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Often undetected and poorly managed, maternal depression and child adjustment problems are common health problems and impose significant burden to society. Studies show evidence of mutual influences on maternal and child functioning, whereby depression in mothers increases risk of emotional and behavioral problems in children and vice versa. Biological mechanisms (genetics, in utero environment) mediate influences from mother to child, while psychosocial (attachment, child discipline, modeling, family functioning) and social capital (social resources, social support) mechanisms mediate transactional influences on maternal depression and child adjustment problems. Mutual family influences in the etiology and maintenance of psychological problems advance our understanding of pathways of risk and resilience and their implications for clinical interventions. This article explores the dynamic interplay of maternal and child distress and provides evidence for a biopsychosocial model of mediating factors with the aim of stimulating further research and contributing to more inclusive therapies for families.
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Mutual influences on maternal depression
and child adjustment problems
Frank J. Elgar
a,
*, Patrick J. McGrath
b
, Daniel A. Waschbusch
b
,
Sherry H. Stewart
b
, Lori J. Curtis
c
a
Cardiff Institute of Society, Health and Ethics, Cardiff University, 53 Park Place, Cardiff CF10 3WT, Wales, UK
b
Department of Psychology, Dalhousie University, Canada
c
Department of Community Health and Epidemiology, Dalhousie University, Canada
Received 6 October 2003; received in revised form 27 January 2004; accepted 13 February 2004
Abstract
Often undetected and poorly managed, maternal depression and child adjustment problems are common health
problems and impose significant burden to society. Studies show evidence of mutual influences on maternal and
child functioning, whereby depression in mothers increases risk of emotional and behavioral problems in children
and vice versa. Biological mechanisms (genetics, in utero environment) mediate influences from mother to child,
while psychosocial (attachment, child discipline, modeling, family functioning) and social capital (social resources,
social support) mechanisms mediate transactional influences on maternal depression and child adjustment problems.
Mutual family influences in the etiology and maintenance of psychological problems advance our understanding of
pathways of risk and resilience and their implications for clinical interventions. This article explores the dynamic
interplay of maternal and child distress and provides evidence for a biopsychosocial model of mediating factors with
the aim of stimulating further research and contributing to more inclusive therapies for families.
D2004 Elsevier Ltd. All rights reserved.
Keywords: Maternal depression; Child behavioral problems; Developmental psychopathology
Depressive disorders in mothers and emotional and behavioral disturbances in children are common
and tend to coexist. Mutual influences on these conditions and the factors that mediate them have
implications for their prevention, assessment, and treatment. Previous empirical reviews have docu-
mented the influences of maternal mood on child adjustment outcomes (e.g., Cummings & Davies,
1994; Downey & Coyne, 1990; Goodman & Gotlib, 1999; Lovejoy, Graczyk, O’Hare, & Neuman,
0272-7358/$ - see front matter D2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2004.02.002
* Corresponding author. Tel.: +44-29-2087-5179; fax: +44-29-2087-4175.
E-mail address: ElgarF@Cardiff.ac.uk (F.J. Elgar).
Clinical Psychology Review 24 (2004) 441 459
2000), but none to date has included a balanced account of simultaneous influences of child behavior on
maternal functioning. The purpose of this article was to concisely review the research on mutual
influences on maternal depression and child adjustment problems with particular foci on mechanisms
that mediate these influences and their potential clinical implications.
1. Scope of the problem
1.1. Epidemiology
The problems are all too familiar to many families. Depressive disorders in mothers and behavioral
and emotional problems in children are among the most common and debilitating mental health
conditions. Many children are repeatedly exposed to maternal depressive episodes and consistently
exposed to subclinical maternal distress. As well, about one in five parents lives with a child suffering
from some form of emotional or behavioral disorder. This double dose of maternal and child
maladjustment hits families and communities hard.
Depression afflicts 1020% of women at any point in time (Kringlen, Torgersen, & Cramer, 2001) and
about a third of all women at some point during their lifetime (Kendler & Prescott, 1999) and is particularly
common among low-income, single mothers (Brown & Harris, 1978). Depression is a highly recurrent
condition with over 80% of cases experiencing more than one depressive episode (Belsher & Costello,
1988). Individuals with three or more previous depressive episodes have a relapse rate as high as 40%
within 1215 weeks after recovery (Keller et al., 1992) and rarely ever return to complete asymptomatic
functioning (Duggan, Sham, Minne, Lee, & Murray, 1998). Depression is also often accompanied by other
disorders. About two thirds of depressed or dysthymic women also meet diagnostic criteria for an anxiety
disorder (Kessler et al., 1994). Unfortunately, for reasons of stigma, unawareness, or access to care,
maternal depression often goes undetected or poorly managed. Less than half of all women who show signs
of depression receive specialist treatment, and the majority of cases that have contact with health providers
are either misdiagnosed or improperly monitored (McGrath, Keita, Stickland, & Russo, 1990).
