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Matern Child Health J (2013) 17:907–917 DOI 10.1007/s10995-012-1071-2

Reported Maternal Postpartum Depression and Risk of Childhood Psychopathology

Meghan J. Walker Caroline Davis Ban Al-Sahab Hala Tamim

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

Abstract Childhood emotional and behavioural disorders are prevalent, can cause significant maladaptation and often persist into adulthood. Previous literature investi- gating the potential influence of postpartum depression (PPD) is inconsistent. The present study examined the association between PPD and childhood behavioural/emo- tional outcomes, while considering a number of potentially important factors. Data were analyzed prospectively from the National Longitudinal Survey of Children and Youth at two follow-up periods (ages 2–3, N = 1,452 and ages 4–5, N = 1,357). PPD was measured using the diagnostic cri- teria of the DSM-IV-TR. Four behavioural/emotional out- comes were analyzed at each follow-up. For both age groups, logistic regression models were used to estimate the associations between PPD and each of the behavioural and emotional outcomes adjusting for child, obstetric, environmental and socio-demographic factors. PPD was

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

associated with the Emotional Disorder-Anxiety among 2–3 year olds [OR = 2.38, 95 % CI 1.15, 4.91]. Among 2–3 year olds, hostile/ineffective parenting was associated with Hyperactivity-Inattention [OR = 1.88, 95 % CI 1.14, 3.11] and Physical Aggression-Opposition [OR = 2.95, 95 % CI 1.77, 4.92]. Among 4–5 year olds, hostile/inef- fective parenting was associated with Hyperactivity-Inat- tention [OR = 2.34, 95 % CI 1.22, 4.47], Emotional Disorder-Anxiety [OR = 2.16, 95 % CI 1.00, 4.67], Phys- ical Aggression-Conduct Disorder [OR = 1.96, 95 % CI 1.09, 3.53] and Indirect Aggression [OR = 1.87, 95 % CI 1.09, 3.21]. The findings of the present study do not suggest that PPD is independently associated with any enduring sequelae in the realm of child behavioural/emotional psy- chology, though the symptoms of PPD may be giving way to other important mediating factors such as parenting style.

Keywords Childhood behaviour Behavioural disorders Emotional disorders Postpartum depression Parenting

Introduction

Behavioural and emotional disorders are prevalent among children and can cause significant impairment and malad- aptation in familial, social, academic and community set- tings. North American epidemiologic studies have indicated that the estimated prevalence of children’s mental disorders ranges from approximately 10–20 % [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

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later psychopathology [3], and are associated with unem-

Methods

ployment, substance abuse and suicide [4]. The burden upon the Canadian economy is extensive. In 2008 it was

Study Design

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 pre- vention 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]. Spe- cifically, 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

The study proceeded as a secondary longitudinal analysis of Canadian children aged 2–5, utilizing data from Cycles 1 through 3 of the National Longitudinal Survey of Children and Youth (NLSCY). The NLSCY is a Canadian popula- tion-based household survey of child health, development and well-being [28]. The study began with a representative sample of children aged 0–11 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 knowledge- able (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 1994–1995, when children were 0–11 months and follow-up data were gathered at Cycle 2 in 1996–1997, when children were 2–3 years of age and at Cycle 3 in 1998–1999, when children were 4–5 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.

prevalence rates of approximately 10–25 % [1116]. A number of studies have focused on the potential

Sample

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, sep- aration 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 associ- ated with adverse effects [2527]. Studies thus far have been unable to clearly establish a direct link between mother’s PPD and psychopathological outcomes in offspring. Behavioural and emotional disorders constitute a major

All variables in the NLSCY pertaining to the present study were collected by self-report by the Person Most Knowl- edgeable (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 mother’s 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 mother’s PPD status were excluded (n = 273), leaving a final sample of 1,357.

public health concern in Canada and the U.S. The epide- miological evidence regarding the influence of PPD on

Measures

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 2–3 and 4–5 while adjusting for a number of potentially important covariates.

