This study of directly interviewed children of depressed, predominantly Hispanic low-income mothers recruited from an urban primary-care practice found a significantly higher lifetime prevalence of depressive disorders, separation anxiety disorder, oppositional defiant disorder, any psychiatric disorder, and suicidal ideation when compared to children of never-depressed control mothers. Children of depressed mothers also reported lower psychosocial functioning across several areas, in particular lower general competence and overall home functioning, more problems with peers and with parents, and lower quality of relationships with their mother and siblings. The higher prevalence of psychopathology and lower functioning in this group of children are reflected in higher rates of outpatient and inpatient psychiatric treatment.
These findings in a low-income, minority population parallel the findings from several studies of children of depressed parents recruited from more affluent Caucasian populations. Children of depressed parents in these prior studies demonstrated increased rates of depressive, anxiety and disruptive behavior disorders, and lower psychosocial functioning[3
]. Consistent with these studies, children of depressed mothers in our study were vulnerable not only to depression but to other disorders as well. Although Downey and Coyne,[11
] in their comprehensive review of the field, commented that children of depressed parents’ social and school problems are not due to lower intellectual capacity, other studies have reported lower scores on intelligence measures in addition to lower academic performance.[12
] In our study, although there was a trend toward more behavioral problems at school, there were no significant differences in academic performance or measured IQ when compared with children of control mothers. We also found that children of depressed mothers had more problems in relationships with family and peers.
Studies have shown that children living in poor neighborhoods are at increased risk for mental health problems, even after accounting for maternal depression.[ 20
] Low socioeconomic status particularly increases risk not only for childhood externalizing problems, such as disobedience, impulsivity, and relationship difficulties,[19
] but also for internalizing problems.[20
] At the same time, poverty has been associated with higher rates of maternal depression and higher numbers of single-mother homes, thus compounding risk for poor children. Several studies have shown that children living in single-mother homes are at increased risk for a range of problems, including emotional and behavior problems.[18
] Achenbach et al.[34
] reported that children with higher scores on internalizing and externalizing problems were more likely to have single, separated, or divorced parents, and parents who were receiving public assistance. More than half the families in our study had no father or stepfather living in the home. The presence of multiple risk factors is associated with higher risk of problematic outcomes in children.[18
It is difficult to compare the findings in our sample to those in samples of more affluent families due to methodological differences across studies, such as recruitment of depressed mothers from psychiatric versus primary-care treatment settings, inclusion of children of depressed fathers in some samples, and different inclusion and exclusion criteria, especially for the control mothers’ group. Our results, however, suggest that the overall lifetime prevalence of psychiatric disorders in children of low-income depressed mothers (84.6% in this sample) is in the upper range of that in children of depressed mothers from more affluent populations, if not somewhat higher. The combination of socioeconomic factors and maternal depression might place children at particularly high risk for emotional and behavioral problems. Of note, in our sample even children of never-depressed mothers had a high lifetime prevalence of psychiatric disorders (50.0%), paralleling the findings from community studies of poor families and children described above.
Results from this study have implications for prevention and early intervention in primary-care practices serving low-income patients. Epidemiologic studies indicate that major depression is prevalent in primary-care settings, and particularly in practices serving low-income populations.[36
] Studies have shown that poor people are less likely to seek mental health treatment,[39
] less likely to receive treatment from mental health specialists,[40
] and more likely to exclusively rely on primary-care physicians for attention to their mental health needs when they do seek help.[42
] As shown in the data from the National Medical Expenditure Survey, medical doctors provide mental health care to 40% of poor and 47% of nearly poor mental health outpatients, as compared to only 27 % of low-income, 33% of middle-income, and 29% of high-income mental health outpatients.[42
] Several studies have recently reported that successful treatment of maternal depression can improve outcomes in the children, including improvement in symptoms and function.[9
] In the STAR*D-Child Study,[9
] results were similar whether mothers were treated in primary-care or psychiatric settings, although lower-income mothers had a poorer response to treatment. In addition to treating depression in the mother, asking basic questions about the emotional health of her children is an important step toward identifying and referring children who may be exhibiting early symptoms. Primary-care physicians who evaluate mothers with depression should add a few screening questions about the children.
Strengths of this study include: diagnostic information obtained directly from both children and mothers in the majority of cases, thus reducing possible bias stemming from including depressed mothers as sole informants[46
]; recruitment of mothers from a primary-care setting, thus allowing access to a sample of depressed mothers with a potentially broader range of illness severity, including some who might not have sought psychiatric treatment; recruitment of depressed and control mothers from the same setting, thus increasing comparability between depressed and control mothers with respect to potentially confounding sociodemographic variables; and, finally, access to families headed by a Spanish-speaking mother, a largely unstudied population, through bilingual clinical interviewers.
This study has several limitations. First, its sample size precludes examination of the specificity of associations of maternal depression with particular offspring diagnoses, for example, with depressive disorders versus oppositional defiant disorder. Second, given recruitment of a sample of convenience, it is not possible to know how representative our sample of mothers is of the population of mothers attending this primary-care practice. Third, information on six children of depressed mothers was obtained solely from their mothers, thus introducing some possible reporting bias. Finally, given that data were collected only on low-income families, this study does not allow a direct, statistical comparison of children of depressed mothers across socioeconomic groups.