frequently reported in patients with anxiety symptoms (Beck and Steer 1993). The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) also points out that individuals with anxiety conditions commonly manifest depressive symptoms. The negative correlation between education and BDI scores suggests that more educated mothers of disturbed children had fewer depressive symptoms than less educated ones. This finding is consistent with those of Patel (2001); showing that the lack of schooling, especially at the secondary level, is a considerable risk factor for the development of mental health problems. Of course the relevance of the type of education offered in schools is also seen as a critical issue (World Health Organisation 2001). The lack of significant differences found between mothers of disturbed children whose problems were considered ‘reactive’ or ‘not reactive’ may reflect on the crude distinction that was used, and on the likelihood that both sets of mothers manifested similar levels of distress regardless of the nature or perceived etiology of their children’s problems. The type of childhood problem (i.e. ‘reactive’ or ‘not reactive’) was also not influenced by the number of children in the family or the marital status of the mother. These findings are meaningful in that they lend support to the idea that stressful and traumatic life events can occur in any type of family. Conclusion The finding that the mothers of the disturbed children presenting for mental health care showed no significant difference in depression and anxiety levels compared to community controls is probably
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better understood in the context of their decisions to seek mental health care for their children. Local research examining these variables in non-clinical (i.e. the general population) contexts would provide an interesting comparison. Also, it is equally important to investigate mental health presentations in the fathers of children with mental health problems. Of course, in clinical practice, clinicians have contact mainly with the mothers of children with mental health problems. This is another issue that warrants exploration, considering there are often no substantive reasons why fathers cannot be involved in their children’s healthcare. Acknowledgements — The support of the University of KwaZulu-Natal is gratefully acknowledged, and the assistance of Ms Carol-Ann Sargent is appreciated.
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