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 0–11 months of age were asked about the mother’s 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

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who reported longer than 14 days were grouped as having PPD. The outcome variables of interest were the presence of behavioural/emotional problem(s) in children. Outcomes were measured by the NLSCY Child Behavioural Scales, which consist of items derived from previously-utilized, population-based surveys with known psychometric prop- erties to operationalize the diagnostic criteria for the cor- responding disorders within the DSM-IV-TR [4]. For children aged 2–3, four outcomes were considered, as identified by factor analysis: Hyperactivity-Inattention [from the Ontario Child Health Study (OCHS) and Mon- treal Longitudinal Survey (MLS)], Emotional-Disorder Anxiety (from the OCHS), Physical Aggression-Opposi- tion (from the OCHS and MLS), and Separation Anxiety (from Achenbach’s Child Behavior Checklist) [28]. For children aged 4–5 years of age, the following four out- comes were considered: Hyperactivity-Inattention (from the OCHS and MLS), Emotional Disorder-Anxiety (from the OCHS), Physical Aggression-Conduct Disorder (from the OCHS and MLS) and Indirect Aggression (from Lag- erspetz, Bjorngvist and Peltonen of Finland) [28]. Consis- tent with previously utilized scoring schemes, children with a scale score above the 80th percentile were classified as having a high degree of that outcome [29]. Covariates were identified a priori as a result of a comprehensive review of the literature. Child factors include the child’s sex and presence of worry/unhappiness. Obstetric factors include preterm birth (gestational age B 258 days), low birthweight (B2499 g), maternal age at child’s birth and mother’s smoking and alcohol status during pregnancy. Environmental factors included parent- ing style, family functioning, current maternal depression and single parent status. Parenting styles, including posi- tive interaction, hostile/ineffective parenting, consistency and punitive/aversive parenting, were measured by a revised version of the Strayhorn and Weidman’s Parenting Practices Scale [30]. Consistent with previous scoring schemes, a scale score in the lowest quartile was indicative of having a low degree of positive interaction and consis- tency, while a score in the highest quartile was indicative of having a high degree of hostile/ineffective parenting and punitive/aversive parenting [31, 32]. Family functioning was measured with the General Functioning subscale of the McMaster Family Assessment Device [33]. Consistent with previous scoring-schemes, a score of C15 was indicative of low family functioning [32, 34]. An abbreviated version of the Centre for Epidemiologic Studies Depression Scale (CES-D) [35] was used to determine severity of current maternal depressive symptoms. Consistent with previous scoring schemes, a score of C13 was indicative of mod- erate to severe depression [32, 34]. Socio-demographic factors include income adequacy, maternal education and

immigration status. Income Adequacy takes into account household income and size [28], corresponding closely to Canada’s poverty line [32]. Presence of a comorbid out- come and child’s outcome history were also analyzed.

Statistical Analyses

Statistics Canada’s microdata publication guides were followed throughout all analyses [28]. Data were weighted to the population level according to longitudinal survey weights derived by Statistics Canada to account for unequal probabilities of sample selection, including non- response and attrition. Rescaled sample weights were applied to preserve the original sample sizes and correct for variance estimation bias. Due to the complex sampling design of the NLSCY, bootstrapping was performed to estimate all confidence intervals (CIs). Analyses were undertaken at Cycle 2 when children were 2–3 years of age and Cycle 3 when children were 4–5 years of age. Descriptive frequencies of the study population were tab- ulated. Crude and adjusted odds ratios (ORs) and 95 % CIs were calculated with logistic regression to estimate the associations between PPD and each of the behavioural and emotional outcomes. All analyses were performed with SPSS Version 16.0, with the exception of bootstrapping, which was performed utilizing SAS, Version 9.2.

Results

A reported 8.4 % (n = 122) of mothers were affected by PPD in the year following birth of the child. A similar proportion reported being currently depressed when the child was 2–3 years of age (8.3 %) and a slightly lower proportion reported being depressed when the child was

4–5 (6.6 %). There were approximately equal proportions

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

sample. A majority of mothers were 25–34 years of age (68.4 %), with a smaller proportion 15–24 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 children’s 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 2–3). Comorbid Emotional Disorder-Anxiety [OR = 1.69, 95 %

CI 1.03, 2.78], comorbid Physical Aggression-Opposition

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

 

OR [95 % CI]

Cycle 2 outcome—ages 2–3 (n = 1,452)

Hyperactivity-inattention

1.65 [0.89, 3.04]

Emotional disorder-anxiety

2.61 [1.40, 4.86]

Physical aggression-opposition

1.94 [0.98, 3.81]