Emotional and behavioral disorders are among the most common chronic health conditions in
children. Community surveys show point prevalence rates from 18 22% for one or more child disorders
(Breton et al., 1999; Offord, Boyle, & Szatmari et al., 1987).Rutter, Tizard, Yule, Graham, and
Whitmore’s (1976) Isle of Wright studies found that 714% of children exhibited at least one disorder
and that risk to children increased with presence of parental depression or ‘‘neurotic disorder.’’ The
Ontario Child Health Survey (OCHS), a Canadian survey of children 4 to 16 years of age, showed a 6-
month prevalence rate of 18.1% for at least one of four conditions—conduct disorder, hyperactivity,
emotional disorder, or somatization (Offord, Boyle, Szatmari et al., 1987). Many children also suffer
from untreated or poorly managed conditions. Fewer than one in five children who show signs of a
psychiatric disorder have any contact with a mental health care provider during the previous 6 months
(Offord, Boyle, Szatmari et al., 1987).
1.2. Burden
The social and economic burden of these conditions is severe. According to the World Health
Organization, by 2020, depression is projected to carry the highest disease burden of all health
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459442
conditions in women, accounting for 5.7% of the total disease burden measured in disability-adjusted life
years (Murray & Lopez, 1996). Depression impairs social and physical functioning, is a major
precipitating factor in suicide, and is associated with health care costs, morbidity, and mortality from
medical illness (Katon & Sullivan, 1990).
The aggregate disease burden of adjustment problems in children is difficult to estimate because many
are precursors to more disabling disorders in later life, but economic studies that followed children to
adulthood found nearly 10-fold increases in costs to public services attributed to child emotional and
behavioral disorders (Knapp, McCrone, Fombonne, Beecham, & Wostear, 2002; Scott, Knapp,
Henderson, & Maughan, 2001). Child adjustment problems have long-term implications for school
performance, interpersonal conflict, substance misuse, delinquency, and suicidal behavior (Elgar &
Arlett, 2002; Elgar, Arlett, & Groves, 2003; Elgar, Knight, Worrall, & Sherman, 2003a). Without
adequate screening and treatment, the prognosis for many childhood disorders is poor. Left untreated,
disruptive and aggressive behavior in childhood persists and may evolve to antisocial behaviors in
adulthood, and child emotional disorders place individuals at long-term risk of mood and anxiety
disorders. One study found that children who showed elevated rates of behavioral problems during
childhood were 4.6 times more likely than healthy children to show psychopathology as adults 14 years
later (Hofstra, Van der Ende, & Verhulst, 2000).
2. Intergenerational influences
2.1. Maternal depression affects child adjustment
There is ample cause for concern for the health and development of children of depressed mothers.
Mood disorders are heritable, affect neuroendocrine and circulatory development during pregnancy, can
be incompatible with good parenting behavior, and can cause significant life stress for children.
Consequently, living with a depressed parent poses risk for social, psychological, and achievement
deficits (Downey & Coyne, 1990; Kurstjens & Wolke, 2001). Observational research shows that infants
and children of depressed mothers, compared to children of nondepressed mothers, are more fussy,
receive lower scores on measures of intellectual and motor development, have more difficult tempera-
ments and less secure attachments to their mothers, react more negatively to stress, show delayed
development of self-regulatory strategies, and exhibit poorer academic performance, fewer social
competencies, lower levels of self-esteem, and higher levels of behavioral problems (Goodman &
Gotlib, 1999; Luoma et al., 2001). Consequently, point prevalence rates of psychiatric disorders among
children of depressed parents have been estimated to be 25 times above normal: 41 77% (Beardslee,
Keller, Lavori, Staley, & Sacks, 1993; Beardslee, Versage, & Gladstone, 1998; Weissman et al., 1986).
2.2. Child behavior affects maternal functioning
While children of depressed mothers are at an increased risk of adjustment problems, conversely,
living with a child with emotional or behavioral disturbances influences maternal functioning and
possibly increases the risk of or exacerbates maternal depression. There are increased rates of depression
among mothers of clinic-referred, disturbed children. Civic and Holt (2000) found that mothers who
reported three or more adjustment problems in their children (e.g., temper tantrums, social problems,
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 443
unhappiness) were 3.6 times more likely than other mothers to show elevated scores on a self-report
screen for depression. The effects of child illness on maternal health may not be specific to child
adjustment problems. Another study reported that 48% of mothers who brought their children for
pediatric care screened positive for depression (Kahn et al., 1999). Mothers of disruptive children report
more life stress than other mothers (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992; Harrison &
Sofronoff, 2002). Under controlled conditions, Pelham et al. (1997) showed that increasingly deviant
child behaviors cause increased depressed, anxious, and hostile feelings and alcohol consumption in
parents. In interviews of 100 mothers, Harrison and Sofronoff (2002) found that the influence of child
hyperactivity on maternal functioning accounted for 21% of the variance in maternal depression but was
moderated by mothers’ perceived control over child behavior. Because such perceived control may
change with maternal mood, successful treatment of disruptive child behavior alleviates stress and
depressive symptoms in mothers. Using Webster-Stratton’s (1981) Parents and Children Series group-
based parenting program for managing disruptive child behavior, Taylor, Schmidt, Pepler, and Hodgins
(1998) found that in addition to improved child behavior, the program also reduced maternal depressive
symptoms.
