maternal postpartum depression and risk of psychopathology

8/10/2019 Maternal Postpartum Depression and Risk of Psychopathology

1/12

Reported Maternal Postpartum Depression and Risk of ChildhoodPsychopathology

Meghan J. Walker Caroline Davis

Ban Al-Sahab Hala Tamim

Published online: 29 June 2012 Springer Science+Business Media, LLC 2012

Abstract Childhood emotional and behavioural disorders

are prevalent, can cause significant maladaptation andoften persist into adulthood. Previous literature investi-

gating the potential influence of postpartum depression

(PPD) is inconsistent. The present study examined the

association between PPD and childhood behavioural/emo-

tional outcomes, while considering a number of potentially

important factors. Data were analyzed prospectively from

the National Longitudinal Survey of Children and Youth at

two follow-up periods (ages 23, N = 1,452 and ages 45,

N = 1,357). PPD was measured using the diagnostic cri-

teria of the DSM-IV-TR. Four behavioural/emotional out-

comes were analyzed at each follow-up. For both age

groups, logistic regression models were used to estimatethe associations between PPD and each of the behavioural

and emotional outcomes adjusting for child, obstetric,

environmental and socio-demographic factors. PPD was

associated with the Emotional Disorder-Anxiety among

23 year olds [OR = 2.38, 95 % CI 1.15, 4.91]. Among23 year olds, hostile/ineffective parenting was associated

with Hyperactivity-Inattention [OR = 1.88, 95 % CI 1.14,

3.11] and Physical Aggression-Opposition [OR= 2.95,

95 % CI 1.77, 4.92]. Among 45 year olds, hostile/inef-

fective parenting was associated with Hyperactivity-Inat-

tention [OR= 2.34, 95 % CI 1.22, 4.47], Emotional

Disorder-Anxiety [OR = 2.16, 95 % CI 1.00, 4.67], Phys-

ical Aggression-Conduct Disorder [OR = 1.96, 95 % CI

1.09, 3.53] and Indirect Aggression [OR = 1.87, 95 % CI

1.09, 3.21]. The findings of the present study do not suggest

that PPD is independently associated with any enduring

sequelae in the realm of child behavioural/emotional psy-chology, though the symptoms of PPD may be giving way

to other important mediating factors such as parenting style.

Keywords Childhood behaviourBehavioural disorders

Emotional disorders Postpartum depression Parenting

Introduction

Behavioural and emotional disorders are prevalent among

children and can cause significant impairment and malad-

aptation in familial, social, academic and community set-

tings. North American epidemiologic studies have indicated

that the estimated prevalence of childrens mental disorders

ranges from approximately 1020 % [1]. Comorbidity is

common, with approximately half living with two or more

concurrent disorders [1]. However, these estimates only

consider children at clinical levels and the proportion who

are affected sub-clinically or remain undiagnosed is

approximately 20 % higher [2]. Behavioural problems

reported in preschool-aged years are highly predictive of

M. J. Walker (&)Division of Epidemiology, Faculty of Medicine, Dalla LanaSchool of Public Health, University of Toronto, Toronto, Canadae-mail: [email protected]

M. J. WalkerPrevention and Cancer Control, Cancer Care Ontario,

620 University Avenue, 11th Floor, Toronto, ON M5G 2L7,Canada

C. DavisDepartment of Psychiatry, Faculty of Medicine, UniversityHealth Network, Toronto, Canada

C. DavisCentre for Addiction and Mental Health, Toronto, Canada

C. Davis B. Al-Sahab H. TamimFaculty of Health Sciences, School of Kinesiology and HealthScience, York University, Toronto, Canada

1 3

Matern Child Health J (2013) 17:907917

DOI 10.1007/s10995-012-1071-2


2/12


3/12

who reported longer than 14 days were grouped as having

PPD.

The outcome variables of interest were the presence of

behavioural/emotional problem(s) in children. Outcomes

were measured by the NLSCY Child Behavioural Scales,

which consist of items derived from previously-utilized,

population-based surveys with known psychometric prop-

erties to operationalize the diagnostic criteria for the cor-responding disorders within the DSM-IV-TR [4]. For

children aged 23, four outcomes were considered, as

identified by factor analysis: Hyperactivity-Inattention

[from the Ontario Child Health Study (OCHS) and Mon-

treal Longitudinal Survey (MLS)], Emotional-Disorder

Anxiety (from the OCHS), Physical Aggression-Opposi-

tion (from the OCHS and MLS), and Separation Anxiety

(from Achenbachs Child Behavior Checklist) [28]. For

children aged 45 years of age, the following four out-

comes were considered: Hyperactivity-Inattention (from

the OCHS and MLS), Emotional Disorder-Anxiety (from

the OCHS), Physical Aggression-Conduct Disorder (fromthe OCHS and MLS) and Indirect Aggression (from Lag-

erspetz, Bjorngvist and Peltonen of Finland) [28]. Consis-

tent with previously utilized scoring schemes, children with

a scale score above the 80th percentile were classified as

having a high degree of that outcome [29].