Separation anxiety

1.34 [0.75, 2.40]

Cycle 3 outcome—ages 4–5 (n = 1,357)

Hyperactivity-inattention

1.69 [0.93, 3.09]

Emotional disorder-anxiety

1.59 [0.78, 3.26]

Physical aggression-conduct disorder

2.00 [1.04, 3.86]

Indirect aggression

1.42 [0.75, 2.67]

[OR = 4.09, 95 % CI 2.41, 6.93] and hostile/ineffective parenting [OR = 1.88, 95 % CI 1.14, 3.11] were signifi- cantly associated with a high degree of Hyperactivity- Inattention. Comorbid Hyperactivity-Inattention [OR =

1.73, 95 % CI 1.03, 2.78], Separation Anxiety [OR = 3.75,

95

% CI 2.48, 5.68] and PPD in the mother [OR = 2.38,

95

% CI 1.15, 4.91] was significantly associated with a

high degree of Emotional Disorder-Anxiety. In regard to Physical Aggression-Opposition, results

indicate that children with high degrees of Hyperactivity- Inattention [OR = 4.17, 95 % CI 2.49, 6.96] and Separa- tion Anxiety [OR = 3.09, 95 % CI 1.93, 4.93] were sig- nificantly more likely to display Physical Aggression- Opposition. Low degrees of consistent parenting [OR = 1.68, 95 % CI 1.01, 2.78] and high hostile/ineffective parenting [OR = 2.95, 95 % CI 1.77, 4.92] were also significant. Children with comorbid Emotional Disorder- Anxiety and Physical Aggression-Opposition were more likely to display high degrees of Separation Anxiety [OR = 3.77, 95 % CI 2.49, 5.71] and [OR = 3.01, 95 % CI 1.87, 4.84], respectively. Table 3 shows results of the multivariable analysis of PPD and behavioural/emotional outcomes at Cycle 3 (ages 4–5). Male sex [OR = 1.80, 95 % CI 1.12, 2.89], comorbid Physical Aggression-Opposition [OR = 2.36, 95 % CI 1.30, 4.27] and hostile/ineffective parenting [OR = 2.34,

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

Inattention at 4–5 years of age. In regards to Emotional Disorder-Anxiety, children with high degrees of Physical Aggression-Conduct Disorder [OR = 2.42, 95 % CI 1.10, 5.33] and Indirect Aggression [OR = 1.94, 95 % CI 1.05, 3.61] were approximately twice as likely to have high degrees of Emotional Disorder- Anxiety. Low Positive Interaction and high hostile/inef- fective parenting were associated with approximately two times the likelihood of reporting a high degree of Emo- tional Disorder-Anxiety [OR = 1.95, 95 % CI 1.02, 3.74 and OR = 2.16, 95 % CI 1.00, 4.67].

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Male children are close to twice as likely to exhibit high degrees of Physical Aggression-Conduct Disorder [OR = 1.80, 95 % CI 1.04, 3.12]. Comorbid Hyperactivity-Inat- tention [OR = 2.85, 95 % CI 1.62, 5.03], Emotional Dis- order-Anxiety [OR = 2.70, 95 % CI 1.27, 5.75] and Indirect Aggression [OR = 2.53, 95 % CI 1.38, 4.64] were also significantly associated with Physical Aggression- Conduct Disorder. Children of parents who exhibit high degrees of hostile/ineffective parenting [OR = 1.96, 95 %

CI

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

95

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

exhibit high degrees of Physical Aggression-Conduct Disorder. Lastly, in the case of Indirect Aggression, male children

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

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

[OR = 1.75, 95 % CI 1.08, 2.84], Emotional Disorder- Anxiety [OR = 2.03, 95 % CI 1.10, 3.75] and Physical Aggression-Conduct Disorder [OR = 2.37, 95 % CI 1.32, 4.26] were also associated with a high degree of Indirect Aggression. Children of mothers who reported high

degrees of hostile/ineffective parenting were close to twice

as

likely to display high Indirect Aggression [OR = 1.87,

95

% CI 1.09, 3.21].

