PSY 211 Literature Worksheet
This worksheet will be completed using all three of the articles for your chosen track and will
inform the literature review section of your final project submission. Each category requires 2 to
3 sentences, but you may include more if necessary.
•
In Module One, you will complete only the Article One section and submit it to your
instructor for feedback.
•
In Module Three, you will have to complete all three sections (Article One, Article
Two, and Article Three) of this worksheet and submit it. Make sure to incorporate
your instructor’s feedback from Article One.
Make sure to use the Example Literature Worksheet as a guide when working on your Module
One and Module Three submissions.
Article One
Citation of Literature
[Include the citation of the reviewed resource in APA format.]
Authors’ Claims
[What claims did the authors make in the study you reviewed?]
Influence of Factors on Human Development
[What factors (physical, social, environmental) influenced development in the study? Describe
those factors and discuss which ones had positive influences and which ones had negative
influences.]
Historical Significance
[Explain how the article’s findings affect the historical evolution of developmental psychology.
What conclusions did you reach about developmental psychology from the article?]
Research Methods and Design
[What were the specific methods used to address the authors’ research question? What type of
research design was used and how was it used to conduct the research?]
Ethics
[How were ethics addressed in the studies? Were the studies conducted ethically? Why or why
not? How do they fit in with the view of ethics over the history of human development?]
Article Two
Citation of Literature
[Include the citation of the reviewed resource in APA format.]
Authors’ Claims
[What claims did the authors make in the study you reviewed?]
Influence of Factors on Human Development
[What factors (physical, social, environmental) influenced development in the study? Describe
those factors and discuss which ones had positive influences and which ones had negative
influences.]
Historical Significance
[Explain how the article’s findings affect the historical evolution of developmental psychology.
What conclusions did you reach about developmental psychology from the article?]
Research Methods and Design
[What were the specific methods used to address the authors’ research question? What type of
research design was used and how was it used to conduct the research?]
Ethics
[How were ethics addressed in the studies? Were the studies conducted ethically? Why or why
not? How do they fit in with the view of ethics over the history of human development?]
Article Three
Citation of Literature
[Include the citation of the reviewed resource in APA format.]
Authors’ Claims
[What claims did the authors make in the study you reviewed?]
Influence of Factors on Human Development
[What factors (physical, social, environmental) influenced development in the study? Describe
those factors and discuss which ones had positive influences and which ones had negative
influences.]
Historical Significance
[Explain how the article’s findings affect the historical evolution of developmental psychology.
What conclusions did you reach about developmental psychology from the article?]
Research Methods and Design
[What were the specific methods used to address the authors’ research question? What type of
research design was used and how was it used to conduct the research?]
Ethics
[How were ethics addressed in the studies? Were the studies conducted ethically? Why or why
not? How do they fit in with the view of ethics over the history of human development?]
Infant and Child Development
Inf. Child. Dev. 23: 353–373 (2014)
Published online 21 November 2013 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/icd.1830
Infant Developmental Outcomes: A
Family Systems Perspective
Ylva Parfitta,*, Alison Pikea and Susan Ayersb
a
School of Psychology, University of Sussex, Brighton, UK
School of Health Sciences, City University London, London, UK
b
The aim of the current study was to examine whether parental
mental health, parent–infant relationship, infant characteristics
and couple’s relationship factors were associated with the infant’s
development. Forty-two families took part at three time points.
The first, at 3 months postpartum, involved a video recorded observation (CARE-index) of parent–infant interactions. At 5 months
postpartum, in-depth clinical interviews (the Birmingham Interview of Maternal Mental Health) assessed parental mental health
and parental perceptions of their relationship with their infant,
their partner and their infant’s characteristics. Finally, the Bayley
Scales III was carried out 17 months postpartum to assess the
infants’ cognitive, language and motor development. A higher
mother–infant relationship quality was significantly associated
with more optimal language development, whilst a higher
father–infant relationship quality was associated with more
advanced motor development. Additionally, maternal postnatal
post-traumatic stress disorder had a negative impact on the
infant’s cognitive development, whilst maternal prenatal depression was associated with a less optimal infant’s language development. The largest prediction was afforded by parental perceptions
of their infant’s characteristics. The findings indicate that such
perceptions may be crucial for the infant’s development and
imply that negative internal parental perceptions should be considered when assessing risk factors or designing interventions to
prevent negative child outcomes. Copyright © 2013 John Wiley &
Sons, Ltd.
Key words: infant development; parental mental health; parent–
infant relationship; couple’s relationship; infant characteristics
*Correspondence to: Ylva Parfitt, School of Psychology, University of Sussex, Brighton, BN1
9QH, UK. E-mail: ylva.parfitt@btopenworld.com
Copyright © 2013 John Wiley & Sons, Ltd.
354
Y. Parfitt et al.
INTRODUCTION
Pregnancy and the first year of an infant’s life are critical times for laying the foundations for the child’s future development. Research suggests that prevalence rates of
developmental problems in the under threes range between 11% and 13% (e.g.
Skovgaard et al., 2007; Tough et al., 2008). The identification of children at risk for
developmental problems is important, as untreated developmental problems may
have significant negative impact on the individuals and have economic and social
impacts on society as a whole (Tough et al., 2008). Research suggests a range of
interrelated risk factors for negative child developmental outcomes, such as poor
mental health of the mother (e.g. Brouwers, Van Baar, & Pop, 2001; Lung, Chiang,
Lin, & Shu, 2009; Murray, 2009), low levels of maternal social support (Tough, Siever,
Benzies, Leew, & Johnston, 2010) and poor quality of the couple’s relationship
(Hanington, Heron, Stein, & Ramchandani, 2012). Other major risk factors include
an impaired parent–infant relationship and attachment problems (Murray & Cooper,
1996; Tomlinson, Cooper, & Murray, 2005; Wan & Green, 2009), and also infant
factors, such as prematurity (Forcada-Guex, Pierrehumbert, Borghini, Moessinger,
& Muller-Nix, 2006), male gender (Hay et al., 2001; Tough et al., 2008) and difficult
infant temperament (Black et al., 2007).
The current study adds to this literature by including both mothers and fathers
in the analysis of the associations between their mental health, relationships with
infant and partner, infant characteristics, and their infant’s development, using
Belsky’s model of determinants of parenting (1984) as a general framework. This
model suggests that the parent–infant relationship (parenting) and the infant’s
characteristics have a direct effect on the child’s development and that parental
mental health and the couple’s relationship are related to infant outcomes by the
effect they have on parenting. However, more recent evidence has also suggested
direct links between parental mental health, the couple’s relationship and infant
developmental outcomes.
Parental Mental Health and Infant Development
There is ample evidence of adverse effects of maternal postnatal depression on the
infant’s cognitive, emotional and language development, behaviour, and mental
health (Lung et al., 2009; Murray, 2009; Murray & Cooper, 1996; Quevedo et al.,
2012). Links between paternal depression and less optimal language development
(Paulson, Keefe, & Leiferman, 2009) and adverse emotional and behavioural outcomes in children have also been found (Ramchandani, Stein, Evans, O’Connor, &
Team, 2005).
Mental health in pregnancy may be especially important for later child outcomes.