Covariates were identified a priori as a result of a

comprehensive review of the literature. Child factors

include the childs sex and presence of worry/unhappiness.

Obstetric factors include preterm birth (gestational

age B 258 days), low birthweight (B2499 g), maternal age

at childs birth and mothers smoking and alcohol status

during pregnancy. Environmental factors included parent-ing style, family functioning, current maternal depression

and single parent status. Parenting styles, including posi-

tive interaction, hostile/ineffective parenting, consistency

and punitive/aversive parenting, were measured by a

revised version of the Strayhorn and Weidmans Parenting

Practices Scale [30]. Consistent with previous scoring

schemes, a scale score in the lowest quartile was indicative

of having a low degree of positive interaction and consis-

tency, while a score in the highest quartile was indicative

of having a high degree of hostile/ineffective parenting and

punitive/aversive parenting [31, 32]. Family functioning

was measured with the General Functioning subscale of the

McMaster Family Assessment Device [33]. Consistent with

previous scoring-schemes, a score ofC15 was indicative of

low family functioning [32,34]. An abbreviated version of

the Centre for Epidemiologic Studies Depression Scale

(CES-D) [35] was used to determine severity of current

maternal depressive symptoms. Consistent with previous

scoring schemes, a score ofC13 was indicative of mod-

erate to severe depression [32, 34]. Socio-demographic

factors include income adequacy, maternal education and

immigration status. Income Adequacy takes into account

household income and size [28], corresponding closely to

Canadas poverty line [32]. Presence of a comorbid out-

come and childs outcome history were also analyzed.

Statistical Analyses

Statistics Canadas microdata publication guides werefollowed throughout all analyses [28]. Data were weighted

to the population level according to longitudinal survey

weights derived by Statistics Canada to account for

unequal probabilities of sample selection, including non-

response and attrition. Rescaled sample weights were

applied to preserve the original sample sizes and correct for

variance estimation bias. Due to the complex sampling

design of the NLSCY, bootstrapping was performed to

estimate all confidence intervals (CIs). Analyses were

undertaken at Cycle 2 when children were 23 years of age

and Cycle 3 when children were 45 years of age.

Descriptive frequencies of the study population were tab-ulated. Crude and adjusted odds ratios (ORs) and 95 % CIs

were calculated with logistic regression to estimate the

associations between PPD and each of the behavioural and

emotional outcomes. All analyses were performed with

SPSS Version 16.0, with the exception of bootstrapping,

which was performed utilizing SAS, Version 9.2.

Results

A reported 8.4 % (n = 122) of mothers were affected by

PPD in the year following birth of the child. A similarproportion reported being currently depressed when the

child was 23 years of age (8.3 %) and a slightly lower

proportion reported being depressed when the child was

45 (6.6 %). There were approximately equal proportions

of male (50.8 %) and female (49.2 %) children in the

sample. A majority of mothers were 2534 years of age

(68.4 %), with a smaller proportion 1524 years of age

(18.8 %) and 12.8 % of mothers C35.

Crude analyses are reported in Table 1and revealed that

PPD was not significantly associated with most childrens

behavioural/emotional outcomes. However, children of

mothers who had PPD were 2.61 times more likely to

display high degrees of Emotional Disorder-Anxiety

[OR = 2.61, 95 % CI 1.40, 4.86] and twice as likely to

display high degrees of Physical Aggression-Conduct

Disorder [OR = 2.00, 95 % CI 1.04, 3.86].

Table2 depicts the multivariable analysis of child,

obstetric, environmental and socio-demographic factors of

behavioural/emotional outcomes at Cycle 2 (ages 23).

Comorbid Emotional Disorder-Anxiety [OR = 1.69, 95 %

CI 1.03, 2.78], comorbid Physical Aggression-Opposition

Matern Child Health J (2013) 17:907917 909

1 3


4/12

[OR = 4.09, 95 % CI 2.41, 6.93] and hostile/ineffective

parenting [OR = 1.88, 95 % CI 1.14, 3.11] were signifi-

cantly associated with a high degree of Hyperactivity-

Inattention. Comorbid Hyperactivity-Inattention [OR =

1.73, 95 % CI 1.03, 2.78], Separation Anxiety [OR = 3.75,95 % CI 2.48, 5.68] and PPD in the mother [OR = 2.38,

95 % CI 1.15, 4.91] was significantly associated with a

high degree of Emotional Disorder-Anxiety.

In regard to Physical Aggression-Opposition, results

indicate that children with high degrees of Hyperactivity-

Inattention [OR = 4.17, 95 % CI 2.49, 6.96] and Separa-

tion Anxiety [OR = 3.09, 95 % CI 1.93, 4.93] were sig-

nificantly more likely to display Physical Aggression-

Opposition. Low degrees of consistent parenting [OR =

1.68, 95 % CI 1.01, 2.78] and high hostile/ineffective

parenting [OR = 2.95, 95 % CI 1.77, 4.92] were also

significant. Children with comorbid Emotional Disorder-Anxiety and Physical Aggression-Opposition were more

likely to display high degrees of Separation Anxiety

[OR = 3.77, 95 % CI 2.49, 5.71] and [OR = 3.01, 95 %

CI 1.87, 4.84], respectively.