Discussion

With the exception of Emotional Disorder-Anxiety among 2–3 year olds, PPD does not appear to be associated with the outcomes measured. However, multivariable analyses revealed that parenting style may be an important factor, given the magnitude and consistency of the associations observed. The persistence of the association between PPD and Emotional Disorder-Anxiety following adjustment is not unforeseen, given that PPD is of the same class of clinical disorders that the Emotional Disorder-Anxiety scale seeks to measure. Clinical Mood and Anxiety Dis- orders have a moderate heritable component, specifically among first-degree relatives [4], therefore symptomatology may be expected in the offspring of afflicted parents. A number of studies have previously assessed the rela- tionship between mother’s PPD status and behavioural/ emotional outcomes in children, with inconsistency in the emotional, attentional and cognitive disturbances reported [12]. In contrast to the results of the present study, a number have reported significant positive associations between PPD and childhood outcomes, including Oppositional-Defiant Disorder and Conduct Disorder [17], inattention-hyper- activity, separation anxiety [18, 19], several depressive and anxiety disorders [36], elevated cortisol levels which have predicted major depression [37], lower cognitive scores [2022, 38], violent behaviour and substance abuse

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Table 2 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 2 (ages 2–3, N = 1,452)

Odds ratios [95 % confidence intervals]

 

Hyperactivity-inattention

Emotional

Physical

Separation

 

disorder-anxiety

aggression-opposition

anxiety

Child factors

Child’s sex

Female

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Male

1.17 [0.73, 1.87]

1.44 [0.96, 2.16]

1.31 [0.82, 2.11]

0.75 [0.52, 1.07]

Obstetric factors

Preterm birth

Not preterm

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Preterm

0.99 [0.44, 2.22]

1.15 [0.49, 2.67]

0.53 [0.18, 1.58]

1.28 [0.63, 2.59]

Birthweight

Normal

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.82 [0.26, 2.66]

0.71 [0.21, 2.37]

3.18 [0.97,10.45]

0.80 [0.35, 1.85]

Maternal age at birth

15–24

2.44 [1.01, 5.90]

2.05 [0.93, 4.51]

0.50 [0.20, 1.31]

1.00 [0.48, 2.10]

25–34

2.11 [0.96, 4.63]

1.69 [0.83, 3.45]

0.67 [0.27, 1.63]

1.01 [0.52, 1.96]

35?

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Smoking status during pregnancy

Did not smoke

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Smoked

1.47 [0.92, 2.35]

0.51 [0.31, 0.82]

1.08 [0.62, 1.87]

1.04 [0.69, 1.58]

Drinking status during pregnancy

Did not drink

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Drank

1.08 [0.64, 1.81]

1.42 [0.86, 2.35]

1.12 [0.60, 2.07]

1.02 [0.66, 1.59]

Postpartum depression

No PPD

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

PPD

1.32 [0.58, 3.00]

2.38 [1.15, 4.91]

1.00 [0.46, 2.18]

0.94 [0.49, 1.78]

Environmental factors

Parenting style: positive interaction

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.90 [0.55, 1.49]

0.51 [0.33, 0.79]

1.40 [0.87, 2.25]

0.86 [0.57, 1.31]

Parenting style: consistency

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.18 [0.74, 1.86]

1.10 [0.72, 1.68]

1.68 [1.01, 2.78]

1.53 [0.99, 2.36]

Parenting style: hostile/ineffective

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

1.88 [1.14, 3.11]

1.22 [0.76, 1.98]

2.95 [1.77, 4.92]

1.41 [0.87, 2.28]

Parenting style: punitive/aversive

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

1.51 [0.94, 2.43]

1.13 [0.71, 1.80]

1.29 [0.81, 2.05]

0.93 [0.60, 1.45]

Family functioning

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.09 [0.39, 3.06]

1.60 [0.76, 3.38]

1.27 [0.49, 3.29]

1.79 [0.89, 3.55]

Current maternal depression

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Moderate to severe

1.79 [0.78, 4.09]

1.27 [0.61, 2.64]

0.94 [0.43, 2.09]

1.30 [0.60, 2.82]

Single parent status

Lives with 2 parents

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Lives with single parent

1.18 [0.50, 2.77]

1.68 [0.91, 3.12]

0.45 [0.18, 1.14]

0.68 [0.36, 1.29]

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Table 2 continued

Odds ratios [95 % confidence intervals]

 