2.3. How strong is the relation?
While the data show statistically significant associations between depressive symptoms in mothers
and adjustment problems in their children, these correlations vary according to the population studied,
measures used, and method of assessment. Marchand and Hock (1998) used Radloff’s (1977) CES-D to
measure maternal depressive symptoms and Achenbach’s (1991) Child Behavior Checklist to measure
child behavior and found that maternal symptoms correlated .22 with child externalizing problems and
.29 with child internalizing problems. In another study that used these same measures with a sample of
young, low-income mothers, it was found that maternal depression correlated .38 with child external-
izing problems and .32 with child internalizing problems (Black et al., 2002). Contrasting the two
studies, it appeared that higher rates of symptoms in a disadvantaged population may have resulted in
stronger relation between maternal and child symptoms. In another study that used the Beck Depression
Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and Child Behavior Checklist, the authors
found that maternal depression correlated .20 with child externalizing behavior and .32 with child
internalizing behavior (Phillips & O’Hara, 1991). Hammen et al. found mothers’ Beck Depression
Inventory scores correlated .39 with child depressive symptoms measured by the Child Depression
Inventory (Kovacs, 1985), .53 with child externalizing behavior measured by the Conners Teacher
Rating Scale (Conners, Sitarenios, Parker, & Epstein, 1998), and .54 with total problem scores on the
Child Behavior Checklist (Hammen et al., 1987). Providing some clarity to such diverse findings, Beck
(1999) conducted a meta-analysis of 33 studies that cited correlations between maternal depression and
child adjustment problems (total N= 4561). Her analysis yielded composite correlations of .29 to .35,
depending on how samples were weighted, which are indicative of 812% of shared variance.
3. Who distresses whom?
Maternal depression contributes to parenting behavior that is either too intrusive or
withdrawn, which may trigger a disruptive outburst in the child, which the depressed mothers
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459444
have difficulty managing, thereby exacerbating the child’s behavior, and so on. Certainly, the
transactional nature of these conditions has implications for their course and treatment, but few
studies have attempted to unravel temporal relations between maternal and child functioning.
Forehand and McCombs (1988) assessed child behavioral problems and maternal depression on
two occasions 1 year apart. With stronger relations found between maternal depression at Time
1 and child problems at Time 2 than between child problems at Time 1 and maternal
depression at Time 2, the authors concluded that maternal depression was the antecedent in the
relation between maternal depression and adolescent functioning. Unfortunately, with just two
assessments and discrepant test retest reliability of their measures of maternal depression (r=.71)
and child adjustment problems (rs=.26.51), differences in cross-lagged relations were difficult
to interpret.
In another panel study, child and parental depression, anxiety, and hostility were assessed in three
annual assessments (Ge, Conger, Lorenz, Shanahan, & Elder, 1995). Symptoms of parent and adolescent
distress were reciprocally related over time after earlier symptoms were statistically controlled, but the
study did not find differences in cross-lagged relations. This failure to replicate Forehand and McCombs’
(1988) result may be attributed to their multivariate analysis that included a latent variable (distress)
representing depression, anxiety, and hostility and therefore obscured differences in temporal relations
across domains of maladjustment.
Our group recently conducted a 4-year cross-lagged panel study of maternal depression and child
adjustment problems (i.e., hyperactivity, aggression, and emotional problems) with the objective of
examining their antecedentconsequence conditions (Elgar, Curtis, & McGrath, Waschbusch, &
Stewart, 2003). Three waves of panel data collected in 2-year intervals showed stability in, and relations
between, maternal depression and child hyperactivity, aggression, and emotional problems. Interestingly,
differences between cross-lagged panel correlations suggested that maternal depressive symptoms
tended to coincide with or precede child emotional problems but tended to change as a consequence
of child aggression and hyperactivity.
We also conducted a study of state-dependent fluctuations in functioning to test relations
between daily-reported maternal mood and disruptive child behavior (Elgar, Waschbusch, McGrath,
Stewart, & Curtis, 2004). Pooled time series analyses revealed that maternal anger and fatigue
were related to previous child hyperactivity and maternal confusion was related to previous child
aggression. However, maternal depression, anger, and anxiety each predicted subsequent child
hyperactivity, and maternal confusion and anxiety each predicted subsequent child aggression.
Thus, while temporal relations change depending on the type of child behavior and dimension of
maternal mood, both short-term and long-term mutual influences appear to operate on maternal
and child functioning.
4. Mediating mechanisms
Current research has moved beyond the question of whether mutual influences on maternal
depression and child adjustment problems exist to the mechanisms that mediate them. Herein lies
a formidable task of identifying the active ingredients in a mix of interrelated mechanisms and
overlapping constructs. Intergenerational transmission of psychopathology involves genetics,
biological neuroregulatory systems, cognitive and interpersonal processes, family functioning,
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 445
and other environmental factors. Some influences run from mother to child, whereby impaired
functioning in the mother increases risk to the child (e.g., genetic transmission). Other influences
run from child to mother (e.g., stress resulting from disruptive child behavior). Other influences
run bidirectionally and perpetuate a cycle of positive or negative influences (e.g., maternal and
child symptoms influencing, and being influenced by, parenting behavior).