Accumulating evidence suggests that exposure to maternal prenatal anxiety and
stress in the womb may have long-term negative developmental consequences for
the baby (e.g. Glover, 2011; Punamaki et al., 2006; Van Batenburg-Eddes et al.,
2009). For example, the results of a large longitudinal study (Evans et al., 2011)
suggested that prenatal exposure to depression may be more predictive of less optimal child cognitive development than postnatal depression. It has been suggested
that this can be explained by abnormal physiological pathways within biological
systems (e.g. neuroendocrine, immune and cardiovascular systems) involved in
pregnancy and stress physiology, through which maternal prenatal mental health
exerts a risk on child development by affecting the fetal development (Federenko
& Wadhwa, 2004; Field, Diego, & Hernandez-Reif, 2006).
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
Infant Development: A Family Systems Perspective
355
The majority of research regarding the association between postnatal parental
mental health and the infant’s development has focused on depression. Less is
known about the effect of other aspects of parental mental health, such as anxiety
and post-traumatic stress disorder (PTSD), on the infant’s subsequent development.
A systematic review of the effects of postnatal maternal anxiety on children
(Glasheen, Richardson, & Fabio, 2010) found that the strongest adverse effects were
on somatic, behavioural and emotional problems in the child, but with inconclusive
evidence regarding the effect on children’s cognitive and general development. Also,
Bosquet Enlow et al. (2011) found that maternal PTSD symptoms 6 months postpartum were associated with measures of emotional regulation when the child was
13 months old. Similarly, Pierrehumbert, Nicole, Muller-Nix, Forcada-Guex, and
Ansermet (2003) found that the severity of PTSD symptoms amongst parents of
premature babies was a significant predictor of their children’s subsequent regulatory (e.g. sleeping and eating) problems. However, no known studies have assessed
infant developmental outcomes in relation to postnatal PTSD.
Infant Characteristics and Infant Development
Early difficult infant temperament has been associated with elevated rates of parental
mental health problems (e.g. Bang, 2011; Melchior et al., 2011), a less optimal parent–
infant relationship (Hofacker & Papousek, 1998; Zhu et al., 2007) and child behavioural problems (Bosquet Enlow et al., 2011; Dale et al., 2011; Jessee, Mangelsdorf,
Shigeto, & Wong, 2012), and also identified as a predictor of later difficult child
temperament (Canals, Hernandez-Martinez, & Fernandez-Ballart, 2011). Parental
perceptions of their infant’s characteristics have also been associated with the child’s
development (Hernandez-Martinez, Canals Sans, & Fernandez-Ballart, 2011; Molfese
et al., 2010). However, generally, it should be noted that the associations between
different variables, such as parental mental health and the infant’s temperament,
are reciprocal, not just one way. One aspect of infant characteristics is infant sleep
disturbance, which has been associated with worse parental prenatal and postnatal
mental health and child behavioural problems (Baird, Hill, Kendrick, & Inskip,
2009; Britton, 2011; Field et al., 2007; Lam, Hiscock, & Wake, 2003).
The Parent–Infant Relationship and Infant Development
Apart from the physiological pathways between women’s prenatal mental health
and child outcomes as mentioned earlier, the parent–infant relationship itself may
serve as an important behavioural pathway between parental mental health and
child outcomes (e.g. Grace, Evindar, & Stewart, 2003; Westbrook & Harden, 2010).
The parent–infant relationship has a central position in Belsky’s process model
(1984), not only as having a direct effect on the child’s development but also as a
mediator of other parental and child predictors. However, although several studies
(e.g. Grace et al., 2003; Murray, FioriCowley, Hooper, & Cooper, 1996; Westbrook &
Harden, 2010) have suggested the existence of mediation effects between parental
mental health and child outcomes through the parent–infant relationship, these
effects are not consistently found (e.g. McManus & Poehlmann, 2012).
Research shows that the quality of the mother–infant interaction may be affected
by maternal depression (for a review, see Field, 2010; Leinonen, Solantaus, &
Punamaki, 2003; for a meta-analysis, see Lovejoy, Graczyk, O’Hare, & Neuman,
2000), with evidence of deficiencies in the mother’s responsiveness and emotional involvement (Black et al., 2007; Murray et al., 1996) or hostile and intrusive interactions
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
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Y. Parfitt et al.
(Mantymaa, Puura, Luoma, Salmelin, & Tamminen, 2004). It has been suggested that
deficient maternal interactions and caregiving consequently affect the infant’s
responsivity (Field, 2010) and attention (Steadman et al., 2007), therein contributing
to less optimal cognitive (Slater, 1995) and language (Stein et al., 2008) child developmental outcomes. Some studies have specifically linked negative parental perceptions and representations of their infant to a less optimal parent–infant relationship
and subsequent child developmental or behavioural outcome (Dollberg, Feldman,
& Keren, 2010; Hernandez-Martinez et al., 2011).
Although most studies have focused on the mother–infant relationship, recent
research on the influence of fathers’ parenting and child development is also
emerging. For example, the extent of fathers’ positive involvement in parenting has
been shown to reduce the likelihood of cognitive delays in their children, especially
for boys (Bronte-Tinkew, Carrano, Horowitz, & Kinukawa, 2008). Conversely,
Ramchandani et al. (2013) found that paternal disengagement and remote interaction
with their babies at 3 months predicted child externalizing behavioural problems at
1 year of age.
The Couple’s Relationship and Infant Development
The aforementioned research shows that the family should be viewed as a system (e.g.
Bell et al., 2007; Cowan & Cowan, 2002) with an awareness of both parents’ contribution to their child’s outcomes and also acknowledgement of possible spillover effects
between the couple’s relationship and parent–infant relationship subsystems (Erel &
Burman, 1995). For example, the couple’s relationship problems may negatively affect
the parent–infant interactions (e.g. Mantymaa et al., 2006) and thereby indirectly contribute to the child’s outcomes (Carlson, Pilkauskas, McLanahan, & Brooks-Gunn,
2011; Leinonen et al., 2003; Westbrook & Harden, 2010) through parenting. Conflicts
within the couple’s relationship may also negatively indirectly influence the child’s
mental health, through having an effect on the child’s emotional security (e.g. Davies,
Harold, Goeke-Morey, & Cummings, 2002; Koss et al., 2011; Kouros, Cummings, &
Davies, 2010). Recently, the couple’s relationship has also been found to serve as a risk
factor for adverse child outcomes (Hanington et al., 2012).
The Present Study
In summary, research suggests that poor parental mental health is a risk factor for
negative infant developmental outcomes but has mainly focused on the effects of
maternal postnatal depression on the infant’s development. Research also suggests
that family relationship dynamics, primarily the parent–infant relationship itself,
may be an important mechanism by which parental mental health, infant characteristics and the couple’s relationship affect the infant’s development. However, there is
limited research including all of these factors and fathers. In addition, studies looking
at risk factors for negative child developmental outcomes need to be extended to also
include other mental health issues, such as PTSD and anxiety amongst both mothers
and fathers.
The main aim of this study was to examine whether parental mental health,
parent–infant relationship, infant characteristics and couple’s relationship variables
were directly or indirectly associated with the infant’s cognitive, language or motor
development. On the basis of previous research findings and Belsky’s model, it
was predicted that a less optimal perceived and observed parent–infant relationship,
poor parental mental health, low quality of the couple’s relationship and difficult
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
Infant Development: A Family Systems Perspective
357
infant temperament would be associated with less optimal infant developmental
scores. Whilst parental mental health, the parent–infant relationship and infant
characteristics would be directly associated with the infant’s development, it was
also predicted that the parent–infant relationship would act as a mediator between
parental mental health, the couple’s relationship, the infant temperament and the
infant’s development.