Hyperactivity-inattention

Emotional

Physical

Separation

 

disorder-anxiety

aggression-opposition

anxiety

Socio-demographic factors

Income adequacy

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.76 [0.79, 3.94]

0.82 [0.44, 1.55]

1.01 [0.39, 2.59]

1.18 [0.65, 2.14]

Maternal education

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.21 [0.59, 2.51]

1.50 [0.79, 2.86]

0.39 [0.17, 0.88]

1.40 [0.74, 2.62]

Maternal immigration status

Non-immigrant

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Immigrant

1.04 [0.45, 2.43]

0.86 [0.41, 1.80]

1.15 [0.52, 2.54]

2.27 [1.15, 4.49]

Comorbid hyperactivity-inattention

 

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.73 [1.07, 2.78]

4.17 [2.49, 6.96]

1.18 [0.74, 1.86]

Comorbid emotional disorder-anxiety

 

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.69 [1.03, 2.78]

1.39 [0.84, 2.29]

3.77 [2.49, 5.71]

Comorbid physical aggression-opposition

 

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

4.09 [2.41, 6.93]

1.39 [0.84, 2.30]

3.01 [1.87, 4.84]

Comorbid separation anxiety

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.15 [0.72, 1.83]

3.75 [2.48, 5.68]

3.09 [1.93, 4.93]

[19, 20]. Other studies however, have reported that effects found in earlier ages may attenuate [23, 24, 39], while others have reported that PPD is not associated with adverse effects among offspring [2527]. These inconsistencies may be due to methodological differences. Studies often employ clinic-based recruitment strategies or diagnostic interviews to determine their samples [17, 36]. While the latter are viewed as the gold standard of psychometric evaluation, their use would limit generalizability to children who experience mental health outcomes at clinically important levels. By contrast, the objective of the present study was to employ a nationally-representative population- level sample of children and utilize a more liberal charac- terization of emotional and behavioural symptomatology. The present study also incorporated a number of important covariates, which may be predictively important. Several studies which have examined more than one type of out- come have not included a measure to adjust for the comorbidity of these outcomes [26, 36]. This may have led to the distortion of the true effect of PPD. The finding that high degrees of several of the behav- ioural/emotional outcomes assessed differed by the child’s sex at ages 4–5 is consistent with what is known about each of the corresponding mental disorders within the

123

DSM-IV-TR [4]. Attention-Deficit/Hyperactivity Disorder (ADHD) and Conduct Disorder (CD) are more frequently observed among male children [4] and indirect aggression is more commonly observed among female children [4042]. The finding that Emotional Disorder-Anxiety did not differ by sex in children at ages 2–3 or 4–5 is also con- sistent with the literature. Rate differentiation by sex of Mood and Anxiety Disorders typically only begins to emerge following puberty [4, 43]. A consistent pattern emerged among the other covariates assessed. Having a comorbid behavioural/emotional out- come or previous history of the behavioural/emotional outcome was significantly associated with each of the outcomes assessed. A number of statistically significant results emerged among parenting techniques and the behavioural/emotional outcomes. These findings suggest that while PPD itself may not be associated with adverse child psychiatric outcomes, parenting styles do appear to be. Hostile/ineffective parenting appeared to be most important, significantly associated with two of four out- comes at ages 2–3 and all outcomes assessed at ages 4–5. It is important to note however, that previous literature lends evidence to the possibility that parenting may be on the causal pathway between PPD and childhood behavioural/

Matern Child Health J (2013) 17:907–917

913

Table 3 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 3 (ages 4–5, N = 1,357)

Odds ratios (95 % confidence intervals)

 

Hyperactivity-

Emotional

Physical aggression-

Indirect

inattention

disorder-anxiety

conduct disorder

aggression

Child factors

Child’s sex

Female

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Male

1.80 [1.12, 2.89]

0.88 [0.50, 1.57]

1.80 [1.04, 3.12]

0.54 [0.35, 0.85]

Worry/unhappiness

No worry/unhappiness

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Worry/unhappiness

1.32 [0.75, 2.34]

1.60 [0.84, 3.04]

1.38 [0.72, 2.65]

1.25 [0.75, 2.09]

Obstetric factors

Preterm birth

Not preterm

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Preterm

0.55 [0.18, 1.70]

1.32 [0.51, 3.39]

0.85 [0.29, 2.50]

1.14 [0.51, 2.57]

Birthweight

Normal

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.07 [0.31, 3.75]

0.66 [0.07, 6.14]

1.27 [0.37, 4.36]

0.56 [0.17, 1.84]

Maternal age at birth

15–24

1.18 [0.44, 3.17]

1.36 [0.35, 5.25]

0.49 [0.16, 1.48]

0.61 [0.29, 1.28]

25–34

0.88 [0.38, 2.02]

0.90 [0.27, 3.02]

1.17 [0.47, 2.89]

0.68 [0.36, 1.28]

35?

