Maternal Depression and Child Cognitive Development
We found that about one fifth of mothers (21.5%) reported low-level depressive symptoms. This finding is similar to results reported by Olson and colleagues from screening implemented at pediatric well-child visits, in which 6% of mothers scored at risk for major depression and 17% had one symptom (Olson, Dietrich, Prazar, & Hurley, 2006). We should note that we used an interview format, which could have resulted in fewer positive screenings, because prior studies have shown that the written format produces more positive screening results (Olson et al., 2005).
The key finding of our study is that even low-level depressive symptoms (below the recommended cutoff point on the PHQ-2) appear to have a negative impact on parenting capacities. Consistent with past studies of more severe depressive symptoms (Rodriguez and Tamis-LeMonda, 2011, Tamis-LeMonda et al., 2001, Tomopoulos et al., 2006), we found that mothers' depressive symptoms had a negative impact on the support for learning and school readiness they offered their preschool-aged children, such as reading to the child and working with them on their colors and numbers. In an extension of prior studies, we also found that mothers with depressive symptoms were less likely to provide an environment that is conducive to learning, with less predictable daily routines and an increased access to television that is inappropriate for children based on age guidelines. It is also an extension of prior work to demonstrate that even low-level symptoms can have these negative impacts on parenting.
Our finding related to the impact of low-level symptoms on parenting suggests that although the cutoff point of 3 may provide the ideal balance of sensitivity and specificity in identifying major depression, the presence of any symptoms may be a concern from a parenting perspective. Research on "minor," "sub-syndromal," or "sub-threshold" depression may help put our findings into context (we will use the term "sub-threshold"). These depressive spectrum disorders are typically defined by the presence of elevated symptoms (above the cutoff point on a screener) but falling short of meeting full diagnostic criteria (Rowe & Rapaport, 2006). Past research suggests that sub-threshold depression can be associated with substantial impairment in work and life functioning (Solomon, Haaga, & Arnow, 2001). These symptoms may also be associated with a history of depression that is improving or indicate a progression toward major depression. In a review of 23 studies that prospectively followed participants and evaluated depressive symptoms, Cuijpers and Smit (2004)) found that the presence of sub-threshold symptoms was significantly associated with the future development of major depressive episodes. Thus some researchers argue for a greater recognition of the full continuum of depressive disorders (Rowe & Rapaport, 2006).
Our findings are similar in nature to studies that report the impact of sub-threshold depression on life functioning, although we have taken that one step further by demonstrating that even non-clinically elevated symptoms can impair function. Our findings further emphasize the point that the relationship between depressive symptoms and child risk may be linear in nature, with increases in depressive symptoms associated with increases in problems with parenting, beginning even when symptoms are very low level.
Based on current screening and referral recommendations that focus on persons who score above clinical cutoff points, mothers with these low-level symptoms would be unlikely to receive any education, counseling, or other treatment related to their depressive symptoms. Although their symptoms may not warrant traditional treatment approaches, our results suggest that they may be impairing parenting functions and should not be ignored. Looking again to the literature on sub-threshold depression, studies (Judd et al., 2004) have shown a benefit of pharmacotherapy in the treatment of sub-threshold depression, whereas others suggest that offering therapy resources may be beneficial (Wells et al., 2005). It may be appropriate for health care providers to take a proactive approach to symptoms of maternal depression as is often done at the very earliest signs of other chronic medical conditions (e.g., prediabetes and prehypertension). Patient education and dietary and lifestyle changes are recommended for these precursor illnesses. Similar interventions for mothers with low-level symptoms of depression may be beneficial to both mother and child.