METHOD
Participants
Participants were 42 families recruited from the Sussex Journey to Parenthood Study
(UK), a longitudinal study of the transition to parenthood from pregnancy to the
postpartum. Inclusion criteria for the Journey to Parenthood Study were that the
women were nulliparous, cohabiting with their partner, fluent in English and over
18 years old. The majority of the participants of the present study were Caucasian
(86%), and 85% had undergone higher education (diploma and beyond). The babies
were born healthy and full term. At the time of the child development assessment,
the infants (23 girls and 19 boys) were between 16 and 20 months old (M = 17.17
months, SD = 0.73). At the time of recruitment, the length of the couple’s relationship
ranged from 1 to 25 years (M = 6.36 years, SD = 4.04) with the women aged between
26 and 46 years (M = 33.41 years, SD = 5.08) and the men aged between 26 and
44 years (M = 34.20, SD = 4.75).
Procedure
Ethical approval was obtained from the NHS Research Ethics Committee and the
University Research Governance Committee. Participants of the Sussex Journey to
Parenthood questionnaire study (N = 141, 75 women and 66 men) were invited to
take part in an observational study of their interaction with their baby approximately
3 months after the birth of their baby. Forty-five families agreed to take part in a short
parent–infant play interaction, conducted separately with the mother and father and
their baby at home and videotaped for later coding. Next, the parents who took part
in the observational study were also invited for a clinical interview (Birmingham
Interview for Maternal Mental Health), which took place approximately 5 months
after the birth of their first baby. There was no attrition between the observations of
interactions and the interviews. The interviews were conducted separately with the
mothers and fathers in their homes, and took between 75 and 120 min to complete.
Finally, 17 months after birth, the same families were invited to have a developmental assessment of their baby. Three families had moved away and were not
available, and one of the families declined to take part, resulting in the final
sample of 42 families.
The infant developmental assessment was carried out in the participants’
homes by a researcher who was qualified and trained in the use of the Bayley
Scales of Infant Development III, following the usual procedures (Bayley, 2006).
One or both parents were present throughout the assessment, which lasted
between 45 min and 1½ h. Written informed consent was obtained before the start
of each assessments, and confidentiality, anonymity and the right to withdraw at
any time were assured. Participants were debriefed and were also offered a brief
summary of their baby’s development after the assessment.
Copyright © 2013 John Wiley & Sons, Ltd.
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Y. Parfitt et al.
Measures
Infant development
The infant’s cognitive, language and motor development was assessed using the
Bayley Scales of Infant Development III (Bayley, 2006). It is composed of rating scales
and qualitative observations. It is an individually administered examination that
assesses the current developmental functioning of the infant. The Bayley Scale is a
widely used tool for assessing children’s development (e.g. Black et al., 2007; Huhtala
et al., 2011). It has been standardized and extensively reviewed for its psychometric
quality and tested for reliability (r, ranging from .86 to .93) and validity using large
samples of children with and without developmental delay (Bayley, 2006). Raw
scores from each scale were converted to three composite scores (M = 100, SD = 15),
one for cognition, one for language and one for motor development.
Mental health, relationship and infant factors
The Birmingham Interview of Maternal Mental Health (5th edition, Brockington,
Chandra, et al., 2006), a semi-structured clinical interview was used to assess
parental mental health. This interview has previously been used in a number of
international reliability studies (e.g. Brockington, Aucamp, & Fraser, 2006;
Chandra, Bhargavaraman, Raghunandan, & Shaligram, 2006) and used to validate
the Postpartum Bonding Questionnaire (Brockington, Fraser, & Wilson, 2006).
Anxiety and depression were rated on a 0–3 point scale (none, mild, moderate
and severe; rated 0–3), and PTSD, on a 0–2 point scale (none, some evidence and
severe). Ratings related to the other key variables under investigation were also
derived from the Birmingham Interview. Principal component analysis was
performed on groups of these interview items, to create summary scores for the
inter-correlated items, in order to reduce the number of predictor variables and
at the same time to retain as much information as possible. Items in the parent–
infant relationship section of the Birmingham Interview were reduced to two
factors of parental perceptions of their relationship with their infant, one for
mothers (explaining 53%) and one for fathers (explaining 62%). Items included
in these factors were angry response, onset of positive feelings, nature and
strength of feelings, and rough treatment towards baby. The infant characteristics
factor included both maternal and paternal reports of their infant’s temperament
and the infant’s sleeping difficulties, explaining 62% of the variance. The couple’s
relationship factor was derived from a combination of items for both parents’ postpartum support and relationship with the partner, explaining 61% of its variance.
In all cases, relevant items were summed using unit weights to form scale scores.
Parent–infant interaction
The CARE-index procedure (Crittenden, 2004) was utilized to analyse and code
short (3–5 min) video recordings of the parent–infant interactions on different
aspects of the parent and infant’s dyadic interactional behaviour. For the current
study, the global dyadic synchrony score was used. This score combines the judgments of parental sensitivity and infant cooperation (Crittenden, 2004) and ranges
from 0 to 14, with a high score, indicating a more optimal interactive relationship.
Reliability was tested for 12% of the video interactions. The intraclass correlation
coefficient (two-way random, absolute agreement, single measure) for this score
was .86, which indicates an excellent agreement between the main rater and first
author (YP).
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
Infant Development: A Family Systems Perspective
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Statistical Analysis
Correlational analyses and multiple regression analyses were conducted to examine
the associations between variables and impact of the predictor variables on the
children’s development. Thereafter, mediation effects were examined in accordance
with Baron and Kenny’s criteria (1986), to explore whether the associations between
the infant’s characteristics, parental mental health and the couple’s relationship with
cognitive, language and motor development were mediated by the quality of
mother–infant and father–infant perceptions of their relationship or observed
mother–infant and father–infant dyadic interaction. For each developmental outcome, mediation was tested through three regression models, separately for each predictor, mediator and outcome. The assumptions of multiple regression were met
regarding multicollinearity, homoscedasticity, and independent and normally distributed errors. Additionally, the developmental outcomes were normally distributed.
RESULTS
Preliminary Analysis and Descriptives
Missing data analysis revealed that 84% of parents had completed all of the measures
included in the present study. Parents with missing data (n = 14, 4 women and 10
men) did not differ from parents with complete data on ethnicity (χ 2(1) = 0.86,
p = .35), marital status (χ 2(1) = 0.70, p = .40), gender (χ 2(1) = 3.08, p = .08) or education
(χ 2(1) = 0.10, p = .75). The little missing completely at random test was not significant
(χ 2 = 18.90, p = ns). This indicates that the data were missing completely at random,
which suggests that the EM method for imputation of data is suitable (Tabachnick
& Fidell, 2007). Missing data for the predictor variables were therefore replaced using
the EM method, which concurs with the way similar studies have dealt with missing
data (e.g. Flykt, Kanninen, Sinkkonen, & Punamaki, 2010).
Mean scores for infant’s developmental ages are reported in Table 1. It shows that
on average the infants’ developmental age is within normal age limits with slightly
higher means than their actual age on most of the scales and just below their actual
age on the gross motor scale. However, when looking at the range of developmental
outcomes, it should be noted that there was variability amongst the children, with
some being considerably less developed than others, at the time of the assessment.