Previous empirical reviews have included models to help organize and interpret this wide area
of research. Cummings and Davies (1994) described one such model that shows multifaceted
linkages between maternal depression and a range of child outcomes. This model was
transactional but lacked specificity about outcomes and causal mechanisms. For example, one
of the three mechanisms in the model, ‘‘parent characteristics,’’ subsumed ‘‘emotional unavail-
ability and all thinking processes of depression’’ (p. 75). Building on this work, Goodman and
Gotlib (1999) presented a more detailed model of four mechanisms involved in the transmission
of influences from maternal depression to child adjustment problems—genetic vulnerabilities,
neuroregulatory functioning, exposure to depressive symptoms, and environmental stress. The
model also addressed moderating factors such as paternal involvement and child intelligence.
However, each mediating mechanism in the model was portrayed as relevant only to the
influence of maternal depression on child adjustment, giving cursory attention to transactional
influences.
The model shown in Fig. 1 is a simplified revision of Goodman and Gotlib’s that depicts pathways of
mutual influences on maternal depression and child adjustment problems. There are three sets of
interrelated, mediating factors. The first, biological mechanisms, includes genetic and in utero
environmental influences that run unidirectionally from mother to child. The second, psychosocial
mechanisms, has the capacity for mutual influences and includes exposure to negative cognitions and
behaviors, family functioning, and all mother child interactions, encompassing mother child attach-
ment, child discipline, and modeling. The third group of mechanisms represents moderating, contextual
factors, including social disadvantage and social resources, which indirectly transmit mutual influences
on maternal and child functioning.
Fig. 1. Theoretical model of mutual influences on maternal depression and child adjustment.
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459446
5. Biological mediation
5.1. Genetics
The risk for a depressive disorder in adult first-degree relatives of depressed patients is higher (20
25%; Tsuang & Faraone, 1990) than in the general population, and twin studies indicate that genetic
effect on depression accounts for 36% of the variance in child depressive symptoms (Sullivan, Neale, &
Kendler, 2000). Indeed, environmental factors do not fully account for the risk posed to children of
depressed mothers, but it should also be recognized that heritability estimates do not account for genetic
influences on environmental and personality factors that in turn indirectly influence the likelihood of
child symptoms (Rutter, Pickles, Murray, & Eaves, 2001). Due to an interaction of genes and
environment or a ‘‘nature– nurture interplay’’ (Silberg & Rutter, 2002), parents who pass on a genetic
risk to their children tend also to create risky environments. An example of such interaction was
demonstrated in a study of ‘‘genetically at-risk’’ adopted children that showed that these children
experienced more negative parenting from their adoptive mothers than their adopted siblings as a
function of their own disruptive behavior (O’Connor, McGuire, Reiss, Hetherington, & Plomin, 1998).
Genetic influences may still play a specific role in child depression, however, as shown in a rare
generational study of 90 childparent grandparent triads (Warner, Weissman, Mufson, & Wickramar-
atne, 1999). This study found that depression in parents and in grandparents both increased risk of
depression in children (consistent with genetic mediation) but that depression in parents but not in
grandparents increased risk for only disruptive behavioral problems (consistent with environmental
mediation). Genetic mediation is an important piece of the puzzle, but it also does not explain why the
risk of adjustment problems in children of depressed mothers extends more broadly than depressive
illness (Rutter, 1990).
5.2. In utero environment
Behavioral deficits in children of depressed mothers are evident in the first few days of life. Newborns
of depressed mothers, compared to newborns of nondepressed mothers, have more difficult tempera-
ments, exhibited by social unresponsiveness, low activity, irritability, and hypersensitivity (Weissman et
al., 1986). These infants also show poor orientation, abnormal reflexes (Da Costa, Dritsa, Larouche, &
Brender, 2000; Field, 2002), and low brain activity in the frontal lobes—a key area of the brain involved
in emotion regulation (Dawson et al., 1999). Maternal depression may affect blood flow to the fetus and
development of neurotransmitter and neuroendocrine systems of the autonomic nervous system. A
system of particular interest is the hypothalamic pituitary adrenal (HPA) axis, which has been linked to
adult depression and attachment disorganization in infants (Ashman, Dawson, Panagiotides, Yamada, &
Wilkinsom, 2002; Hertzgaard, Gunnar, Erickson, & Nachmais, 1995). Neurological data corroborate
behavioral evidence of elevated heart rate and cortisol levels, lower vagal tone, more gaze aversion,
decreased physical activity, and fewer vocalizations in infants of depressed mothers (Field et al., 1988).
Given that such abnormal autonomic functioning appears to endure to childhood (Dawson et al., 2003),
some researchers proposed that early exposure to maternal stress and depression sensitizes children’s
pituitaryadrenal responses to later stress exposure in childhood (Essex, Klein, Cho, & Kalin, 2002).