Our findings highlight the importance of screening for maternal depression beyond the postpartum period. A great deal of attention has been directed at postpartum screening, but our results are consistent with past research in suggesting that screening should continue beyond the postpartum period (McLearn et al., 2006). A number of valid screening options exist, including the two-item brief screening option (Kroenke et al., 2003, Whooley et al., 1997), which may be useful to nurses and physicians with time constraints who are interested in incorporating screening into their practice. Olson and colleagues (2006) have demonstrated the feasibility of implementing the brief screening option during well-child care visits in pediatric clinics. The American Psychological Association Web site provides information about various versions of the PHQ and links to free screening forms in multiple languages.
In recent years, nurses, pediatricians, and family practice physicians have increasingly viewed enhancing support for learning and healthy child development in the home as within their scope of practice. As an example of a pediatric intervention to support learning, the successful Reach Out and Read program is now being implemented in more than 4,000 practices in all 50 states (Zuckerman, 2009). Reach Out and Read physicians give books to their patients at each visit between 6 months and 5 years, and they emphasize to parents the importance of reading to their children. Reach Out and Read has demonstrated a positive impact on parenting behaviors around literacy, as well as on child language outcomes. It may be important for health professionals engaged in such programs to understand the impact of even low-level depressive symptoms on a parents' likelihood of engaging in activities to promote learning, such as reading to their child.
Our study is not without limitations. Although the screening tool we used in our study is particularly useful because it is widely used in clinic settings, it is a very brief measure of depressive symptoms. Also, we have no objective measures of mothers' support for child learning. It is possible that mothers with depressive symptoms may view their own parenting more negatively, and thus the relationship we found between depressive symptoms and support for learning could be inflated. Finally, our study is focused on low-income preschool-aged children and their mothers. The generalizability of our findings to other samples should be explored.
In summary, the high rates of low-level depressive symptoms and of mothers' reports that these symptoms affect the way that they care for their children indicate that resources to screen for and address depressive symptoms in mothers should receive high priority in pediatric health care settings. Screening and interventions are needed to ensure that children affected by maternal depression receive the support they need to enter school well-equipped for success. Future studies should examine this issue from a longitudinal perspective to help us more fully understand depressive symptoms at all levels of severity and their long-term impact on child outcomes.
Discussion
We found that about one fifth of mothers (21.5%) reported low-level depressive symptoms. This finding is similar to results reported by Olson and colleagues from screening implemented at pediatric well-child visits, in which 6% of mothers scored at risk for major depression and 17% had one symptom (Olson, Dietrich, Prazar, & Hurley, 2006). We should note that we used an interview format, which could have resulted in fewer positive screenings, because prior studies have shown that the written format produces more positive screening results (Olson et al., 2005).
The key finding of our study is that even low-level depressive symptoms (below the recommended cutoff point on the PHQ-2) appear to have a negative impact on parenting capacities. Consistent with past studies of more severe depressive symptoms (Rodriguez and Tamis-LeMonda, 2011, Tamis-LeMonda et al., 2001, Tomopoulos et al., 2006), we found that mothers' depressive symptoms had a negative impact on the support for learning and school readiness they offered their preschool-aged children, such as reading to the child and working with them on their colors and numbers. In an extension of prior studies, we also found that mothers with depressive symptoms were less likely to provide an environment that is conducive to learning, with less predictable daily routines and an increased access to television that is inappropriate for children based on age guidelines. It is also an extension of prior work to demonstrate that even low-level symptoms can have these negative impacts on parenting.
Our finding related to the impact of low-level symptoms on parenting suggests that although the cutoff point of 3 may provide the ideal balance of sensitivity and specificity in identifying major depression, the presence of any symptoms may be a concern from a parenting perspective. Research on "minor," "sub-syndromal," or "sub-threshold" depression may help put our findings into context (we will use the term "sub-threshold"). These depressive spectrum disorders are typically defined by the presence of elevated symptoms (above the cutoff point on a screener) but falling short of meeting full diagnostic criteria (Rowe & Rapaport, 2006). Past research suggests that sub-threshold depression can be associated with substantial impairment in work and life functioning (Solomon, Haaga, & Arnow, 2001). These symptoms may also be associated with a history of depression that is improving or indicate a progression toward major depression. In a review of 23 studies that prospectively followed participants and evaluated depressive symptoms, Cuijpers and Smit (2004)) found that the presence of sub-threshold symptoms was significantly associated with the future development of major depressive episodes. Thus some researchers argue for a greater recognition of the full continuum of depressive disorders (Rowe & Rapaport, 2006).