Table3 shows results of the multivariable analysis of

PPD and behavioural/emotional outcomes at Cycle 3 (ages

45). Male sex [OR = 1.80, 95 % CI 1.12, 2.89], comorbid

Physical Aggression-Opposition [OR = 2.36, 95 % CI

1.30, 4.27] and hostile/ineffective parenting [OR = 2.34,

95 % CI 1.22, 4.47] were associated with Hyperactivity-

Inattention at 45 years of age.

In regards to Emotional Disorder-Anxiety, children withhigh degrees of Physical Aggression-Conduct Disorder

[OR = 2.42, 95 % CI 1.10, 5.33] and Indirect Aggression

[OR = 1.94, 95 % CI 1.05, 3.61] were approximately

twice as likely to have high degrees of Emotional Disorder-

Anxiety. Low Positive Interaction and high hostile/inef-

fective parenting were associated with approximately two

times the likelihood of reporting a high degree of Emo-

tional Disorder-Anxiety [OR = 1.95, 95 % CI 1.02, 3.74

and OR = 2.16, 95 % CI 1.00, 4.67].

Male children are close to twice as likely to exhibit high

degrees of Physical Aggression-Conduct Disorder [OR =

1.80, 95 % CI 1.04, 3.12]. Comorbid Hyperactivity-Inat-

tention [OR = 2.85, 95 % CI 1.62, 5.03], Emotional Dis-

order-Anxiety [OR = 2.70, 95 % CI 1.27, 5.75] and

Indirect Aggression [OR = 2.53, 95 % CI 1.38, 4.64] were

also significantly associated with Physical Aggression-

Conduct Disorder. Children of parents who exhibit highdegrees of hostile/ineffective parenting [OR = 1.96, 95 %

CI 1.09, 3.53] and punitive/aversive parenting [OR = 2.08,

95 % CI 1.18, 3.36] were approximately twice as likely to

exhibit high degrees of Physical Aggression-Conduct

Disorder.

Lastly, in the case of Indirect Aggression, male children

were less likely to exhibit Indirect Aggression [OR = 0.54,

95 % CI 0.35, 0.85]. Comorbid Hyperactivity-Inattention

[OR = 1.75, 95 % CI 1.08, 2.84], Emotional Disorder-

Anxiety [OR = 2.03, 95 % CI 1.10, 3.75] and Physical

Aggression-Conduct Disorder [OR = 2.37, 95 % CI 1.32,

4.26] were also associated with a high degree of IndirectAggression. Children of mothers who reported high

degrees of hostile/ineffective parenting were close to twice

as likely to display high Indirect Aggression [OR = 1.87,

95 % CI 1.09, 3.21].

Discussion

With the exception of Emotional Disorder-Anxiety among

23 year olds, PPD does not appear to be associated with

the outcomes measured. However, multivariable analyses

revealed that parenting style may be an important factor,given the magnitude and consistency of the associations

observed. The persistence of the association between PPD

and Emotional Disorder-Anxiety following adjustment is

not unforeseen, given that PPD is of the same class of

clinical disorders that the Emotional Disorder-Anxiety

scale seeks to measure. Clinical Mood and Anxiety Dis-

orders have a moderate heritable component, specifically

among first-degree relatives [4], therefore symptomatology

may be expected in the offspring of afflicted parents.

A number of studies have previously assessed the rela-

tionship between mothers PPD status and behavioural/

emotional outcomes in children, with inconsistency in the

emotional, attentional and cognitive disturbances reported

[12]. In contrast to the results of the present study, a number

have reported significant positive associations between PPD

and childhood outcomes, including Oppositional-Defiant

Disorder and Conduct Disorder [17], inattention-hyper-

activity, separation anxiety [18,19], several depressive and

anxiety disorders [36], elevated cortisol levels which have

predicted major depression [37], lower cognitive scores

[2022, 38], violent behaviour and substance abuse

Table 1 Unadjusted analysis of postpartum depression and behav-ioural/emotional outcomes

OR [95 % CI]

Cycle 2 outcomeages 23 (n = 1,452)

Hyperactivity-inattention 1.65 [0.89, 3.04]

Emotional disorder-anxiety 2.61 [1.40, 4.86]

Physical aggression-opposition 1.94 [0.98, 3.81]Separation anxiety 1.34 [0.75, 2.40]

Cycle 3 outcomeages 45 (n = 1,357)

Hyperactivity-inattention 1.69 [0.93, 3.09]

Emotional disorder-anxiety 1.59 [0.78, 3.26]