Similarly, Table 1 also indicates that all the composite scores of the infants’ performance on the Bayley Scales III are within normal limits. Descriptive statistics (means
and standard deviations) for parental mental health and parent–infant interaction
variables are also given in Table 1.
Univariate Predictors of Infant Development
To examine the prediction that a less optimal parent–infant relationship, parental
mental health problems, a low quality of the couple’s relationship and negative infant characteristics were associated with less optimal infant developmental scores;
correlation analyses were conducted on the main variables of interest. Correlations
between these are presented in Table 2. As shown, the infant’s negative characteristics were substantially associated with less optimal cognitive, language and motor
developmental outcomes. Also, maternal perceptions of a less optimal mother–infant
relationship were moderately associated with a poorer language development for the
infant, and paternal perceptions of a less optimal father–infant relationship were
moderately associated with a poorer motor development. For mental health issues,
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
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360
Table 1. Means and standard deviations for Bayley Scales developmental ages and
composite scores, parental mental health and parent–infant interaction variables
Scores
a
Cognitive development (months)
Receptive development (months)a
Expressive development (months)a
Fine motor development (months)a
Gross motor development ( months)a
Cognitive composite b
Language composite b
Motor composite b
Maternal prenatal depression
Maternal postnatal depression
Maternal prenatal anxiety
Maternal postnatal anxiety
Maternal post-traumatic stress disorder
Paternal prenatal depression
Paternal postnatal depression
Paternal prenatal anxiety
Paternal postnatal anxiety
Mother–infant global synchrony c
Father–infant global synchrony c
Range
Mean (SD)
12–21
10–26
8–22
11–23
7–20
75–125
68–129
64–121
0–3
0–2
0–3
0–3
0–2
0–3
0–2
0–3
0–2
2–13
2–12
18. 00 (2.06)
19.70 (3.40)
17.95 (3.17)
19.51 (2.44)
16.40 (3.19)
101.90 (10.99)
106.98 (14.58)
100.83 (12.07)
0.48 (0.77)
0.52 (0.70)
0.91 (1.00)
0.86 (0.98)
0.21 (0.51)
0.32 (0.67)
0.24 (0.60)
0.98 (0.88)
0.46 (0.64)
7.83 (2.64)
7.69 (2.42)
Note. N = 42. aThe mean age of the infants at the time of the developmental assessment was 17.2 months.
b
A score of 100 on any of the composites defines the average performance of a given age group. Scores of 85
and 115 are 1 SD below and above the mean. About 68% of all infants obtain composite scores between 85
and 115, about 98% score in the 70–130 range. Nearly all infants obtain scores between 55 and 145. cThese
scores are derived from observations of the parent–infant relationship.
maternal postnatal PTSD was moderately associated with poorer cognitive outcomes, whilst there was a moderate correlation between maternal prenatal depression and less optimal language development. All of these significant correlations
were in the predicted direction, with the higher developmental scores, the less
difficult infant characteristics, a more optimal parent–infant relationship and better
parental mental health.
Multivariate Predictors of Infant Development
To further examine the impact of the aforementioned predictor variables on the
infant’s development, three multiple regression analyses were conducted. A datadriven approach was used, where predictors that yielded medium-sized correlations
≥.2 (Cohen, 1992) with the infant developmental outcomes were entered into the
regressions in one step to test the independent contribution by each of these on the
infant’s cognitive, language and motor developmental outcomes.
The results of the first regression analysis regarding the infant’s cognitive development are shown in Table 3. This model included maternal prenatal depression,
maternal postnatal PTSD, maternal perceptions of the mother–infant relationship
and the infant’s characteristics factors. Overall, the predictors explained 27.5% of
the variance of the cognitive composite score, F(4, 37) = 3.50, p = .016, with a unique
significant contribution of maternal postnatal PTSD (β = .34, t = 2.20, p = .03).
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
361
Table 2. Correlations between infant developmental scores and predictor variables
Infant Development: A Family Systems Perspective
Copyright © 2013 John Wiley & Sons, Ltd.
Inf. Child. Dev. 23: 353–373 (2014)
DOI: 10.1002/icd
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Table 3. Multiple regression analyses regarding the parental mental health status, the
couple’s relationship, infant’s characteristics and parent–infant relationship in predicting
the infant’s cognitive development
Cognitive development
B
Predictor
Prenatal depression (women)
Postnatal post-traumatic stress disorder (women)
Mother–infant relationshipa
Infant’s characteristics
Total R2
F
**
Note. *p < .05. p < .01.
1.98
7.08
0.71
0.74
.28*
3.50
SE B
β
2.23
3.21
0.57
0.59
.14
.34*
.19
.21
***
p < .001. aPerceived parent–infant relationship, derived from interviews.
Regression results for the infant’s language development are detailed in Table 4.
The model included maternal and paternal prenatal depression, parental
perceptions of the mother–infant, the father–infant relationship and the infant’s
characteristics factors as well as the mother–infant and father–infant dyadic
interaction synchrony scores. The overall regression model for language
development was significant, F(7, 34) = 3.15, p = .01, with 39% of the variance
accounted for by the predictors. The only predictor adding a unique significant
contribution to infant language development, and thus in line with the
predictions, was the infant’s characteristics (β = .35, t = 2.13, p = .04). The total
regression model for motor development included the infant’s characteristics,
the perceived father–infant relationship factor, and the mother–infant and
father–infant dyadic interaction synchrony scores derived from observations
(Table 5). However, the total model failed to reach significance with only 18%
of the variance being accounted for by the predictors, F(4, 36) = 1.91, p = .13,
and contrary to predictions, none of the individual predictors contributed
significantly to motor development.
Mediation Analysis
Finally, to test the hypothesis that the parent–infant relationship would act as a
mediator between parental mental health, the couple’s relationship, the infant temperament and the infant’s development, mediation was tested through three regression models, separately for each predictor, mediator and developmental outcome.
For the cognitive developmental outcome, the first regression models showed
that both maternal PTSD, F(1, 40) = 5.62, p = .02, and the infant’s characteristics,
F(1, 40) = 7.56, p = .01, each significantly predicted the cognitive outcome. In the
second regression models, only the infant’s characteristics were significantly
associated with one of the mediators, the perceived father–infant relationship,
F(1, 40) = 5.55, p = .02. However, in the third regression model, the mediator
(the father’s perception of the father–infant relationship) failed to significantly
predict the outcome (cognitive development), whilst the infant’s characteristics
remained significantly associated with the outcome (β = .42, t = 2.71, p = .01).
For the language developmental outcome, a similar pattern of associations was
found, where maternal prenatal depression, F(1, 40) = 6.84, p = .01, and the infant’s
characteristics, F(1, 40) = 17.21, p = .001, fulfilled the first criteria of significantly
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Table 4. Multiple regression analyses regarding the parents’ mental health status, infant’s
characteristics and parent–infant relationship in predicting the infant’s language development
Language Development
B
Predictor
Prenatal depression (women)
Prenatal depression (men)
Mother–infant relationshipa
Father–infant relationshipa
Dyadic synchrony: mother–infantb
Dyadic synchrony: father–infantb
Infant’s characteristics
Total R2
F
4.14
0.82
0.70
0.43
0.18
1.05
1.66
.39**
3.15
SE B
β
3.01
3.45
0.84
0.71
0.86
0.93
0.78
.22
.04
.14
.09
.03
.17
.35*
Note. *p < .05. **p < .01. ***p < .001. aPerceived parent–infant relationship, derived from interviews.
b
Observed parent–infant relationship, derived from observations.