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Smoking status during pregnancy

Did not smoke

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Smoked

1.08 [0.62, 1.86]

0.68 [0.32, 1.42]

1.25 [0.69, 2.24]

1.85 [1.10, 3.12]

Drinking status during pregnancy

Did not drink

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Drank

1.05 [0.59, 1.86]

1.85 [0.91, 3.75]

0.73 [0.38, 1.40]

0.81 [0.49, 1.33]

Postpartum depression

No PPD

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

PPD

1.08 [0.46, 2.56]

0.86 [0.31, 2.36]

1.42 [0.61, 3.32]

0.76 [0.37, 1.59]

Environmental factors

Parenting style: positive interaction

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.72 [0.43, 1.22]

1.95 [1.02, 3.74]

1.15 [0.65, 2.05]

1.29 [0.79, 2.09]

Parenting style: consistency

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.34 [0.79, 2.27]

1.15 [0.61, 2.15]

0.92 [0.51, 1.67]

1.27 [0.79, 2.05]

Parenting style: hostile/ineffective

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

2.34 [1.22, 4.47]

2.16 [1.00, 4.67]

1.96 [1.09, 3.53]

1.87 [1.09, 3.21]

Parenting style: punitive/aversive

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

1.08 [0.62, 1.88]

1.26 [0.60, 2.63]

2.08 [1.18, 3.66]

0.88 [0.53, 1.45]

Family functioning

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.51 [0.19, 1.41]

1.29 [0.44, 3.77]

0.77 [0.33, 1.81]

0.88 [0.40, 1.92]

Current maternal depression

Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Moderate to severe

2.38 [0.90, 6.28]

2.17 [0.80, 5.89]

1.16 [0.50, 2.72]

0.93 [0.41, 2.09]

914

Matern Child Health J (2013) 17:907–917

Table 3 continued

 

Odds ratios (95 % confidence intervals)

 

Hyperactivity-

Emotional

Physical aggression-

Indirect

inattention

disorder-anxiety

conduct disorder

aggression

Single parent status

Lives with two parents

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Lives with single parent

0.77 [0.34, 1.77]

1.50 [0.56, 4.03]

1.12 [0.51, 2.43]

1.54 [0.75, 3.17]

Socio-demographic factors

Income adequacy

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.84 [0.31, 2.27]

0.74 [0.24, 2.26]

1.55 [0.70, 3.44]

1.13 [0.53, 2.41]

Maternal education

High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.74 [0.69, 4.39]

0.29 [0.09, 0.95]

0.60 [0.22, 1.63]

1.07 [0.46, 2.49]

Maternal immigration

Non-immigrant

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Immigrant

0.96 [0.28, 3.35]

2.08 [0.11, 38.33]

0.17 [0.01, 2.54]

1.61 [0.70, 3.72]

Comorbid hyperactivity-inattention

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.53 [0.76, 3.07]

2.85 [1.62, 5.03]

1.75 [1.08, 2.84]

Comorbid emotional disorder-anxiety

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.80 [0.88, 3.71]

2.70 [1.27, 5.75]

2.03 [1.10, 3.75]

Comorbid physical aggression-conduct disorder

 

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

2.36 [1.30, 4.27]

2.42 [1.10, 5.33]

2.37 [1.32, 4.26]

Comorbid indirect aggression

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

1.69 [0.99, 2.88]

1.94 [1.05, 3.61]

2.53 [1.38, 4.64]

History of outcome

No

1.00 Reference

1.00 Reference

1.00 Reference

Yes

3.90 [2.16, 7.05]

2.65 [1.31, 5.35]