Physical aggression-conduct disorder 2.00 [1.04, 3.86]

Indirect aggression 1.42 [0.75, 2.67]

910 Matern Child Health J (2013) 17:907917

1 3


5/12

Table 2 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 2(ages 23, N = 1,452)

Odds ratios [95 % confidence intervals]

Hyperactivity-inattention Emotionaldisorder-anxiety

Physicalaggression-opposition

Separationanxiety

Child factors

Childs sexFemale 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Male 1.17 [0.73, 1.87] 1.44 [0.96, 2.16] 1.31 [0.82, 2.11] 0.75 [0.52, 1.07]

Obstetric factors

Preterm birth

Not preterm 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Preterm 0.99 [0.44, 2.22] 1.15 [0.49, 2.67] 0.53 [0.18, 1.58] 1.28 [0.63, 2.59]

Birthweight

Normal 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Low 0.82 [0.26, 2.66] 0.71 [0.21, 2.37] 3.18 [0.97,10.45] 0.80 [0.35, 1.85]

Maternal age at birth

1524 2.44 [1.01, 5.90] 2.05 [0.93, 4.51] 0.50 [0.20, 1.31] 1.00 [0.48, 2.10]

2534 2.11 [0.96, 4.63] 1.69 [0.83, 3.45] 0.67 [0.27, 1.63] 1.01 [0.52, 1.96]

35? 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Smoking status during pregnancy

Did not smoke 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Smoked 1.47 [0.92, 2.35] 0.51 [0.31, 0.82] 1.08 [0.62, 1.87] 1.04 [0.69, 1.58]

Drinking status during pregnancy

Did not drink 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Drank 1.08 [0.64, 1.81] 1.42 [0.86, 2.35] 1.12 [0.60, 2.07] 1.02 [0.66, 1.59]

Postpartum depression

No PPD 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

PPD 1.32 [0.58, 3.00] 2.38 [1.15, 4.91] 1.00 [0.46, 2.18] 0.94 [0.49, 1.78]

Environmental factorsParenting style: positive interaction

High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Low 0.90 [0.55, 1.49] 0.51 [0.33, 0.79] 1.40 [0.87, 2.25] 0.86 [0.57, 1.31]

Parenting style: consistency


Low 1.18 [0.74, 1.86] 1.10 [0.72, 1.68] 1.68 [1.01, 2.78] 1.53 [0.99, 2.36]

Parenting style: hostile/ineffective

Low 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

High 1.88 [1.14, 3.11] 1.22 [0.76, 1.98] 2.95 [1.77, 4.92] 1.41 [0.87, 2.28]

Parenting style: punitive/aversive


High 1.51 [0.94, 2.43] 1.13 [0.71, 1.80] 1.29 [0.81, 2.05] 0.93 [0.60, 1.45]Family functioning


Low 1.09 [0.39, 3.06] 1.60 [0.76, 3.38] 1.27 [0.49, 3.29] 1.79 [0.89, 3.55]

Current maternal depression


Moderate to severe 1.79 [0.78, 4.09] 1.27 [0.61, 2.64] 0.94 [0.43, 2.09] 1.30 [0.60, 2.82]

Single parent status

Lives with 2 parents 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Lives with single parent 1.18 [0.50, 2.77] 1.68 [0.91, 3.12] 0.45 [0.18, 1.14] 0.68 [0.36, 1.29]


1 3


6/12

[19,20]. Other studies however, have reported that effects

found in earlier ages may attenuate [23, 24, 39], while

others have reported that PPD is not associated with adverseeffects among offspring [2527]. These inconsistencies

may be due to methodological differences. Studies often

employ clinic-based recruitment strategies or diagnostic

interviews to determine their samples [17, 36]. While the

latter are viewed as the gold standard of psychometric

evaluation, their use would limit generalizability to children

who experience mental health outcomes at clinically

important levels. By contrast, the objective of the present

study was to employ a nationally-representative population-

level sample of children and utilize a more liberal charac-

terization of emotional and behavioural symptomatology.

The present study also incorporated a number of importantcovariates, which may be predictively important. Several

studies which have examined more than one type of out-

come have not included a measure to adjust for the

comorbidity of these outcomes [26,36]. This may have led

to the distortion of the true effect of PPD.

The finding that high degrees of several of the behav-

ioural/emotional outcomes assessed differed by the childs

sex at ages 45 is consistent with what is known about

each of the corresponding mental disorders within the

DSM-IV-TR [4]. Attention-Deficit/Hyperactivity Disorder

(ADHD) and Conduct Disorder (CD) are more frequently

observed among male children [4] and indirect aggressionis more commonly observed among female children [40

42]. The finding that Emotional Disorder-Anxiety did not

differ by sex in children at ages 23 or 45 is also con-

sistent with the literature. Rate differentiation by sex of

Mood and Anxiety Disorders typically only begins to

emerge following puberty [4, 43].