Table 5. Multiple regression analyses regarding the infant’s characteristics and parent–
infant relationship in predicting the infant’s motor development
Motor development
Predictor
B
SE B
β
Father–baby relationshipa
Dyadic synchrony: mother–infantb
Dyadic synchrony: father–infantb
Infant’s characteristics
Total R2
F
0.73
0.76
0.45
0.80
.18
1.91
0.61
0.77
0.83
0.65
.20
.17
.09
.21
*
**
***
Note. p < .05. p < .01. p < .001. aPerceived parent–infant relationship, derived from interviews.
b
Observed parent–infant relationship, derived from observations.
predicting the language developmental outcome, with only the infant’s characteristics factor being significantly associated with one of the mediators, the father–
infant relationship factor, F(1, 40) = 5.55, p = .02. As indicated earlier, the perceived
father–infant relationship was not a significant predictor of the language outcome
in the third regression analysis, whilst the infant’s characteristics factor remained
significant (β = .53, t = 3.69, p = .001).
For the motor developmental outcome, the infant’s characteristics factor was the
sole predictor that reached significance in the first regression analysis, F(1, 39) = 4.50,
p = .04. Also, as indicated earlier, the infant’s characteristics were only significantly
associated with one of the mediators, the perceived father–infant relationship factor.
However, in the third regression analysis, neither the infant’s characteristics nor the
father–infant relationship factor reached significance in predicting the motor
developmental outcome. These results, contrary to the hypothesis, indicate that none
of the parent–infant relationship variables mediated the relationship between
parental mental health, the infant’s characteristics or the couple’s relationship, and
the developmental outcomes.
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Y. Parfitt et al.
DISCUSSION
This study examined the association between parental mental health, the infant’s
characteristics, the couple’s relationship, parental perceptions of the parent–infant
relationship, parent–infant interaction, and infant’s cognitive, language and motor
development, using interviews and observations. The results showed that parent’s
perceptions of their infant’s characteristics were an important predictor of children’s
cognitive, language and motor development, whilst the mother’s perceptions of the
mother–infant relationship were mainly associated with the child’s language development and the father’s perception of the father–infant relationship with the child’s
motor development. However, no associations were found between observed
parent–infant interactions and the infant’s development. Amongst the parental
mental health variables, maternal postnatal PTSD was predictive of less optimal
infant cognitive development, and maternal prenatal depression was significantly
associated with less optimal infant language development. The hypotheses were
thus partially supported. Contrary to predictions, none of the parent–infant relationship variables acted as mediators between the other predictors and infant’s developmental outcomes. The following discussion further explores these findings in relation
to previous research, Belsky’s model of parenting (1984), and methodological issues
and implications.
Parental Mental Health and Infant Development
It was hypothesized that prenatal and postnatal mental health (depression, anxiety
and PTSD) would be associated with children’s development. Contrary to evidence
from several previous studies (e.g. Murray, 2009; Paulson et al., 2009; Quevedo et al.,
2012; Ramchandani et al., 2005), no significant associations between maternal or paternal postnatal depression and child developmental outcomes were found. These inconsistent results may be partly due to measurement issues, as previous research has
predominantly used self-report questionnaires to measure mental health. A recent
study (Keim et al., 2011) that used interviews to measure maternal psychological
health (anxiety, depression and stress) and infant cognitive development also found
no evidence of negative effects on the child’s development from poor psychological
health but, on the contrary, found that moderate psychosocial stress was associated
with accelerated motor and language development.
Another explanation for the lack of association between parental depression and
infant development at 17 months postpartum in the present study could be that such
effects are not apparent until later on in the child’s development. For example, a large
Taiwanese birth cohort study (Lung et al., 2009) did not find any significant effects of
parental mental health on the infant’s language and social development at 18 months
postpartum, but at 36 months, this effect became significant. Fletcher, Feeman,
Garfield, and Vimpani (2011) similarly found that early paternal depression
predicted child outcomes 4 years later. This highlights the importance of long-term
follow-ups of children’s developmental outcomes in relation to parental mental
health. Also, parental mental health symptoms should be followed up over time to
enable analyses of any differential effects of early, concurrent and chronic mental
health problems on child developmental outcomes.
In contrast, significant associations were uncovered between maternal prenatal
depression and language development. This finding corresponds to previous
research suggesting that prenatal exposure to depression may be even more detrimental and predictive of child developmental outcomes than parental postnatal
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mental health (e.g. Evans et al., 2011; Talge, Neal, & Glover, 2007). Importantly, the
current study also found that maternal postnatal PTSD was a significant predictor
of a less optimal cognitive development for the infant. As a novel finding, this
requires replication and further examination of the underlying mechanisms.
Although no previous studies have examined this, Bosquet Enlow et al. (2011) found
that maternal postpartum PTSD symptoms were associated with difficulties for the
infant to regulate emotions at 13 months postpartum. It could be speculated that this
may reduce the infant’s capacity to attend to cognitive learning activities and result in
a less optimal cognitive development. Another speculative mechanism could be the
mother’s insecure attachment style, which may have increased her vulnerability to
develop PTSD (e.g. Iles, Slade, & Spiby, 2011) and resulted in harmful effects on the
infant’s cognitive development. Other possible reasons may be that mothers with
PTSD may avoid contact and play with the baby (Nicholls & Ayers, 2007) or,
similarly to mothers with postnatal depression, lack contingent responses that in turn
limit their baby’s exposure to inferential learning (e.g. Hay et al., 2001).
The Couple’s Relationship and Infant Development
Contrary to predictions and recent research (e.g. Hanington et al., 2012), the couple’s
relationship was not associated with any of the infant developmental outcomes in the
present study. However, the results of the present study demonstrated a significant
association between the father’s perception of the couple’s relationship and the
father–infant relationship. This is in line with Erel and Burman’s ‘spill over hypothesis’ (1995) and other evidence of the couple’s relationship being predictive of a better
parent–infant relationship (Carlson et al., 2011), especially for the paternal parenting
behaviour (Florsheim & Smith, 2005). Contrary to Belsky’s model and previous
research (e.g. Leinonen et al., 2003; Westbrook & Harden, 2010) and as discussed
later, no mediation effects occurred through the perceived parent–infant relationship or observed parent–infant interaction between the couple’s relationship and
infant development.
Infant Characteristics and Infant Development
A key finding of this study was that the infant’s characteristics factor, which included
both parents’ perceptions of their infant’s temperament and sleep disturbances, was
an important predictor of all three infant developmental outcomes. This finding
supported the hypothesis and Belsky’s model (1984), which suggests a direct effect
of infant characteristics on the infant’s development. Empirical evidence also agrees
that early infant characteristics are an important factor to consider when predicting
the child’s developmental (Hernandez-Martinez et al., 2011; Molfese et al., 2010)
and behavioural outcomes, especially when combined with parental mental health
problems (e.g. Black et al., 2007; Jessee et al., 2012).
