Interaction Effects between Maternal Lifetime ... - Springer Link

J Child Fam Stud (2011) 20:596–604 DOI 10.1007/s10826-010-9433-0

ORIGINAL PAPER

Interaction Effects between Maternal Lifetime Depressive/Anxiety Disorders and Correlates of Children’s Externalizing Symptoms Genevie`ve Piche´ • Lise Bergeron • Mireille Cyr Claude Berthiaume

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Published online: 23 October 2010 Ó Springer Science+Business Media, LLC 2010

Abstract We investigated the interaction effects between mother’s lifetime depressive/anxiety disorders and psychosocial correlates of 6 to 11 year-old children’s selfreported externalizing symptoms in the Quebec Child Mental Health Survey. A representative subsample of 1,490 Quebec children aged 6 to 11 years was selected from the original sample. We conducted multiple linear regression analyses using externalizing symptoms as reported by children through the Dominic questionnaire and multiple child, family and socioeconomic characteristics. Two variables interacted significantly with mother’s lifetime depressive/anxiety disorders to predict 6 to 11 year-old children’s self-reported externalizing symptoms: physical/sexual abuse and mother’s caring behaviours. Results underline the main contribution of motherchild relationship and stressful events in the association between mother’s lifetime depressive/anxiety disorders and children’s externalizing symptoms. It is suggested to develop preventive intervention programs oriented towards children of lifetime depressed/anxious parents who also report parent-child relational difficulties.

G. Piche´ (&) Department of Psychoeducation and Psychology, Universite´ du Que´bec en Outaouais, 5 rue St-Joseph, bureau J-2224, St-Je´roˆme, QC J7Z 0B7, Canada e-mail: [email protected] L. Bergeron M. Cyr Department of Psychology, Universite´ de Montre´al, Montreal, QC, Canada L. Bergeron C. Berthiaume Research Unit, Rivie`re-des-Prairies Hospital and FernandSeguin Research Center, Montreal, QC, Canada

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Keywords Maternal depressive/anxiety disorders Child psychiatry Externalizing symptoms Intergenerational transmission Psychosocial variables

Introduction Parental mental health or psychiatric problems heighten children’s vulnerability to develop internalizing, but also externalizing symptoms and disorders. Results of past epidemiological studies show that the prevalence of externalizing disorders is two to five times more likely in youth of depressed or anxious parents (Bergeron et al. 2000; Ford, Goodman and Meltzer 2004). Associations between parents’ depressive/anxiety disorders and externalizing disorders in children and youths are consistently found across three age-groups: 6–8 years, 9–11 years and 12–14 years (Bergeron et al. 2000). As mental health problems, particularly externalizing behavior symptoms, affect children’s quality of life and healthy development, it is of the utmost importance to gain a better understanding of the nature and strength of the influence of parental depressive/anxiety disorders on children externalizing disorders. Although relatively few studies investigated the mechanisms underlying the association between parental depressive/anxiety disorders and youth externalizing disorders, researchers generally agree about the main contribution of three family characteristics: parent-child relationship, family cohesion and marital satisfaction (Elgar et al. 2007; Fendrich et al. 1990; Harnish et al. 1995). Regarding the quality of parent-child relationship, parent-child discord (e.g., arguing, fighting) as well as parental rejection are found to contribute to the development of disruptive disorders in children of depressed parents (Fendrich et al. 1990).