A consistent pattern emerged among the other covariates

assessed. Having a comorbid behavioural/emotional out-

come or previous history of the behavioural/emotional

outcome was significantly associated with each of the

outcomes assessed. A number of statistically significant

results emerged among parenting techniques and thebehavioural/emotional outcomes. These findings suggest

that while PPD itself may not be associated with adverse

child psychiatric outcomes, parenting styles do appear to

be. Hostile/ineffective parenting appeared to be most

important, significantly associated with two of four out-

comes at ages 23 and all outcomes assessed at ages 45. It

is important to note however, that previous literature lends

evidence to the possibility that parenting may be on the

causal pathway between PPD and childhood behavioural/

Table 2 continued

Odds ratios [95 % confidence intervals]

Hyperactivity-inattention Emotionaldisorder-anxiety

Physicalaggression-opposition

Separationanxiety

Socio-demographic factors

Income adequacy


Low 1.76 [0.79, 3.94] 0.82 [0.44, 1.55] 1.01 [0.39, 2.59] 1.18 [0.65, 2.14]

Maternal education


Low 1.21 [0.59, 2.51] 1.50 [0.79, 2.86] 0.39 [0.17, 0.88] 1.40 [0.74, 2.62]

Maternal immigration status

Non-immigrant 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Immigrant 1.04 [0.45, 2.43] 0.86 [0.41, 1.80] 1.15 [0.52, 2.54] 2.27 [1.15, 4.49]

Comorbid hyperactivity-inattention

No 1.00 Reference 1.00 Reference 1.00 Reference

Yes 1.73 [1.07, 2.78] 4.17 [2.49, 6.96] 1.18 [0.74, 1.86]

Comorbid emotional disorder-anxiety


Yes 1.69 [1.03, 2.78] 1.39 [0.84, 2.29] 3.77 [2.49, 5.71]

Comorbid physical aggression-opposition


Yes 4.09 [2.41, 6.93] 1.39 [0.84, 2.30] 3.01 [1.87, 4.84]

Comorbid separation anxiety


Yes 1.15 [0.72, 1.83] 3.75 [2.48, 5.68] 3.09 [1.93, 4.93]


1 3


7/12


8/12

emotional outcomes. The literature on PPD and subsequent

maternal depression indicates that child management may

be one of the areas wherein the depressive state of the

mother may manifest. This evidence comes from a number

of studies which have noted increased levels of intrusive-

ness, dysfunctional attachment and interactive patterns [15,

4446]. As reviewed by Beck (1999) [47], depressed

mothers may be more inconsistent and ineffective in their

child management, monitoring and discipline-administra-tion techniques. These mothers are also more likely to

submit to a childs non-compliance and use forceful control

strategies [47].

There is also evidence of the relationship between par-

enting behaviours and development of certain mental dis-

orders. Both ADHD and Oppositional Defiant Disorder/

Conduct Disorder have been linked to inconsistent, unre-

sponsive, coercive, critical and rejecting parenting patterns

[4850], as well as hostile and punitive disciplinary patterns

[51,52]. Research has also indicated that positive, involved

and supportive parenting and lower levels of harsh, punitive

parenting may predict more optimal behavioural, academic

and social adjustment and appears to buffer the effects of

psychological adversity in school-aged children [53]. Other

findings from a study of Canadian infants have indicated

that parenting interventions with depressed mothers can

result in improvements in mother-infant interactions [54].

However, while parenting practices may be related tochildrens mental health outcomes, the causal chain of

events is unclear. The childhood outcomes discussed in the

present study are often associated with significant caregiver

stress and strain [55]. Therefore it is possible that these

parenting styles may be a reaction to a childs previously

established troubled behaviour.

The present study has a number of strengths. Data were

utilized from a nationally representative dataset, making

results generalizable to Canadian children aged 25. The

Table 3 continued

Odds ratios (95 % confidence intervals)

Hyperactivity-inattention

Emotionaldisorder-anxiety

Physical aggression-conduct disorder

Indirectaggression

Single parent status

Lives with two parents 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Lives with single parent 0.77 [0.34, 1.77] 1.50 [0.56, 4.03] 1.12 [0.51, 2.43] 1.54 [0.75, 3.17]

Socio-demographic factors

Income adequacy


Low 0.84 [0.31, 2.27] 0.74 [0.24, 2.26] 1.55 [0.70, 3.44] 1.13 [0.53, 2.41]

Maternal education


Low 1.74 [0.69, 4.39] 0.29 [0.09, 0.95] 0.60 [0.22, 1.63] 1.07 [0.46, 2.49]

Maternal immigration

Non-immigrant 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference

Immigrant 0.96 [0.28, 3.35] 2.08 [0.11, 38.33] 0.17 [0.01, 2.54] 1.61 [0.70, 3.72]

Comorbid hyperactivity-inattention


Yes 1.53 [0.76, 3.07] 2.85 [1.62, 5.03] 1.75 [1.08, 2.84]