Apart from these authors, there is limited research regarding parental perceptions
of their infant’s characteristics in relation to their mental health, their relationship
with their infant and infant developmental outcomes. It would also be necessary to
follow the trajectories of the child’s development across the first years of development in order to analyse whether different factors play a role over time. For example,
Feldman and Eidelman (2009) suggested that although biological infant characteristics, such as the infant’s neonatal vagal tone at birth, were initially linked to the
baby’s cognitive and social emotional development across the first year, environmental factors such as parental mental health interfered with the child’s development at a
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later stage. In the current study, the infant’s development was assessed at one time
point only. This meant that the infant’s earlier development could not be controlled
for. However, it may be possible that the parental perceptions of their infant’s characteristics included aspects of the infant’s development. For example, a parent with
a developmentally more able child may also perceive their child as more temperamentally ‘easy’. One other aspect of the baby’s characteristics that has been
linked to less optimal child developmental outcomes is male gender (e.g. Tough
et al., 2008). Infant gender was therefore initially included in the analysis, but
no significant associations were found with the infant’s gender and any of the
other variables, so was therefore excluded.
The Parent–Infant Relationship and Infant Development
The role of the parental perceptions of the parent–infant relationship and parent–
infant interactions for the infant’s developmental outcome was of central importance
to this study. The results are partly in line with the prediction of a significant association between these and child development. It was found that the perceived mother–
infant relationship was significantly associated with the language development and
also that the perceived father–infant relationship was significantly correlated with
the motor development. However, neither the mother–infant nor father–infant global
dyadic interaction scores reached significance in their association with developmental outcomes, although the correlations were in the predicted direction. Furthermore,
none of the relationship variables made a unique contribution to the variance of any
of the developmental outcomes. The link between the mother–infant relationship
and language development concurs with other studies. For example, Leigh, Angela
Nievar, and Nathans (2011) found that sensitive mother–infant interactions positively influenced the child’s later expressive language, and Stein et al. (2008) found
that a poorer quality of maternal caregiving at 10 months predicted a lower language
outcome at 36 months.
There is sparse research with which to compare the finding of a link between the
father–infant relationship and children’s motor development. However, one speculative explanation for this comes from a study (Liu, Liu, & Lin, 2001) that concluded
that physical touch was beneficial to the baby’s psychomotor development. As the
father’s play with their baby is characterized by being more physically stimulating
than the mother’s play (e.g. Kobayashi, 2008; Lewis & Lamb, 2003), the baby who
has a more optimal relationship with their father may get extra stimulation through
touch and affection from the father (Combs-Orme & Renkert, 2009), which consequently aids their motor development. These results indicate that mothers’ and
fathers’ relationships with their infant may influence different areas of their development. Further studies of child developmental outcomes may therefore benefit from
comparing the types of play and care activities that mothers and fathers engage in
with their infant and later child developmental outcomes.
Finally, it was predicted that the parent–infant relationship would have a mediating role between the other variables and the infant’s developmental outcomes, but no
such mediation effect was found. The lack of significant mediation effects of the
parent–baby relationship may be due to methodological issues, such as the small
sample size. Another methodological limitation and potential explanation for the
lack of mediation effects could be that the observational measure of the parent–infant
interaction was collected a few weeks before the parental mental health interview
measure. However, similarly to the current study, McManus and Poehlmann (2012)
found no mediation effects of the quality of parent–infant interaction between maternal depression and children’s cognitive development.
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Methodological Issues and Future Directions
This study benefitted from ‘gold standard’ methods with direct observations, indepth interviews and assessments of the infant’s development. The benefit of
using face-to-face interview measures rather than self-report measures for
predicting children’s outcomes has previously been acknowledged by Pawlby,
Sharp, Hay, and O’Keane (2008). As previously discussed, different
measurement approaches are likely to influence results of studies. In the current
study, the interview measure and observational measure for the parent–infant
relationship differed in their links with child development and were not
significantly correlated with each other. These measures thus reflect different
aspects of the parent–infant relationship. Interestingly, the interview measure
appeared to be a better predictor of the infant’s development than the observational measure of the parent–infant interaction. One reason for this could be that
the observational measure was collected at a slightly earlier time point than the
interview measure. However, the predictive power of self-reported parental
mental representations and parental beliefs about their relationship with their
baby has been found in other studies of child behaviour outcomes (e.g. Barnett,
Shanahan, Deng, Haskett, & Cox, 2010). Flykt et al. (2010) suggested that
interview measures of the parent–infant relationship reflect parents’ attachment-related internal working models (e.g. Fonagy & Target, 2002) to a greater
extent than direct parent–infant interactions, which are only snap-shots of the
relationship, whereas parents’ reflections represent many hundreds of hours of
experience.
Similarly, research suggests that specific facets of parenting, such as the
capacity for a parent to mentalize (Slade, Grienenberger, Bernbach, Levy, &
Locker, 2005) and to be mind-minded (Meins et al., 2003) in their relationship
with their infant, may be especially important for positive child outcomes, such
as the child’s eventual attachment security (Slade et al., 2005), language
acquisition, and ultimately more optimal scholastic, emotional, social and
behavioural adjustments (Berlin, Cassidy, & Appleyard, 2008). Mindmindedness has also been linked to parental prenatal predictions of their
infants’ characteristics (e.g. Arnott & Meins, 2008) and may thus help to explain
the mechanisms by which parental perceptions of their infant’s characteristics
were significantly linked to the infant’s later developmental outcome in the
present study. These findings highlight the need to consider parent’s verbal
reports of their internal perceptions of their baby and their relationship when
designing interventions to prevent poor child outcomes and to include measures
accounting for parental internal representations of their baby in future research
of risk factors for negative child outcomes. Prenatal interventions may be
especially useful in helping both parents to form a positive representation and
interpretation of their unborn baby from the very outset. Future studies would
also benefit from including measures of parental mind-mindedness and
reflective functioning, as another parental mediator between mental health
and child outcomes.
This study’s inclusion of both mothers and fathers enabled comparisons within
couples of each parent’s relative contribution to their infant’s developmental
outcome. However, a major limitation of the study was the small sample size,
which limited the statistical power and increased the risk for Type II errors. Also,
the small sample size restricted the types of analysis possible. Structural equation
modelling would have allowed for the analysis of more complex interactional
effects. The socially low risk sample of well-educated and cohabiting parents in
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Y. Parfitt et al.
the current sample may have protected the children from negative outcomes and
may therefore have restricted the differences in developmental outcomes to be
detected (e.g. Bronte-Tinkew et al., 2008). However, it could be argued that the
homogenous sample controlled for socio-economical risk factors (e.g. Mensah &
Kiernan, 2009) and therefore allowed for these factors to be excluded in the analyses, allowing the focus to be on the predictor variables of interest.
The small sample size also limited the number of predictor variables that could be
included in the regressions. To minimize the number of predictors in the models whilst
retaining maximal information, principal component analysis was used to provide a
summary of groups of inter-correlated variables using unit weights. To reduce the
predictor variables further, the current study also used a combined dyadic synchrony
measure for the mother–infant interaction and one for the father–infant interaction, despite rating these interactions on seven separate dimensions. It would have been beneficial to have examined whether these would have differential effects on the child
developmental outcomes. This would be recommended in future larger scale studies.
Other methodological limitations include the retrospective measures of mental
health variables in pregnancy, which could be subjected to recall biases. The study
would also benefit from a long-term follow-up of child developmental outcome, as
earlier studies (Lung et al., 2009) have suggested that the impact of factors such as
parental mental health may take time to emerge fully. Moderating effects of
combinations of predictor variables on infant developmental outcomes may also
benefit further investigations.
