Professional Documents
Culture Documents
DOI 10.1007/s10995-012-1071-2
M. J. Walker (&)
Division of Epidemiology, Faculty of Medicine, Dalla Lana
School of Public Health, University of Toronto, Toronto, Canada
e-mail: meghan.walker@utoronto.ca
M. J. Walker
Prevention and Cancer Control, Cancer Care Ontario,
620 University Avenue, 11th Floor, Toronto, ON M5G 2L7,
Canada
C. Davis
Department of Psychiatry, Faculty of Medicine, University
Health Network, Toronto, Canada
C. Davis
Centre for Addiction and Mental Health, Toronto, Canada
C. Davis B. Al-Sahab H. Tamim
Faculty of Health Sciences, School of Kinesiology and Health
Science, York University, Toronto, Canada
Introduction
Behavioural and emotional disorders are prevalent among
children and can cause significant impairment and maladaptation in familial, social, academic and community settings. 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
123
908
later psychopathology [3], and are associated with unemployment, substance abuse and suicide [4]. The burden
upon the Canadian economy is extensive. In 2008 it was
estimated that the direct and indirect costs attributed to
mental health disorders in Canada among adults totalled
more than $51 billion in 2003 [5]. Consequently, the World
Health Organization (WHO) has indicated that early prevention is the only sustainable approach in significantly
reducing this burden [6]. Largely due to substantial gaps in
knowledge regarding the implicated risk, protective and
mediating factors, a majority of current interventions are
therapeutic as opposed to preventive [7].
The etiology of psychiatric disorders has been widely
studied and appears to be highly multifactorial [8]. The
potential influence of maternal psychological morbidity has
been examined at great length. Pregnancy and the postpartum
period represent a time of increased vulnerability for women,
particularly for the development of mood disorders [9]. Specifically, postpartum depression (PPD) is perhaps the most
commonly experienced. PPD is defined by the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition-Text
Revision (DSM-IV-TR) [4] as a major depressive episode
lasting longer than two weeks, depressed mood or loss of
interest, somatic symptoms, guilt or suicidal ideation [10].
North American and European literature commonly suggests
prevalence rates of approximately 1025 % [1116].
A number of studies have focused on the potential
influences of prenatal and postpartum depression on the
offspring of depressed mothers. Few studies have focussed
specifically upon childhood psychological disturbances,
however outcomes including Oppositional-Defiant Disorder
and Conduct Disorder [17], inattention-hyperactivity, separation anxiety [18, 19], lower cognitive scores [2022],
violent behaviour and substance abuse [19, 20] have been
reported. Others have reported that the adverse effects
reported in childhood appear to attenuate with age [23, 24],
while some have reported no evidence that PPD is associated with adverse effects [2527]. Studies thus far have been
unable to clearly establish a direct link between mothers
PPD and psychopathological outcomes in offspring.
Behavioural and emotional disorders constitute a major
public health concern in Canada and the U.S. The epidemiological evidence regarding the influence of PPD on
childhood behavioural/emotional outcomes is equivocal
and research which considers a comprehensive range of
potentially important confounders is lacking. Such research
may ultimately guide the development of more effective
prevention practices, as called for by the WHO [6]. Thus,
the objective of the present study was to investigate, across
the Canadian provinces and territories, the most prevalent
behavioural/emotional outcomes in relation to PPD in the
biological mother, among children aged 23 and 45 while
adjusting for a number of potentially important covariates.
123
Methods
Study Design
The study proceeded as a secondary longitudinal analysis of
Canadian children aged 25, utilizing data from Cycles 1
through 3 of the National Longitudinal Survey of Children
and Youth (NLSCY). The NLSCY is a Canadian population-based household survey of child health, development
and well-being [28]. The study began with a representative
sample of children aged 011 years from the 10 Canadian
provinces. From 1994 to present, the children have been
followed at 2-year intervals. At all cycles, the NLSCY
administers questionnaires to the person most knowledgeable (PMK) about the index child and/or to the index child.
The NLSCY has been previously described [28]. Baseline
data were collected at Cycle 1 in 19941995, when children
were 011 months and follow-up data were gathered at
Cycle 2 in 19961997, when children were 23 years of age
and at Cycle 3 in 19981999, when children were 45 years
of age. Data were collected through telephone interviews.