Comorbid emotional disorder-anxiety


Yes 1.80 [0.88, 3.71] 2.70 [1.27, 5.75] 2.03 [1.10, 3.75]

Comorbid physical aggression-conduct disorder


Yes 2.36 [1.30, 4.27] 2.42 [1.10, 5.33] 2.37 [1.32, 4.26]

Comorbid indirect aggression


Yes 1.69 [0.99, 2.88] 1.94 [1.05, 3.61] 2.53 [1.38, 4.64]

History of outcomeNo 1.00 Reference 1.00 Reference 1.00 Reference

Yes 3.90 [2.16, 7.05] 2.65 [1.31, 5.35] 3.62 [2.14, 6.12]


1 3


9/12

large sample allowed for ample statistical power in the

analysis of multivariable relationships. The present study

accounted for outcome comorbidity and a previous history

of outcome. Including such measures is important in reli-

ably assessing the relationship between PPD and mental

health outcomes in epidemiological research given that

comorbidity is common in psychiatric illness [43], and

childrens early and later mental health status are oftenhighly correlated. To the authors knowledge, this is the

first study to consider parenting style while investigating

the relationship between postpartum depression and

childhood outcomes, a factor which has been associated

with both postpartum depression and childhood behav-

ioural/emotional outcomes.

It is important to consider several limitations. Perhaps

the most important is reliance upon self-report by biolog-

ical mothers to obtain measures of exposure and outcomes,

instead of the use of clinically-trained assessors. While

biological mothers are generally recognized as reliable

informants regarding their offspring, a concern exists thatmaternal PPD may cause mothers to over-report disordered

behaviours among their children [39]. It is also generally

recognized in the field of child psychiatric epidemiology

that reports from multiple informants are optimal [56] and

it may have been beneficial to supplement PMK reports

with those of a second party. While the NLSCY also col-

lected data on behavioural/emotional outcomes from

school-aged childrens teachers, a majority of these data

were missing. Missing data was also present due to the

longitudinal nature of this study. Among all the NLSCY

participants, the response rate at cycle 2 was 91.7 and

89.6 % at cycle 3. An additional limitation was thepotential for misclassification introduced by utilization of

the 80th percentile cut-off for classifying children into

outcome groups. While it would have been ideal to treat

these variables as linear, the distribution of scale scores

demonstrated high levels of skewness, as is commonly

found in ratings of problematic behaviour [57]. The non-

normal distribution would make elevated scale scores rare

and equal scale division problematic. Lastly, factors such

as familial history of psychiatric disorders were not col-

lected and could not be adjusted for. One population-based

study indicated that approximately 4 % of fathers experi-

ence PPD and paternal PPD may be associated with

behavioural/emotional disorders among offspring [58].

Residual confounding is likely to exist, as familial history

could not be accounted for in the analysis.

The findings of the present study do not suggest that

PPD is independently associated with any enduring

sequelae in the realm of child behavioural/emotional psy-

chology, though the symptoms of PPD may be giving way

to other important mediating factors such as parenting

style. Specifically, the present study has highlighted

positive parenting techniques and practices as a potential

area for intervention, as negativistic parenting techniques

may be a function of PPD and appear to be associated with

childhood emotional/behavioural outcomes. The results

have also demonstrated the need for further research in

clarifying the relationship between these factors to identify

where prevention efforts should be targeted to reduce the

burden of childhood psychiatric illness.

Acknowledgments While the research and analyses are based ondata from Statistics Canada, the opinions expressed do not representthe views of Statistics Canada. The authors would like to thank theNLSCY study participants, Statistics Canada, Human Resources andSkills Development Canada (HRSDC) and the staff at the TorontoRegionStatistics Canada Research Data Centre.

References

1. Waddell, C., Offord, D. R., Shepherd, C. A., Hua, J. M., &McEwan, K. (2002). Child psychiatric epidemiology and Cana-dian public policy-making: The state of the science and the art ofthe possible. Canadian Journal of Psychiatry, 47, 825832.

2. Waddell, C., McEwan, K., Shepherd, C. A., Offord, D. R., &Hua, J. M. (2005). A public strategy to improve the mental healthof Canadian children. Canadian Journal of Psychiatry, 50,226233.

3. Loeber, R., Burke, J., & Pardini, D. A. (2009). Perspectives onoppositional defiant disorder, conduct disorder, and psychopathicfeatures.Journal of Child Psychology Psychiatry, 50, 133142.

4. American Psychiatric Association. (2000). Diagnostic and sta-tistical manual of mental disorders, 4th edn, Text Revision.Arlington: American Psychiatric Publishing Inc.

5. Lim, K. L., Jacobs, P., Ohinmaa, A., Schopflocher, D., & Dewa,C. S. (2008). A new population-based measure of the economic

burden of mental illness in Canada. Chronic Diseases in Canada,28, 9298.6. World Health Organization. (2004).Prevention of mental disor-

ders: Effective interventions and policy options. Geneva, Swit-zerland: World Health Organization.