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Interestingly, children of depressed parents who report a high level of parent-child discord have almost a sixfold increased risk of having a disruptive disorder, compared to children whose parents report a low level of parent-child discord (Fendrich et al. 1990). In addition, another dimension of parent-child relationship, parental nurturance or warmth, is shown to mediate the association between parental depression symptoms and children’s externalizing problems (Elgar et al. 2007; Harnish et al. 1995). These findings suggest that some dimensions of the parent-child relationship (e.g., punitive and caring behaviors) may play a central role in the association between parental psychopathology and children’s externalizing disorders (Deater-Deckard and Dodge 1997; Lahey et al. 1999). Fendrich et al.’s study (1990) also suggest that low level of family cohesion contributes to the prediction of conduct disorders in children of depressed parents. Social control theory (Hirschi 2007) may be used to explain this finding, by proposing that youths developing weaker bonds with their family might be at higher risk of externalizing behaviors (Loeber et al. 2009). Among other family characteristics emerging from recent studies, results from Hammen et al. (2004) underline that youths of depressed mothers are more likely to report externalizing disorders under conditions of low marital satisfaction. This brief review indicates that the association between parental depressive/anxiety disorders and children’s externalizing disorders may be influenced by several family characteristics. However, one major shortcoming of these past studies is that they were not conducted in representative samples of young children from the general population. Also, several child and socioeconomic variables (e.g., gender, progression in school, family income), which were suggested by theoretical models (Goodman and Gotlib 1999; Van Doesum et al. 2005), have been less studied. Moreover, until now, the interaction effects of parental depressive/anxiety disorders and other psychosocial correlates of 6–11 year-old children’s externalizing symptoms have never been documented. The objective of this study was to investigate the interaction effects between mother’s depressive/anxiety disorders and individual, familial and socioeconomic correlates of 6–11 year-old children’s externalizing symptoms. We hypothesized that maternal depressive/anxiety disorders may interact with several individual (e.g., age, gender), family (e.g., mother-child relationship) and socioeconomic (e.g., family income) variables, to statistically predict children’s externalizing symptoms. For example, we anticipated that younger children, boys and children whose mothers are less caring will be at a higher risk of reporting externalizing symptoms in contexts of maternal depression/anxiety. This present study is highly

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relevant since this type of multivariate analysis has not, to our knowledge, been conducted using data from a representative sample of children aged 6–11 years from the general population.

Method The Quebec Child Mental Health Study (QCMHS) The Quebec Child Mental Health Study (QCMHS) is an epidemiological cross-sectional study conducted in 1992, designed to determine the prevalence and identify the correlates for the most frequent mental disorders in children and adolescents from the general population. The target population was Quebec children aged 6–14 years who lived at home for at least 2 weeks per month in the 12 months preceding the interview. The children and one of their parents had to speak either French or English to be included in the study. A complex sampling design was used to avoid high travel costs and ensure representativeness across Quebec’s 16 administrative areas. Of the 3,209 families initially contacted, 486 refused to participate and 323 were excluded (changed residence or failed contact attempts). The response rate (83.5%) was computed on the basis of numbers of participants, refusals, those not reached, and a weight according to the eligibility rate. A brief questionnaire (a selection of sociodemographic, child’s mental health, and service utilization items from the overall questionnaire) was administered to a majority of the families who refused to participate. No statistically significant differences were found between participating and non-participating families. The original survey was conducted with the approval of the Institutional Review Board (IRB) of the Rivie`re-des-Prairies Hospital (Bergeron et al. 2000). The Present Study In this present study, we selected a subsample of 1,490 Quebec children from the original sample (N = 2400) of the QCMHS, whose parent respondent was the biological mother. As 92.5% of parent respondents were biological mothers in the QCMHS (5.8% of biological fathers and 1.7% of adoptive parents), we decided to select only children whose parent respondent was their biological mothers for statistical analyses. Although categorizing subgroups based on the type of parent respondent would have been interesting, this decision helps maintain sufficient statistical power and control for the biological link between mother and child. This sample size was sufficient for the detection of small effects with a statistical power of 99% at the 0.05 significance level (Cohen 1988).