Conclusions and Implications
In conclusion, the results of this study showed that parental perceptions of early characteristics of their infants may have an important role in predicting infant’s cognitive,
language and motor development. The negative impact of maternal postnatal PTSD
on the infant’s cognitive development is a new and important finding, which should
be addressed in future research. Maternal prenatal depression was also significantly
related to the infant’s language development, whilst paternal mental health was
mainly linked to the couple’s relationship and father–baby relationship. Despite
the parent–infant relationship being widely viewed as providing a mechanism by
which poor parental mental health, child characteristics and the couple’s relationship
affect child development, no such mediation effect was found. However, the maternal perceptions of the mother–infant relationship showed a significant association
with the infant’s language development and paternal perceptions of the father–infant
relationship with the infant’s cognitive development. Importantly, it needs to be
emphasized that the results of the current study should be considered as preliminary
due to the small sample size. It would therefore be valuable for future research, with
larger sample sizes, to use more sophisticated modelling techniques to more fully
examine the complex interplay among these variables within family systems, over
longer periods and in different sociodemographic groups.
ACKNOWLEDGEMENTS
This research was partly supported by the British Academy research grant LRG45508. We are very grateful to all of the parents who took part in this research. We
are also grateful to Angela de Mille for her assistance with the CARE-index coding
of mother–infant and father–infant interactions.
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Article
Family Disruption in Childhood
and Risk of Adult Depression
Stephen E. Gilman, Sc.D.
Ichiro Kawachi, M.D., Ph.D.
Garrett M. Fitzmaurice, Sc.D.
Stephen L. Buka, Sc.D.
Objective: The authors examined the
risk that family disruption and low socioeconomic status in early childhood confer on the onset of major depression in
adulthood.
Method: Participants were 1,104 offspring of mothers enrolled during pregnancy in the Providence, R.I., site of the
National Collaborative Perinatal Project.
Measures of childhood family disruption
and socioeconomic status were obtained
before birth and at age 7. Structured diagnostic interviews were used to assess respondents’ lifetime history of major depressive episode between the ages of 18
and 39. Survival analysis was used to identify childhood risks for depression onset.
Results: Parental divorce in early childhood was associated with a higher lifetime
risk of depression among subjects whose
mothers did not remarry as well as among
subjects whose mothers remarried. These
effects were more pronounced when accompanied by high levels of parental
conflict. Independent of the respondents’
adult socioeconomic status, low socioeconomic status in childhood predicted an elevated risk of depression.
Conclusions: Family disruption and low
socioeconomic status in early childhood
increase the long-term risk for major depression. Reducing childhood disadvantages may be one avenue for prevention
of depression. Identification of modifiable
pathways linking aspects of the early
childhood environment to adult mental
health is needed to mitigate the long-term
consequences of childhood disadvantage.
(Am J Psychiatry 2003; 160:939–946)
A
n unresolved question concerning the development
of adult depression is whether early childhood adversity
confers risk that persists beyond childhood. It is known
that family disruption and low socioeconomic status
among children are related to behavioral and psychological disturbances as well as delays in cognitive development
(1, 2). In the United States, the proportion of children
under age 18 in households headed by a single female
increased from 9.0% in 1959 to 22.4% in 1999; the prevalence of child poverty in female-headed households increased from 24.1% to 57.4% over the same time period
(3). Moreover, epidemiologic evidence suggests that rates
of depression have increased in recent generations (4).
There is concern that these trends in the structure and socioeconomic circumstances of families contribute to increasing rates of depression.
In cross-sectional studies of adults (5, 6), reports of family
disruption and low socioeconomic status are more common among depressed individuals than nondepressed individuals. Prospective data from several cohort studies have
also demonstrated a link between childhood adversity and
depressive symptoms in adulthood (7–9).
Previous investigations of the long-term psychiatric
consequences of the childhood environment are limited
in several respects. First, research in this area has often
been conducted by analyzing cross-sectional samples of
selected populations and has often relied on retrospective
Am J Psychiatry 160:5, May 2003
reports of the childhood environment. Although results
from longitudinal population-based studies are emerging,
most have used scales of psychological distress and depressive symptoms rather than psychiatric diagnoses
based on modern diagnostic criteria. These scales often
lack comparability across studies and do not correspond
to DSM criteria for a depressive disorder. Second, although
there is a close relation between socioeconomic status
and family disruption in childhood (10), few studies have
demonstrated their independent effects on adult mental
health. Third, the long-term effects of divorce and other
forms of family disruption on the development of depression are in doubt because of the unanswered question of
whether it is the disruption or the often attendant parental
conflict that poses the salient risk for subsequent depression (see, for example, Ni Bhrolchain et al. [11]).
In this study, we examined the prospective associations
between family disruption and low socioeconomic status
during the first 7 years of life and the adult onset of major
depression. We also analyzed retrospective reports of parental conflict to investigate the impact of family disruption with and without conflict on subsequent depression.
Method
Study Sample and Adult Follow-Up Procedures
Subjects were offspring of participants in the Providence, R.I.,
site of the National Collaborative Perinatal Project (12), a multihttp://ajp.psychiatryonline.org
939
FAMILY DISRUPTION AND DEPRESSION
site study that enrolled more than 50,000 pregnancies nationally
and followed the offspring prospectively through the first 7 years
of life. Obstetrical intake occurred between 1959 and 1966. In
Providence, a total of 4,140 pregnancies were enrolled.
From the 4,140 Providence National Collaborative Perinatal
Project births, 1,780 individuals were selected for participation in
the adult follow-up study. Selection occurred in two separate
phases; in each, a stratified random sample was drawn from the
entire cohort to investigate the association between several early
life factors and adult psychiatric disorders. During phase one,
initiated in 1984, 995 eligible subjects 18–27 years old with and
without maternal pregnancy/delivery complications were selected (13). In the second phase, initiated in 1996, 1,056 subjects
30–39 years old with and without learning disabilities were selected (14). There was a small overlap (N=271) between the firstand second-phase samples. For participants included in both
phases, phase-two interviews were used unless depression had
been reported at the initial (phase-one) assessment, in which
case the earlier information was used. Written informed consent
was obtained from all subjects.
Measures
Family disruption during childhood was defined according to
the number of parents living in the household at the time of enrollment and at age 7 and according to any changes in the parents’
marital status during the first 7 years of life. This scheme resulted
in the following six-category measure of early childhood family
disruption: 1) one parent in the household at birth and age 7, no
changes in parents’ marital status; 2) two parents at birth, mother
widowed at age 7; 3) two parents at birth, mother separated at age
7; 4) two parents at birth, mother divorced at age 7; 5) two parents
at birth and age 7, mother divorced and remarried; and 6) two parents at birth and age 7, no changes in parents’ marital status.
In preliminary analyses, we examined the relation between several indicators of childhood socioeconomic status (parental occupation, education, and household income) and adult depression.
Because parental occupation was the indicator of childhood socioeconomic status most strongly associated with the onset of
depression, childhood socioeconomic status based on parental
occupation was used in the present analyses. Occupation was defined as either manual or nonmanual according to 1960 U.S. Census categories (15). Subjects in two-parent households were assigned to the occupational category of the parent in the higher
category, and subjects in one-parent households were assigned to
the occupational category of the parent with whom they were
living, even if the other parent was in a higher category. Subjects
with parents outside of the paid labor force at the time of either
childhood assessment were categorized as not employed. Accordingly, parental occupation at the respondent’s birth and seventh
year was coded in the following five categories: 1) manual at birth
and age 7; 2) not employed at either occasion; 3) manual at birth,
nonmanual at age 7; 4) nonmanual at birth, manual at age 7; and
5) nonmanual at birth and age 7.