7. Waddell, C., McEwan, K., Peters, R. D., Hua, J. M., & Garland,O. (2007). Preventing mental disorders in children: A publichealth priority.Canadian Journal of Public Health, 98, 174178.

8. Hill, J. (2002). Biological, psychological and social processes inthe conduct disorders. Journal of Child Psychology and Psychi-atry, 43, 133164.

9. Dennis, C.-L. E., Janssen, P. A., & Singer, J. (2004). Identifyingwomen at-risk for postpartum depression in the immediatepostpartum period. Acta Psychiatrica Scandinavica, 110,338346.

10. Bashiri, N., & Spielvogel, A. M. (1999). Postpartum depression:A cross-cultural perspective.Primary Care Update for OB/GYNS,6, 8287.

11. Paulson, J. F., Dauber, S., & Lieferman, J. A. (2006). Individualand combined effects of postpartum depression in mothers andfathers on parenting behaviour. Pediatrics, 118, 659668.

12. Moehler, E., Brunner, R., Wiebel, A., Reck, C., & Resch, F.(2006). Maternal depressive symptoms in the postnatal period areassociated with long-term impairment of mother-child bonding.

Archives of Womens Mental Health, 9, 273278.13. Bennett, H., Einarson, A., Taddio, A., Koren, G., & Einarson, T.

R. (2004). Prevalence of depression during pregnancy: System-atic review. Obstetrics & Gynecology, 103, 698709.


1 3


10/12

14. Hiltunen, P., Jokelainen, J., Ebeling, H., Szajnberg, N., &Moilanen, I. (2004). Seasonal variation in postnatal depression.

Journal of Affective Disorders, 78, 111118.15. Meredith, P., & Noller, P. (2003). Attachment and infant diffi-

cultness in postnatal depression. Journal of Family Issues, 24,668686.

16. Chung, T. K. H., Lau, T. K., Yip, A. S. K., Chiu, H. F. K., & Lee,D. T. S. (2001). Antepartum depressive symptomatology isassociated with adverse obstetric and neonatal outcomes. Psy-chosomatic Medicine, 63, 830834.

17. Pawlby, S., Sharp, D., Hay, D., & OKeane, V. (2008). Postnataldepression and childhood outcome at 11 years: The importance ofaccurate diagnosis.Journal of Affective Disorders, 107, 241245.

18. Lusskin, S. I., Pundiak, T. M., & Habib, S. M. (2007). Perinataldepression: Hiding in plain sight. Canadian Journal of Psychia-try, 52, 479488.

19. Hay, D. F., Angold, A., Pawlby, S., & Harold, G. T. (2003). Path-ways to violence in the children of mothers who were depressedpostpartum.Developmental Psychology, 39, 10831094.

20. Johnson, P. L., & Flake, E. M. (2007). Maternal depression andchild outcomes. Psychiatric Annals, 37, 404410.

21. Sharp, D., Hay, D. F., Pawlby, S., Schmucker, G., Allen, H., &Kumar, R. (1995). The impact of postnatal depression on boysintellectual development. Journal of Child Psychology and Psy-chiatry, 36, 13151336.

22. Kurstjens, S., & Wolke, D. (2001). Effects of maternal depressionon cognitive development of children over the first 7 years of life.

Journal of Child Psychology and Psychiatry, 42, 623636.23. Murray, L., Hipwell, A., Hooper, R., Stein, A., & Cooper, P.

(1996). The cognitive development of 5-year old children ofpostnatally depressed mothers. Journal of Child Psychology andPsychiatry, 37, 927935.

24. Murray, L. (1992). The impact of postnatal depression on infantdevelopment. Journal of Child Psychology and Psychiatry, 33,543561.

25. Hay, D. F., Pawlby, S., Waters, C. S., & Sharp, B. (2008).Antepartum and postpartum exposure to maternal depression:Different effects on different adolescent outcomes. Journal ofChild Psychology and Psychiatry, 49, 10791088.

26. Philipps, L. H. C., & OHara, M. W. (1991). Prospective study ofpostpartum depression: 4-year follow-up of women and chil-dren. Journal of Abnormal Psychology, 100, 151155.

27. Caplan, H. L.,Cogill,S. R.,Alexandra,H., Robson, K. M.,Katz, R.,&Kumar, R. (1989). Maternal depression and the emotional develop-ment of the child. British Journal of Psychiatry, 154, 818822.

28. Human Resources Development Canada and Statistics Canada.(2005). National Longitudinal Survey of Children and Youth:Users Handbook and Microdata Guide. Cycle 6. Ottawa: Min-ister of Industry.

29. Hotton, T. (2003). Childhood aggression and exposure to vio-lence in the home. Statistics Canada, Crime and Justice ResearchPaper Series. Ottawa: Minister of Industry.

30. Strayhorn, J. M., & Weidman, C. S. (1988). A parent practices

scale and its relation to parent and child mental health. Journal ofthe American Academy of Child and Adolescent Psychiatry, 27,613618.