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Weighed estimates based on the QCMHS representative sample revealed a slightly higher percentage of boys (51.9%) than girls (48.1%). French was the mother tongue for 87.8% of children, and Quebec was the birthplace for 91% of the sample. About one family in four (23.4%) was in the ‘‘low-income’’ category, and 13.1% of the children lived in a single-parent family. In addition, 62.7% of the mothers had completed high school. More than one-third (35.9%, n = 535) of biological mothers of the sample had at least one depressive or anxiety disorder in their lifetime, compared to 64.1% who had never had any internalizing disorder. Approximately 30% of those mothers with at least one internalizing disorder reported a combination of both depressive and anxiety disorder. Measurement of Mental Disorders In this study, the printed version of the Dominic (Valla et al. 1994; Valla et al. 2000), a pictorial self-report measure, was used directly with children to assess three externalizing disorders (oppositional defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder), based on DSM-III-R criteria. For these disorders, there are no major differences between DSM-III-R and DSM-IV symptoms or syndromes. The Dominic had been devised to minimize errors caused by 6–11 years-olds’ lack of attention, motivation, memory, and understanding (Valla et al. 2000). All questions from the Dominic were formulated in the present tense (e.g., Is it hard for you to keep your mind on your work?). The comprehension of the situations depicted in the drawings included in the Dominic was tested in a sample of 150 children from the general population. The internal consistency (Cronbach’s alpha coefficient = 0.62–0.88), test–retest reliability (intraclass correlation coefficients = 0.59 to 0.74) and concurrent validity (kappas = 0.64 to 0.88) were assessed in a sample of 143 children from the general population and outpatient clinics (Valla et al. 1994; Valla et al. 2000). In addition, norms for the Dominic were determined in the representative subsample of 1,575 children aged 6–11 years from the QCMHS (Bergeron et al. 2000; Breton et al. 1999). In the present study, symptom scores for the three externalizing disorders evaluated by the Dominic (Bergeron et al. 2000; Bergeron et al. 2007) were combined to define an externalizing symptom score, which constitutes the dependent variable considered in the statistical analyses. Measurement of Psychosocial Variables The independent variables were defined by several child, family and socioeconomic characteristics, including interactions between mother’s lifetime depressive/anxiety disorders and each of the psychosocial variables. Our choice

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of specific psychosocial variables to be investigated in this study was based on: (1) the list of variables included in the QCMHS (Bergeron et al. 2000); (2) theoretical integrative models on the intergenerational transmission of psychopathology and (3) previous empirical studies conducted on samples of children from the general population, in which mental disorders or symptoms were defined according to DSM criteria. All the variables were assessed by parent report. Child Characteristics Age was treated as a continuous variable. Gender differences were also studied. Progression in school (lifetime) was defined by presence or absence of school delay or special placement for learning, emotional, or behavior disorders. The list of the child’s stressful events (past 6 months and lifetime) included 23 situations on which most authors agree. These events were all interpreted as undesirable, except three on which consensus is less clear: adoption (lifetime), birth of a sibling (lifetime), and moving (6 months). One item from the list of stressful events was the child being victim of physical or sexual abuse during his or her lifetime, as reported by the parent. Chronic physical illness (duration of at least 6 months) was defined by the presence or absence of at least one chronic physical illness with or without loss of autonomy or use of medication. Social competence (past 6 months) was assessed by means of three questions from the parent version of the Child Behavior Checklist (Achenbach & Edelbrock, 1983). In the QCMHS, frequency of participation in groups and activities with friends referred to the number of times per week or month (Bergeron et al. 2000). Family Characteristics In this study, only children living with at least a biological mother were included in our analyses. Therefore, three types of family structure (past 6 months) were identified in our coding criteria: (1) two biological parents; (2) singleparent family; and (3) blended family. Only-child status was included in ordinal position (only child, 1st born, 2nd born, 3rd born or later born. Mother’s depressive/anxiety disorders (lifetime) was measured through the Diagnostic Interview Schedule Self-Administered (DISSA) (Kovess and Fournier 1990), an abridged version of the Diagnostic Interview Schedule (DIS) (Robins et al. 1981). It was validated in Quebec using a sample of French-speaking participants from the general population and was compared with the DIS and the diagnoses from psychiatrists. The kappa values obtained for the comparison with the DIS were 0.54 for panic disorder, 0.47 for social phobia, 0.40 for agoraphobia, 0.38 for major depression and generalized