There are two important aspects of in utero influences on fetal development. First, they function
independently of genetics. In a cross-fostering study with rat pups, Francis, Diorio, Liu, and Meaney
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 447
(1999) found that both the quality of the parent pup interaction and the pup’s associated physiological
stress responses mediated by the HPA axis were passed on intergenerationally independent of genetic
influence. In fact, Weaver, Grant, and Meaney (2002) found that the rate of hippocampal apoptosis (cell
loss) in isolated rat pups could be changed by altering the degree of physical contact with the mother.
The animal data are consistent with human studies that reveal that intergenerational transmission of
attachment strategies can change with intensive parent training (van Ijzendoorn, Juffer, & Duyvesteyn,
1995). Second, unlike genetic mediation, the long-term effects of maternal depression on fetal
development show ‘‘multifinality’’ or a range of emotional and behavioral outcomes stemming from
common problems of emotional regulation and temperament. However, other research shows how child
behavior can influence maternal functioning, implicating the role of psychosocial factors.
6. Psychosocial mediation
Depression affects how people think and feel about themselves and about other people (Beck,
1967), so children of depressed mothers are regularly exposed to symptoms of dysphoric mood,
irritability, confusion, helplessness, and hopelessness and are likely to experience the psychological
unavailability of their mothers. Conversely, mothers of children with adjustment problems are
regularly exposed to aggressive, hyperactive, delinquent, or emotionally disturbed behavior. Mutual
influences on maternal depression and child adjustment problems share at least four mechanisms
of psychosocial mediation: motherchild attachment, child discipline practices, modeling, and
family functioning.
6.1. Attachment
In the first year of life, infants normally develop a mutual emotional bond with the mother. Such
attachment reflects an innate tendency for the mother and child to respond to one another in ways that
increase the likelihood of survival through proximity in times of stress and is observed in humans and
nonhumans (Bowlby, 1988). Sensitive and responsive parenting promotes the expectation of care when
it is needed, shaping the socioemotional development of the child. Bowlby (1973, p. 208) identified the
quality of the attachment relationship as a precipitating factor in adjustment problems involving distrust
or anxiety, claiming that unmet needs for security can lead the child to view the world as ‘‘comfortless
and unpredictable, and they respond either by shrinking from it or doing battle with it.’’ Prolonged
postpartum maternal depression interferes with the mother’s emotional availability and sensitivity to the
child’s needs, disrupting the development of secure attachment bond (Cicchetti, Rogosch, & Toth, 1998).
Though not inevitable, insecure attachment relationships are more common with mothers suffering from
postpartum depression (Atkinson et al., 2000; Martins & Gaffan, 2000). Laboratory studies reveal that
depressed mothers show fewer positive and animated faces and voices, more sad and angry faces, fewer
expressions of interest, and less accurate matching of happy facial expressions to happy vocal
expressions (Field, 2002; Lundy, Field, & Pickens, 1996). The effects of these behaviors on the child
can be immediately reciprocated back to the mother, with the infant showing unresponsiveness to facial
expressions, fussiness and inconsolability, and disturbed sleep. As Field (2002, p. 62) described, most
mothers and infants have smooth, harmonious interactions, but depressed mothers and their infants have
more interactions that are ‘‘choppy, uncoordinated, and unpleasant to observe.’
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459448
The long-term consequences of insecure attachment entail chronic difficulties in emotional
regulation, sensitivity to stress, and social functioning. Having few opportunities to refine the
skills needed to regulate emotion increases the child’s risk of maladjustment (Carlson & Sroufe,
1995). One study found that depression during pregnancy and at 4 months postpartum predicted
attachment insecurity when the child was 14 months old and problem behaviors and intellectual
competencies when the child was 30 months old (Carter, Garrity-Rokous, Chazan-Cohen, Little, &
Briggs-Gowan, 2001). In another study, children of postpartum depressed mothers were followed
up at 3 years, 10 months of age (Sharp et al., 1995). After controlling for birth weight, parental
IQ, family functioning, and home environment, the children still scored significantly below normal
on standardized tests of intellectual attainment. Murray (1992) also found that maternal depression
at 2 months postpartum increased risk of insecure mother child attachments 16 months later and,
at 5-year follow-up, attachment security at 18 months of age mediated a negative relation between
postnatal depression at 2 months and child prosocial behavior at age 6 (Murray et al., 1999).
Characteristics of insecure attachment in adolescence, while not necessarily determined by infant
attachment, also relate to psychosocial functioning. We recently found that insecure attachment
characteristics in 16-year-old juvenile delinquents related to the severity of their substance use
problems and delinquent behavior (Elgar, Knight, Worrall, & Sherman, 2003b).
6.2. Child discipline
A second psychosocial mediator of mutual influences on maternal and child functioning is parenting
behavior. Depression affects mothers’ ability to show firm and consistent discipline with children and to
avoid ‘‘giving in’’ to tantrums through negative reinforcement. Patterson examined the role of effective
discipline in the development of conduct problems in children (Patterson, DeBayshe, & Ramsey 1989;
Patterson, Reid, & Dishion, 1992). In his ‘‘coercive family process model,’’ he proposed that the
effectiveness with which parents manage aggression and noncompliance in their children shapes the
developmental course of these behaviors (Patterson, 1982). In the coercive family, as the child’s
aggression grows more frequent and intense, parents’ attempts to manage the aggression become less
effective. Passively allowing coercive child behavior to be reinforced by the immediate rewards of
aggression increases the likelihood of its repetition and escalation. Child aggression becomes resistant to
change when it is punished in an unpredictable, erratic fashion and when a parent’s use of discipline is
shaped by mood or whim (Patterson et al., 1992).