All interviews were conducted by Statistics Canada staff
trained through self-study materials and classroom sessions
[28]. Data were accessed through the Statistics Canada
Toronto Region Research Data Centres.
Sample
All variables in the NLSCY pertaining to the present study
were collected by self-report by the Person Most Knowledgeable (PMK) about the child. Cases where the PMK
was not the biological mother were excluded. However, the
PMK was the biological mother for a majority of children
at all data cycles. At Cycle 2, n = 1709 children were
eligible, however children for whom the PMK was not the
birth mother or had missing data on mothers PPD status
were excluded (n = 257), leaving a final sample of 1452.
At cycle 3, n = 1,630 children were eligible, however
children for whom the PMK was not the birth mother, had
missing data on mothers PPD status were excluded
(n = 273), leaving a final sample of 1,357.
Measures
The main exposure variable was presence of PPD at cycle
1. The PMK was asked whether they had PPD within the
first year following birth and asked to quantify the number
of days, weeks or months. Only PMKs of children
011 months of age were asked about the mothers PPD
status, limiting the recall period to a maximum of 1 year. A
derived variable was created, consistent with diagnostic
criteria of the DSM-IV-TR [4]; mothers who reported
14 days or less were grouped as not having PPD and those
909
Results
A reported 8.4 % (n = 122) of mothers were affected by
PPD in the year following birth of the child. A similar
proportion 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 1 and 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].
Table 2 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
123
910
Emotional disorder-anxiety
Physical aggression-opposition
Separation anxiety
Indirect aggression
123
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 Disorders 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 relationship 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-hyperactivity, 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
911
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
Emotional
disorder-anxiety
Physical
aggression-opposition
Separation
anxiety
Female
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Male
Not preterm
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Preterm
Normal
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
3.18 [0.97,10.45]
1524
2534
35?
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Smoked
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Drank
No PPD
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
PPD
Child factors
Childs sex
Obstetric factors
Preterm birth
Birthweight
Postpartum depression
Environmental factors
Parenting style: positive interaction
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
High
Low
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
High
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
Family functioning
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Moderate to severe
1.00 Reference
1.18 [0.50, 2.77]
1.00 Reference
1.68 [0.91, 3.12]
1.00 Reference
0.45 [0.18, 1.14]
1.00 Reference
0.68 [0.36, 1.29]
123
912
Table 2 continued
Odds ratios [95 % confidence intervals]
Hyperactivity-inattention
Emotional
disorder-anxiety
Physical
aggression-opposition
Separation
anxiety
Socio-demographic factors
Income adequacy
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
Non-immigrant
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Immigrant
Low
Maternal education
Comorbid hyperactivity-inattention
No
1.00 Reference
1.00 Reference
1.00 Reference
Yes
1.00 Reference
1.00 Reference
1.00 Reference
Yes
1.00 Reference
1.00 Reference
1.00 Reference
Yes
1.00 Reference
1.00 Reference
1.00 Reference
123
913
Table 3 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 3
(ages 45, N = 1,357)
Odds ratios (95 % confidence intervals)
Hyperactivityinattention
Emotional
disorder-anxiety
Indirect
aggression
Female
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Male
Child factors
Childs sex
Worry/unhappiness
No worry/unhappiness
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Worry/unhappiness
Obstetric factors
Preterm birth
Not preterm
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Preterm
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
1524
2534
35?
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Birthweight
Normal
Low
Maternal age at birth
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Smoked
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Drank
Postpartum depression
No PPD
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
PPD
Environmental factors
Parenting style: positive interaction
High
1.00 Reference
Low
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
High
Family functioning
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
1.00 Reference
2.38 [0.90, 6.28]
1.00 Reference
2.17 [0.80, 5.89]
1.00 Reference
1.16 [0.50, 2.72]
1.00 Reference
0.93 [0.41, 2.09]
123
914
Table 3 continued
Odds ratios (95 % confidence intervals)
Hyperactivityinattention
Emotional
disorder-anxiety
Indirect
aggression
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Socio-demographic factors
Income adequacy
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
Maternal education
High
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Low
Maternal immigration
Non-immigrant
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Immigrant
No
1.00 Reference
1.00 Reference
1.00 Reference
Yes
Comorbid hyperactivity-inattention
1.00 Reference
1.00 Reference
1.00 Reference
Yes
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
1.00 Reference
Yes
History of outcome
No
1.00 Reference
1.00 Reference
1.00 Reference
Yes
123
915
References
1. Waddell, C., Offord, D. R., Shepherd, C. A., Hua, J. M., &
McEwan, K. (2002). Child psychiatric epidemiology and Canadian public policy-making: The state of the science and the art of
the 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 health
of Canadian children. Canadian Journal of Psychiatry, 50,
226233.