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anxiety and 0.36 for simple phobia. Compared with clinical diagnoses, kappa values ranged from 0.45 (phobias) to 0.63 (depression). In this context, kappa values lower than 0.40 (minimum acceptable kappa value) may be explained, in part, by the small sample (N = 237) used to analyze the level of agreement between the DISSA and the DIS. It is also possible that the difference regarding the format of these two instruments (self-administered vs. face-to-face interview) explain the low agreement for some diagnoses. Despite these limitations, the acceptability of the DISSA in the present study was based on three considerations: (1) the short self-administered format allowed to integrate this instrument in a comprehensive battery assessing multiple correlates; (2) it was not significantly associated with a social desirability scale; (3) previous studies demonstrated significant main effects between the most severe period of lifetime depressive/anxiety symptoms in parents and current mental disorders evaluated by the Dominic (Bergeron et al. 2000). The Dyadic Adjustment Scale (DAS) (Spanier 1976) assessed the relationship over the past 6 months between the mother and a spouse who had lived with her for at least 12 months. The Parent Behaviors and Attitudes Questionnaire measured the frequency (past 6 months) of mothers’ caring behaviors, punitive behaviors, and autonomy-promoting attitudes (PBAQ) (Bergeron et al. 2000). Caring was defined as affective support and instrumental support (e.g., helping the child to accomplish difficult tasks). Punitive parental behavior was defined by social isolation (forbidding the child to play with other children), deprivation of privileges, rejection and physical punishment. Permissiveness was assessed according to three major categories of the child’s autonomous behavior: basic autonomy (e.g., choosing his or her own hair style), autonomy in the community (e.g., going to the grocery store or other stores) and social autonomy (e.g., choosing his or her own friends). The PBAQ includes 23 items assessed on a 4-point Likert scale. In the QCMHS, psychometric properties and norms were established for each of the three PBAQ’s subscales according to gender and three age-groups (6-8, 9-11, 12-14). A standardized score (Z score) for each item was calculated, and then all zscores were added for each subscale. Subscales were treated as a continuous variable in the QCMHS (Bergeron et al. 2000) and in the present study. The list of parent’s stressful events (past 6 months) included 23 situations considered in the literature to be major changes (Bergeron et al. 2000). Chronic physical illness (duration of at least 6 months) in family members was defined by the number of illnesses in target child, parents and siblings. The Social Support Scale (SSS) included three questions drawn from a Social Support Questionnaire that evaluates mother’s perception (present

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period) of emotional, instrumental, and normative support received from the spouse and/or others for parenting tasks. These questions were chosen from a factorial analysis (factor loading coefficients: 0.78) of six preliminary questions during the QCMHS pilot study (Bergeron et al. 2000). Socioeconomic Characteristics Parent’s level of education was defined according to three categories: (1) high school or less; (2) college or equivalent; and (3) university graduate. Family income was measured by a question on gross family income (past 12 months). A variable labelled ‘‘sufficient family income’’ was defined by four categories proposed in the QCMHS (very low, low, low average, high average or high) (Bergeron et al. 2007). Statistical Analyses All statistical analyses were adjusted for the complex sampling design used. Hence, we weighed data according to the sampling plan and the estimated design effect (i.e., correction factor) of 1.14. We verified colinearity between the independent variables and results indicated no multicolinearity problems in our data. We conducted multiple linear regression analyses using a hierarchical backward elimination strategy. Complementary analyses were conducted to identify possible interaction effects between mother’s lifetime depressive/anxiety disorders and psychosocial correlates of children’s externalizing symptoms, according to gender (6–8 year-old, 9–11 year-old).