It is widely reported that depressed mothers tend to be lax, inconsistent, and ineffective in
disciplining their children (Cunningham, Benness, & Seigel, 1988; Lovejoy et al., 2000). Child
behavior worsens as the mother grows weary and withdrawn as a consequence to low mood,
resulting ultimately in less effective discipline and more frustration for all family members. The
cycle is perpetuated in part by low self-esteem and self-efficacy in the mother (Teti & Gelfand,
1991), expressed emotion (Bolton et al., 2003), and child adjustment problems (Pevalin, Wade, &
Brannigan, 2003). These problems in children are not limited to disruptive behavior. A study of
276 families in inner-city London found that maternal history of depression increased the risk of
child depression by 78% but that this influence was almost entirely mediated by child-rated
neglect and abuse (Bifulco et al., 2002). A recent study of 61 mothers from poor communities in
Britain found that mothers’ expressed emotion not only related to ‘‘child-blaming’’ attributions but
also mediated the relation between maternal mood and child symptoms (Bolton et al., 2003).
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 449
Other research showed that mothers’ negative attitudes towards children moderate the influence of
maternal depression on children’s feelings of global self-worth (Goodman, Adamson, Riniti, &
Cole, 1994). It should also be recognized that much variability exists between families in how
mothers and children respond to distress in the family and that many mothers of maladjusted
children and many children of depressed mothers show no ill effects. In fact, some children as
young as 2 years of age engage in comforting behaviors in response to parental distress (Radke-
Yarrow, Zahn-Waxler, Richardson, Susman, & Martinez, 1994).
6.3. Modeling
Beyond attachment and child discipline, it is also possible that social learning plays a role in
mediating maternal depression and child adjustment. Bandura (1986) described a child’s developing self-
schema as shaped by observation and emulation of the behaviors of others. There are data that are
consistent with the notion that mothers and children model distress symptoms of one another. Breznitz
and Sherman (1987) found that in conversations between young children and depressed mothers,
children matched the low tone and slow rates of speech of their mothers. Consistent with Bandura’s
(1986) suggestion that mothers provide more salient models for girls than for boys, Hops, Sherman, and
Biglan (1990) found that 11- to 16-year-old daughters of depressed mothers exhibited more dysphoric
affect and less happy affect than younger girls (3 to 10 years old) or boys of either age, and at similar
levels to those displayed by their mothers. This finding was replicated by Inoff-Germain, Nottelmann,
and Radke-Yarrow (1992) who also found that daughters of depressed mothers were more likely than
their sons in the same age group to match their mothers’ low mood. Despite the intuitive appeal of social
learning theory, it is difficult to validate in the context of family influences on psychological problems.
Behavioral synchrony may occur when children (especially girls) emulate the depressive symptoms
modeled by their mothers, but the trend is also attributable to postpubertal sex differences in rates of
depressive symptoms in adolescents (Offord, Boyle, Szatmari et al., 1987). Another limitation of social
learning theory is that it does not explain why some children respond to maternal depression with
hyperactive, impulsive, or aggressive behavior.
6.4. Family functioning
Maternal depression and child adjustment problems each affect, and are affected by, family
dysfunction. This fourth mechanism overlaps with child discipline and modeling but deserves
special attention, given that discord in the family is both a consequence of, and precursor to,
ineffective child discipline, maternal depressive symptoms, and disruptive child behavior (Webster-
Stratton & Hammond, 1999). Marital discord affects children through the chronic arousal caused
by witnessing conflict (Cummings & Davies, 1994), negative reinforcement (e.g., acting out to
interrupt conflict between parents; Kelly, 2000), or modeling aggressive behavior seen at home
(Bandura, 1973). Whether children are participants or bystanders to negative interactions, they will
emulate overt aggression (Pike & Plomin, 1996; Webster-Stratton & Hammond, 1988) as well as
subtle, vindictive aggression (Webster-Stratton & Hammond, 1999). Family discord also makes
scapegoating of children more likely. Children are often blamed for breaking up the family or for
a range of associated adversities, such as relationship problems, excessive drinking, drug misuse,
and general social disadvantage (Kelly, 2000).