History of parental conflict was determined by responses to
four questions asked during the adult follow-up assessment:
1) Did your parents argue or fight in front of you? 2) Did either/
any of your parents ever hit the other? 3) Did they hit the other often? 4) Did you ever see it happen? Participants endorsing at least
three of the four parental conflict questions were coded as having a high level of parental conflict. Although this measure is imprecise and based on retrospective reports, the inclusion of information on parental conflict in the investigation of long-term
effects of family disruption is essential for understanding the potential pathogenic mechanisms involved.
Lifetime diagnosis of major depressive episode was determined
by using the National Institute of Mental Health Diagnostic Interview Schedule (DIS) (16), administered to subjects in adulthood
940
http://ajp.psychiatryonline.org
by trained interviewers. The DIS has been used widely in community samples with demonstrated reliability and validity for the diagnosis of depression (17, 18). During the first phase of the followup study, diagnoses were based on DSM-III criteria, and in the
second phase, begun in 1996, the DSM-IV version of the DIS was
used. The analyses presented here combine DSM-III and DSM-IV
diagnoses of major depressive episode, which are similar although
not identical. Changes in diagnostic criteria for depression appeared to have little impact on the identification of cases in community surveys (19). This was also true in the present sample; we
observed a high level of concordance between DSM-III and DSMIV diagnoses of depression in the subset of respondents for whom
we were able to assign both diagnoses (9).
Statistical Analysis
Discrete-time survival analysis, a Cox regression model for the
analysis of events that are recorded in discrete time intervals, was
used to model the retrospectively reported age at onset of depression (20). This model yields estimates of risk for the initial onset of
depression that account for the number of years during which respondents were at risk for a first depressive episode. The analyses
described here, therefore, were based on the person-years from
birth through age at onset of depression for those respondents
with a lifetime history of depression, and on the person-years
from birth through age at interview for those respondents without a lifetime history of depression. The following control variables were included in the survival models: family history of mental disorders before the birth of the child, maternal age at the time
of the respondent’s birth, and the respondent’s age at interview,
sex, and race/ethnicity. Family history of mental disorders before
the birth of the child was included as a control because of the
known higher risk for depression among offspring of depressed
parents (21). Family history was determined by the mother’s report on enrollment of whether she or the subject’s father had ever
received treatment for emotional or behavioral problems. Finally,
we included a set of indicator variables representing the factors
used to select participants for the Providence National Collaborative Perinatal Project follow-up study (i.e., pregnancy or delivery
complications and potential learning disabilities at age 7).
Results
Characteristics of the Sample
The demographic characteristics of the 1,780 subjects
originally selected for follow-up are shown in Table 1;
1,267 of these subjects were successfully located and interviewed, and complete data were available for 1,104 of the
subjects. These 1,104 subjects make up the sample for the
current analysis. The demographic characteristics of the
current analysis sample, also shown in Table 1, were virtually identical to those of the original selected sample.
Slightly more than half of the subjects in the current analysis were male, the majority were white, and the mean age
was 29.1 (SD=5.7). More than half of respondents lived in
two-parent families between birth and age 7. The subjects
came from predominantly working class backgrounds; the
parental occupations of 39.9% of the respondents was
manual at their birth and seventh year. The current analysis sample was approximately balanced with regard to the
study selection factors. Of the 1,104 respondents included
in the current analysis sample, 242 (21.9%) were chosen
for a history of pregnancy or delivery complications and
Am J Psychiatry 160:5, May 2003
GILMAN, KAWACHI, FITZMAURICE, ET AL.
TABLE 1. Characteristics of the Providence, R.I., National Collaborative Perinatal Project Sample Selected for Follow-Up to
Adulthood and the Sample in the Current Analysis of the Relation of Childhood Family Disruption to the Onset of Depression
Original Selected Sample
With Characteristic
Characteristic
Sex
Male
Female
Race/ethnicity
White
Nonwhite
Age at interview (years)
18–22
23–27
30–34
35–39
Early childhood family disruption
Family disruption: two parents at birth and
Mother widowed at age 7
Mother separated at age 7
Mother divorced at age 7
Mother divorced and remarried at age 7
No family disruption
One parent at birth and age 7
Two parents at birth and age 7
Parental occupation at subject’s birth and age 7
Manual at birth and at age 7
Not employed at birth or age 7
Manual at birth and nonmanual at age 7
Nonmanual at birth and manual at age 7
Nonmanual at birth and at age 7
Nb
1,780
Lifetime Prevalence of Depression
in Current Analysis Samplea
N
%
N
%
975
805
54.8
45.2
580
524
52.5
47.5
120
146
20.7
27.9
N
%
1,334
416
76.2
23.8
800
304
72.5
27.5
209
57
26.1
18.8
202
250
435
217
18.3
22.6
39.4
19.7
17
32
142
75
8.4
12.8
32.6
34.6
1,750
1,467
25
203
153
99
1.7
13.8
10.4
6.7
21
157
120
65
1.9
14.2
10.9
5.9
5
40
40
26
23.8
25.5
33.3
40.0
104
883
7.1
60.2
71
670
6.4
60.7
14
141
19.7
21.0
629
333
176
141
250
41.1
21.8
11.5
9.2
16.4
440
219
129
105
211
39.9
19.8
11.7
9.5
19.1
116
53
34
27
36
26.4
24.2
26.4
25.7
17.1
1,529
a Lifetime prevalence of depression in the current analysis sample
b Data were not available for all variables for the 1,780 subjects in
is 24.1% (N=266).
the original selected sample.
339 (30.7%) were chosen for the presence of potential
learning disabilities at age 7; the numbers of respondents
selected for the absence of these factors were 212 (19.2%)
and 311 (28.2%), respectively.
The lifetime prevalence of major depression in the sample was 24.1% (N=266); this is somewhat higher than in
nationally representative surveys (e.g., 17.1% in the National Comorbidity Survey [22]). Table 1 shows the lifetime
prevalence of depression within each category of the sociodemographic variables. On preliminary inspection, we
observed substantial variability in the lifetime risk of depression across categories of early childhood family disruption (χ2=23.7, df=5, p=0.0003), attributable mainly to
higher lifetime risks among respondents who experienced
parental divorce in early childhood (regardless of subsequent remarriage) than among respondents whose parents’ marital status remained unchanged between birth
and age 7. Lifetime risk of depression also varied according to parental occupation, with the highest socioeconomic status category (employed in nonmanual occupations at both times) predicting a lower risk of depression
(χ2=9.6, df=4, p=0.05).
Respondents whose parents were unemployed or had
manual occupations were considerably more likely to reside in one-parent families than were respondents whose
parents had nonmanual occupations. For example, 41
(12.2%) of respondents born to parents with nonmanual
occupations lived in one-parent families, compared with
Am J Psychiatry 160:5, May 2003
Current Analysis
Sample (N=1,104)
24 (30.4%) and 171 (25.9%) of respondents born to parents
who were not employed or had manual occupations, respectively (χ2=28.2, df=2, p
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