31. Charach, A., Cao, H., Schachar, R., & To, T. (2006). Correlatesof methylphenidate use in Canadian children: A cross-sectionalstudy. Canadian Journal of Psychiatry, 51, 1726.

32. To, T., Cadarette, S. M., & Liu, Y. (2001). Biological, social, andenvironmental correlates of preschool development. Child: Care,

Health and Development, 27, 187200.33. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The

McMaster family assessment device. Journal of Marital andFamily Therapy, 9, 171180.

34. Landy, S., Tam, K. K. (1998). Understanding the contribution ofmultiple risk factors on child development at various ages.Gatineau: Applied Research Branch, Strategic Policy, HumanResources Development Canada.

35. Radloff, L. S. (1977). The CES-D scale: A self-report depressionscale for research in the general population. Applied Psycholog-ical Measurement, 1, 385404.

36. Halligan, S. L., Murray, L., Martins, C., & Cooper, P. J. (2007).Maternal depression and psychiatric outcomes in adolescent

offspring: A 13-year longitudinal study. Journal of AffectiveDisorders, 97, 145154.

37. Halligan, S. L., Herbert, J., Goodyer, I. M., & Murray, L. (2003).Exposure to postnatal depression predicts elevated cortisol inadolescent offspring. Biological Psychiatry, 55, 376381.

38. Cornish, A. M., McMahon, C. A., Ungerer, J. A., Barnett, B.,Kowalenko, N., & Tennant, C. (2005). Postnatal depression andinfant cognitive and motor development in the second postnatalyear: The impact of depression chronicity and infant gender.

Infant Behavior and Development, 28, 407417.39. Boyle, M. H., & Pickles, A. R. (1997). Influence of maternal

depressive symptoms on ratings of childhood behavior. Journalof Abnormal Child Psychology, 25, 399412.

40. Hess, N. H., & Hagen, E. H. (2006). Sex differences in indirectaggression: Psychological evidence from young adults. Evolutionand Human Behavior, 27, 231245.

41. Osterman, K., Bjorkqvist, K., Lagerspetz, K. M. J., Kaukiainen,A., Landau, S. F., Fraczek, A., et al. (1998). Cross-cultural evi-dence of female indirect aggression. Aggressive Behaviour, 24,18.

42. Bjorkqvist, K., Lagerspetz, K. M. J., & Kaukiainen, A. (1992).Do girls manipulate and boys fight? Developmental trends inregard to direct and indirect aggression. Aggressive Behavior, 18,117127.

43. Marshall, T., & Ramchandani, P. (2008). Emotional disorders andchildren and adolescents. Medicine, 36, 478481.

44. Shaw, D. S., Schonberg, M., Sherrill, J., Huffman, D., Lukon, J.,Obrosky, D., et al. (2006). Responsivity to offsprings expressionof emotion among childhood-onset depressed mothers. Journal ofClinical Child and Adolescent Psychology, 35, 490503.

45. Edhborg, M., Lundh, W., Seimyr, L., & Widstrom, A. M. (2001).The long-term impact of postnatal depressed mood on mother-child interaction: A preliminary study. Journal of Reproductiveand Infant Psychology, 19, 6171.

46. Hart, S., Field, T., & del Valle, C. (1998). Depressed mothersinteractions with their one-year-old infants. Infant Behavior and

Development, 21, 519525.47. Beck, C. T. (1999). Maternal depression and child behaviour prob-

lems: A meta-analysis.Journal of Advanced Nursing, 29, 623629.48. Patterson, G. R. (1982). Coercive family process. Eugene, Ore-

gon: Castalia Publishing Company.49. Harrington, R. (2004). Behavioural disorders in children and

adolescents. Medicine, 32, 5557.50. Morrell, J., & Murray, L. (2004). Parenting and the development

of conduct disorder and hyperactive symptoms in childhood: Aprospective longitudinal study from 2 months to 8 years. Journalof Child Psychology and Psychiatry, 44, 489508.

51. Nix, R. L., Pinderhughes, E. E., Dodge, K. A., Bates, J. E., Pettit,G. S., & McFadyen-Ketchum, S. A. (1999). The Relationbetween mothers hostile attribution tendencies and childrensexternalizing behavior problems: The mediating role of mothersharsh disciplining practices. Child Development, 70, 896909.

52. Rey, J. M., Walter, G., Plapp, J. M., & Denshire, E. (2000).Family environment in attention deficit hyperactivity, opposi-tional defiant and conduct disorders. Australian and New Zealand

Journal of Psychiatry, 34, 453457.


1 3


11/12


12/12

C o p y r i g h t o f M a t e r n a l & C h i l d H e a l t h J o u r n a l i s t h e p r o p e r t y o f S p r i n g e r S c i e n c e & B u s i n e s s

M e d i a B . V . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a

l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t ,

d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

maternal postpartum depression and risk of psychopathology

Documents