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459450
7. Social capital
Mutual influences on maternal depression and child adjustment problems involve multiple, interwo-
ven mechanisms that operate within the family context. However, these problems also tend to coexist
with shared contextual factors, such as low income, social disadvantage, and low social support (Curtis,
Dooley, Lipman, & Fenny, 2001; Dodge, Pettit, & Bates, 1994; Pevalin et al., 2003). The classic
Camberwell Study of women in north London shows the devastating effects of poverty and lack of
access to the labor market on women’s mental health (Brown & Harris, 1978; Brown, Harris, &
Hepworth, 1995). This study found that childless women from all socioeconomic groups had similar
rates of depression, but women with children were more likely to be depressed if they were poor. In
another study of inner-city Londoners by Bifulco et al. (2002), rates of psychiatric disorder in children of
low-income families were four times higher than in a comparison sample of average-income families
(43% vs. 11%). Similarly, in Canada, the Ontario Child Health Study found that the prevalence rates of
emotional and behavioral problems in the ‘‘6 to 11’’ age group were three times higher among families
who received income support than among families that did not receive income support (40% vs. 14%;
Offord, Boyle, & Jones, 1987). Reasons for the link between mental health and socioeconomic
conditions are complex, but generally, low-income families are more isolated from communities, have
fewer resources of extrafamilial social support (Hashima & Amato, 1994), and have greater difficulty in
accessing child care and mental health services than mid- and high-income families (Dodge et al., 1994;
Hunsley, Aubry, & Lee, 1997). Moreover, relations between social capital and financial resources and
mental health tend to be transactional; marginalized groups have poor health, and poor health leads to
further marginalization.
8. Age, gender, and taxonomy
Three caveats in mutual family influences on psychological symptoms are their timing, sex differ-
ences, and the type and severity of symptoms on which they operate. First, certain mechanisms of mutual
influences function differently across stages of child development. Goodman and Gotlib (1999, p. 459)
noted that ‘‘researchers have tended to study children of depressed mothers either in one developmental
period or in such a broad age range that two or more distinct developmental stages are included (and
confounded).’’ Attachment difficulties usually germinate in infancy. There may be a delayed ‘‘switching
on’’ of a genetic predisposition to an emotional problem during childhood. Inadequate discipline by
parents and disruptive child behavior may first emerge in adolescence. The strength of any influence of
maternal mood on child adjustment or of child adjustment on maternal mood may change across age
groups. Exploration of developmental differences in mutual influences on maternal depression and child
adjustment problems is a fruitful area for future research.
Second, it is yet unclear whether boys and girls are equally sensitive to maternal depression in terms
of their adjustment outcomes. In a community study in New Zealand, authors found significant relations
between maternal depressive symptoms and subsequent depressive symptoms in adolescent females but
no association between maternal depressive symptoms and depressive symptoms in adolescent males
(Fergusson, Horwood, & Lynskey, 1995). This result is attributable to either a higher prevalence of
internalizing symptoms in adolescent females than in adolescent males or higher sensitivity in daughters
than in sons in responding to depressive episodes in mothers. Other studies have shown equivalent
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 451
relations between maternal depressive symptoms and adjustment problems in both males and females
(Elgar, Curtis et al., 2003), but future research may need to tap broader aspects of child adjustment to
confirm this. There is growing recognition that boys and girls likely differ in the development of
behavioral problems, but research and theory in some areas are yet in their formative stages (e.g.,
antisocial behavior in girls).
A third consideration is whether mutual influences exist only at clinically elevated levels of
distress or at the full range of symptoms shown in community studies. Clinical studies have clearly
shown mutual influences on maternal and child adjustment, but community studies have been less
consistent in this regard (Compas, Howell, Ledoux, Phares, & Williams, 1989; Fergusson et al.,
1995). It may be that maternal depression influences only extreme cases of child adjustment
problems—an association that is obscured in community samples (Downey & Coyne, 1990).It
may also be that symptom screening instruments in community studies do not always produce the
data variance that is needed to reliably show relations in maternal and child functioning (i.e., floor
effects). To elucidate aspects of motherchild relations in the full range of psychological
functioning, further research is needed using both clinical and nonclinical measures of mood
and behavior in clinical and community populations.
9. Clinical implications
Common mental health problems in mothers and children are intrinsically intertwined. Their mutual
influences account for an important segment of a wide network of interrelations that includes fathers,
siblings, schools, communities, and peers. Our focus in this article was on depressive illness in mothers
and adjustment difficulties in children and multiple, overlapping pathways of mutual risk. The good
news is that clinical interventions for either maternal depression or childhood disorders can potentially
enhance functioning in both children and mothers by way of reduced stress and conflict, improved
mother child relations, and more effective discipline practices. For social service professionals,
curtailing the psychosocial effects of child poverty or helping unemployed mothers reenter the workforce
can help to address the harmful effects of poverty and social exclusion on maternal and child health
(Brown & Harris, 1978; Offord, Boyle, & Jones, 1987).Brown et al. (1995) found in their research that
the crucial factor linking financial stress to maternal depression is a sense of humiliation and entrapment
rather than income per se. Each mechanism that mediates mutual influences on maternal depression and
child adjustment problems is a fulcrum of better interventions.
It is recognized that intergenerational transmission of psychopathology may be interrupted with
dyadic assessment and treatments for parents and children, yet this principle has yet to be fully integrated
into common psychological treatments (Rutter, 1990). Some treatment models (e.g., psychostimulant
medication for child hyperactivity) focus almost exclusively on individual symptoms and do not always
account for family influences on treatment outcomes. However, when parents are the facilitators of
treatments for children, their thinking will likely influence the success of the interventions (Hoza et al.,
2000)—especially when the intervention is self-administered by the parent with little or no contact with
a therapist (Elgar & McGrath, 2003). In fact, maternal depression and stress are predictive of whether or
not children who were referred for treatment for conduct problems will actually attend sessions,
suggesting that some of the most distressed families that are referred to specialist care may not even
engage in therapy (Calam, Bolton, & Roberts, 2002).