3.62 [2.14, 6.12]

emotional outcomes. The literature on PPD and subsequent maternal depression indicates that child management may be one of the areas wherein the depressive state of the mother may manifest. This evidence comes from a number of studies which have noted increased levels of intrusive- ness, dysfunctional attachment and interactive patterns [15, 4446]. As reviewed by Beck (1999) [47], depressed mothers may be more inconsistent and ineffective in their child management, monitoring and discipline-administra- tion techniques. These mothers are also more likely to submit to a child’s non-compliance and use forceful control strategies [47]. There is also evidence of the relationship between par- enting behaviours and development of certain mental dis- orders. Both ADHD and Oppositional Defiant Disorder/ Conduct Disorder have been linked to inconsistent, unre- sponsive, coercive, critical and rejecting parenting patterns [4850], as well as hostile and punitive disciplinary patterns

123

[51, 52]. Research has also indicated that positive, involved and supportive parenting and lower levels of harsh, punitive parenting may predict more optimal behavioural, academic and social adjustment and appears to buffer the effects of psychological adversity in school-aged children [53]. Other findings from a study of Canadian infants have indicated that parenting interventions with depressed mothers can result in improvements in mother-infant interactions [54]. However, while parenting practices may be related to children’s mental health outcomes, the causal chain of events is unclear. The childhood outcomes discussed in the present study are often associated with significant caregiver stress and strain [55]. Therefore it is possible that these parenting styles may be a reaction to a child’s previously established troubled behaviour. The present study has a number of strengths. Data were utilized from a nationally representative dataset, making results generalizable to Canadian children aged 2–5. The

Matern Child Health J (2013) 17:907–917

915

large sample allowed for ample statistical power in the analysis of multivariable relationships. The present study accounted for outcome comorbidity and a previous history of outcome. Including such measures is important in reli- ably assessing the relationship between PPD and mental health outcomes in epidemiological research given that comorbidity is common in psychiatric illness [43], and children’s early and later mental health status are often highly correlated. To the authors’ knowledge, this is the first study to consider parenting style while investigating the relationship between postpartum depression and childhood outcomes, a factor which has been associated with both postpartum depression and childhood behav- ioural/emotional outcomes. It is important to consider several limitations. Perhaps the most important is reliance upon self-report by biolog- ical mothers to obtain measures of exposure and outcomes, instead of the use of clinically-trained assessors. While biological mothers are generally recognized as reliable informants regarding their offspring, a concern exists that maternal PPD may cause mothers to over-report disordered behaviours among their children [39]. It is also generally recognized in the field of child psychiatric epidemiology that reports from multiple informants are optimal [56] and it may have been beneficial to supplement PMK reports with those of a second party. While the NLSCY also col- lected data on behavioural/emotional outcomes from school-aged children’s teachers, a majority of these data were missing. Missing data was also present due to the longitudinal nature of this study. Among all the NLSCY participants, the response rate at cycle 2 was 91.7 and 89.6 % at cycle 3. An additional limitation was the potential for misclassification introduced by utilization of the 80th percentile cut-off for classifying children into outcome groups. While it would have been ideal to treat these variables as linear, the distribution of scale scores demonstrated high levels of skewness, as is commonly found in ratings of problematic behaviour [57]. The non- normal distribution would make elevated scale scores rare and equal scale division problematic. Lastly, factors such as familial history of psychiatric disorders were not col- lected and could not be adjusted for. One population-based study indicated that approximately 4 % of fathers experi- ence PPD and paternal PPD may be associated with behavioural/emotional disorders among offspring [58]. Residual confounding is likely to exist, as familial history could not be accounted for in the analysis. The findings of the present study do not suggest that PPD is independently associated with any enduring sequelae in the realm of child behavioural/emotional psy- chology, though the symptoms of PPD may be giving way to other important mediating factors such as parenting style. Specifically, the present study has highlighted

positive parenting techniques and practices as a potential area for intervention, as negativistic parenting techniques may be a function of PPD and appear to be associated with childhood emotional/behavioural outcomes. The results have also demonstrated the need for further research in clarifying the relationship between these factors to identify where prevention efforts should be targeted to reduce the burden of childhood psychiatric illness.

Acknowledgments While the research and analyses are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada. The authors would like to thank the NLSCY study participants, Statistics Canada, Human Resources and Skills Development Canada (HRSDC) and the staff at the Toronto Region—Statistics Canada Research Data Centre.

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