Our findings are similar in nature to studies that report the impact of sub-threshold depression on life functioning, although we have taken that one step further by demonstrating that even non-clinically elevated symptoms can impair function. Our findings further emphasize the point that the relationship between depressive symptoms and child risk may be linear in nature, with increases in depressive symptoms associated with increases in problems with parenting, beginning even when symptoms are very low level.
Based on current screening and referral recommendations that focus on persons who score above clinical cutoff points, mothers with these low-level symptoms would be unlikely to receive any education, counseling, or other treatment related to their depressive symptoms. Although their symptoms may not warrant traditional treatment approaches, our results suggest that they may be impairing parenting functions and should not be ignored. Looking again to the literature on sub-threshold depression, studies (Judd et al., 2004) have shown a benefit of pharmacotherapy in the treatment of sub-threshold depression, whereas others suggest that offering therapy resources may be beneficial (Wells et al., 2005). It may be appropriate for health care providers to take a proactive approach to symptoms of maternal depression as is often done at the very earliest signs of other chronic medical conditions (e.g., prediabetes and prehypertension). Patient education and dietary and lifestyle changes are recommended for these precursor illnesses. Similar interventions for mothers with low-level symptoms of depression may be beneficial to both mother and child.
Our findings highlight the importance of screening for maternal depression beyond the postpartum period. A great deal of attention has been directed at postpartum screening, but our results are consistent with past research in suggesting that screening should continue beyond the postpartum period (McLearn et al., 2006). A number of valid screening options exist, including the two-item brief screening option (Kroenke et al., 2003, Whooley et al., 1997), which may be useful to nurses and physicians with time constraints who are interested in incorporating screening into their practice. Olson and colleagues (2006) have demonstrated the feasibility of implementing the brief screening option during well-child care visits in pediatric clinics. The American Psychological Association Web site provides information about various versions of the PHQ and links to free screening forms in multiple languages.
In recent years, nurses, pediatricians, and family practice physicians have increasingly viewed enhancing support for learning and healthy child development in the home as within their scope of practice. As an example of a pediatric intervention to support learning, the successful Reach Out and Read program is now being implemented in more than 4,000 practices in all 50 states (Zuckerman, 2009). Reach Out and Read physicians give books to their patients at each visit between 6 months and 5 years, and they emphasize to parents the importance of reading to their children. Reach Out and Read has demonstrated a positive impact on parenting behaviors around literacy, as well as on child language outcomes. It may be important for health professionals engaged in such programs to understand the impact of even low-level depressive symptoms on a parents' likelihood of engaging in activities to promote learning, such as reading to their child.
Our study is not without limitations. Although the screening tool we used in our study is particularly useful because it is widely used in clinic settings, it is a very brief measure of depressive symptoms. Also, we have no objective measures of mothers' support for child learning. It is possible that mothers with depressive symptoms may view their own parenting more negatively, and thus the relationship we found between depressive symptoms and support for learning could be inflated. Finally, our study is focused on low-income preschool-aged children and their mothers. The generalizability of our findings to other samples should be explored.
In summary, the high rates of low-level depressive symptoms and of mothers' reports that these symptoms affect the way that they care for their children indicate that resources to screen for and address depressive symptoms in mothers should receive high priority in pediatric health care settings. Screening and interventions are needed to ensure that children affected by maternal depression receive the support they need to enter school well-equipped for success. Future studies should examine this issue from a longitudinal perspective to help us more fully understand depressive symptoms at all levels of severity and their long-term impact on child outcomes.
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