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459452
Parent training programs teach that the management of disruptive child behavior relies on change in
parent behavior. Behavioral treatments for adult depression emphasize the response contingencies of
family members and peers. There is potential for enhancing unilateral treatment models by considering
sometimes latent influences of maternal adjustment on child health and child adjustment on maternal
health. This principle was demonstrated in the Multimodal Treatment Study of Children with Attention
Deficit Hyperactivity Disorder, in which mothers’ self-reported use of dysfunctional discipline, low self-
esteem, and low parenting efficacy each predicted worse child outcomes in treatment for the disorder
(Hoza et al., 2000). On the other hand, the positive consequences of family influences were
demonstrated in a 3-year trial by Cicchetti, Rogosch, and Toth (2000). They found that when toddlers
participated in treatment for maternal depression (‘‘toddlerparent psychotherapy’’), not only did
mothers show better outcomes than a nontreatment group, but also at a 3-year follow up, the children
showed higher IQ than children whose mothers received individual psychotherapy. Other studies show
similar success using attachment-centered and cognitivebehavioral interventions for mothers and
children (Sexson, Glanville, & Kaslow, 2001). The data from these and other studies converge on an
important implication: concomitant or prior treatment of maternal depression by medication or
psychotherapy may enhance the treatment of child behavior problems, and concomitant or prior
treatment of child behavior problems may enhance efficacy of depression treatments in mothers. Just
as there is evidence that untreated problems in children or mothers can deleteriously influence the health
of the other, there is also evidence that interventions that exploit these influences can extend the benefits
of individual treatments to other family members.
10. Future research
Transactional models of family influences on psychopathology add another dimension to our
understanding of how conditions, such as maternal depression and child emotional and behavioral
problems, develop, sustain, and subside. However, it is an area of research built predominantly on
descriptive, cross-sectional studies and in need of more rigorous study. Closer examination of key
mediating mechanisms is needed to refine integrative models of mutual influences, making them more
relevant to clinical practice as well as our understanding of maternal and child mental health. First, to
better quantify the mutual effects on maternal and child functioning, experimental data are needed from
clinical trials of psychosocial interventions that include outcome measures for siblings, fathers, and other
family members. Research is also needed to determine whether combining parent training and treatment
for maternal depression has a greater effect than either intervention alone in reducing the risk of child
disorders, and to determine the optimal timing of these interventions. Second, some studies suggested
that child symptoms may be related more to those of the father than the mother and that sex differences
exist in how sons and daughters are influenced by parents’ symptoms (e.g., Banez & Compas, 1990;
Compas, Howell, Ledoux, et al., 1989; Compas, Howell, Phares, Williams, & Giunta, 1989; Forehand &
Smith, 1986; Ge et al., 1995). While studies have not consistently shown such sex differences, further
research is needed on the influence of distress in fathers and paternal involvement on child and maternal
functioning. Third, longitudinal research is needed to determine whether child reactions to specific
dimensions of maternal mood and parents’ reactions to internalizing and externalizing child behavior
differ across stages of child development. It cannot be assumed that such influences are consistent across
symptom categories and across age groups until there are data that indicate so. Finally, longitudinal
F.J. Elgar et al. / Clinical Psychology Review 24 (2004) 441–459 453
research is also needed to identify developmental trajectories of mothers and children who are resilient to
mental health problems within the family. Researchers have just begun to examine potential moderating
factors (e.g., sibling relationships, child intelligence, paternal involvement in child rearing, school
environments) that contribute to maternal and child resilience.
11. Conclusion
Unraveling mutual influences on maternal and child health illuminates aspects of risk and resilience
that are important to clinical practice. This article described the epidemiology and burden of maternal
depression and child adjustment problems and presented a biopsychosocial model of their mutual
influences. The practical implications of this model and an agenda for further research were also
discussed. To conclude, in a research literature that is dominated by negative, even pathological,
language used to describe the negative consequences of these influences, it is worth appreciating that
many children of depressed mothers are healthy and can be a positive influence in treating the
depression. Likewise, many mothers of disturbed children are healthy and highly motivated to support
and facilitate interventions for their children. Moreover, maternal depression is not a static health
determinant for child mental health. Because both conditions are highly treatable, their interconnections
can be harnessed for enhancing prevention and treatment interventions.
Acknowledgements
This paper was supported by doctoral fellowships from the Hospital for Sick Children Foundation and
Nova Scotia Health Research Foundation awarded to the first author, grants from the Canadian Institutes
for Health Research awarded to the second author, and grants from the Children’s Miracle Network/
Canadian Psychiatric Research Foundation, IWK Foundation, Nova Scotia Health Research Foundation,
and Social Sciences and Humanities Research Council of Canada awarded to the third author. We also
thank Dr. Dan Offord for his comments on earlier drafts of this article.
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