3. Loeber, R., Burke, J., & Pardini, D. A. (2009). Perspectives on
oppositional defiant disorder, conduct disorder, and psychopathic
features. Journal of Child Psychology Psychiatry, 50, 133142.
4. American Psychiatric Association. (2000). Diagnostic and statistical 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 disorders: Effective interventions and policy options. Geneva, Switzerland: World Health Organization.
7. Waddell, C., McEwan, K., Peters, R. D., Hua, J. M., & Garland,
O. (2007). Preventing mental disorders in children: A public
health priority. Canadian Journal of Public Health, 98, 174178.
8. Hill, J. (2002). Biological, psychological and social processes in
the conduct disorders. Journal of Child Psychology and Psychiatry, 43, 133164.
9. Dennis, C.-L. E., Janssen, P. A., & Singer, J. (2004). Identifying
women at-risk for postpartum depression in the immediate
postpartum 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). Individual
and combined effects of postpartum depression in mothers and
fathers 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 are
associated 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: Systematic review. Obstetrics & Gynecology, 103, 698709.
123
916
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 difficultness 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 is
associated with adverse obstetric and neonatal outcomes. Psychosomatic Medicine, 63, 830834.
17. Pawlby, S., Sharp, D., Hay, D., & OKeane, V. (2008). Postnatal
depression and childhood outcome at 11 years: The importance of
accurate diagnosis. Journal of Affective Disorders, 107, 241245.
18. Lusskin, S. I., Pundiak, T. M., & Habib, S. M. (2007). Perinatal
depression: Hiding in plain sight. Canadian Journal of Psychiatry, 52, 479488.
19. Hay, D. F., Angold, A., Pawlby, S., & Harold, G. T. (2003). Pathways to violence in the children of mothers who were depressed
postpartum. Developmental Psychology, 39, 10831094.
20. Johnson, P. L., & Flake, E. M. (2007). Maternal depression and
child 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 boys
intellectual development. Journal of Child Psychology and Psychiatry, 36, 13151336.
22. Kurstjens, S., & Wolke, D. (2001). Effects of maternal depression
on 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 of
postnatally depressed mothers. Journal of Child Psychology and
Psychiatry, 37, 927935.
24. Murray, L. (1992). The impact of postnatal depression on infant
development. 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 of
Child Psychology and Psychiatry, 49, 10791088.
26. Philipps, L. H. C., & OHara, M. W. (1991). Prospective study of
postpartum depression: 4-year follow-up of women and children. 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 development 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: Minister of Industry.
29. Hotton, T. (2003). Childhood aggression and exposure to violence in the home. Statistics Canada, Crime and Justice Research
Paper 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 of
the American Academy of Child and Adolescent Psychiatry, 27,
613618.
31. Charach, A., Cao, H., Schachar, R., & To, T. (2006). Correlates
of methylphenidate use in Canadian children: A cross-sectional
study. Canadian Journal of Psychiatry, 51, 1726.
32. To, T., Cadarette, S. M., & Liu, Y. (2001). Biological, social, and
environmental 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 and
Family Therapy, 9, 171180.
123
917
56. Costello, E. J. (1989). Developments in child psychiatric epidemiology. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 836841.
57. Taylor, T. K., Burns, G. L., Rusby, J. C., & Foster, E. M. (2006).
Oppositional defiant disorder toward adults and oppositional
defiant disorder toward peers: Initial evidence for two separate
constructs. Psychological Assessment, 18, 439443.
58. Ramchandani, P., Stein, A., Evans, J., OConnor, T. G., & The
ALSPAC Study Team. (2005). Paternal depression in the postnatal period and child development: A prospective population
study. The Lancet, 365, 22012205.
123
Copyright of Maternal & Child Health Journal is the property of Springer Science & Business
Media B.V. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.