Results The results of the multiple regression analyses are presented in two sections. First, statistically significant components of interactions and main effects obtained in the whole sample multiple linear regression models are presented (Table 1). Second, significant results obtained in the complementary analyses according to two age-groups and gender are described (Tables 2 and 3). Main Results Physical or sexual abuse, in interaction with lifetime depressive/anxiety disorders in mothers, was found to be associated with externalizing symptoms in children (b = 0.428, t = 2.362, P = 0.018) (Table 1). Among children of lifetime depressed/anxious mothers, physical or sexual abuse was significantly associated with a higher score of children’s externalizing symptoms. Regarding

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Table 1 Significant interaction effects between mother’s lifetime depressive/anxiety disorders and correlates of externalizing symptoms in children 6–11 years old (N = 1,490) Independent variables

Children’s externalizing symptoms

1. Age

Main effect only***

2. Gender

Main effect only***

3. Progression in school

Main effect only**

4. Child stressful events: physical or sexual abuse

0.428 [0.072, 0.783]*

5. Birth (brother or sister)

ns

6. Parent-child relationship: mother’s caring behaviours 7. Parent-child relationship: mother’s punitive behaviours

0.102 [0.026, 0.173]** Main effect only***

8. Parent’s stressful events

ns

9. Social support

ns

10. Mother’s level of education

ns

Adjusted R2

0.084

*** P \ 0.001, ** P \ 0.01, * P \ 0.05 For significant interaction effects, the unstandardized regression coefficient is reported (B) with the confidence interval of 95% in the parenthesis

mother-child relationship, mother’s caring behaviors were found to interact with mother’s lifetime depressive/anxiety disorders (b = 0.102, t = 2.710, P = 0.007) (Table 1). Children whose mothers had a lifetime depressed/anxious mothers and a low level of caring behaviors reported more externalizing symptoms. Table 1 shows main effects for (1) age (older vs. younger) (b = 0.070, t = 5.316,

P \ 0.001), (2) gender (boys vs. girls) (b = 0.280, t = 6.336, P \ 0.001), (3) progression in school (irregular vs. regular) (b = 0.207, t = 2.776, P = 0.006) and mother’s punitive behaviors (low score vs. average score) (b = 0.086, t = 3.848, P \ 0.001). Analyses According to Two Age-Groups (6 To 8 Years, 9 To 11 Years) Only one interaction effect was found between mother’s lifetime depressive/anxiety disorders and children’s externalizing symptoms among children aged 6 to 8 years (Table 2). Children who were victims of physical/sexual abuse and whose mothers had a lifetime depressive/anxiety disorders reported more externalizing symptoms (b = 0.580, t = 2.577, P = 0.010). Table 2 shows main effects for (1) age (older vs. younger) (b = 0.105, t = 2.701, P = 0.007), gender (boys vs. girls) (b = 0.249, t = 3.949, P \ 0.001) and (3) school progression (irregular vs. regular) (b = 0.283, t = 2.008, P = 0.045). Mother’s caring behaviors interacted with mother’s lifetime depressive/anxiety disorders to statistically predict children’s externalizing symptoms among children aged 9–11 years (t = 2.530, P = 0.012) (Table 2). Children whose mothers had a lifetime depressive/anxiety disorders and a low level of caring reported more externalizing symptoms (b = 0.028). Table 2 shows main effects for (1) age (older vs. younger) (b = 0.092, t = 2.427, P = 0.015), (2) gender (boys vs. girls) (b = 0.327, t = 5.243, P \ 0.001) and (3) mother’s punitive behaviors (low score vs. average score) (b = 0.027, t = 3.897, P \ 0.001).

Table 2 Significant interaction effects between mother’s lifetime depressive/anxiety disorders and correlates of externalizing symptoms in children 6–8 years old and 9–11 years old (6–8 years (n = 737), 9–11 years (n = 753)) Independent variables

Externalizing symptoms 6–8 years old

9–11 years old

1. Age

Main effect only**

Main effect only*

2. Gender

Main effect only***

Main effect only***


Main effect only*

ns


0.580 [0.138, 1.021]**

ns


ns

ns

6. Parent-child relationship: mother’s caring behaviours

ns

0.028 [0.006, 0.050]*

7. Parent-child relationship: mother’s punitive behaviours

ns

Main effect only***


ns

ns

9. Social support

ns

ns


ns

ns

Adjusted R2

0.055

0.079


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J Child Fam Stud (2011) 20:596–604 Table 3 Significant interaction effects between mother’s lifetime depressive/anxiety disorders and correlates of externalizing symptoms in girls and boys aged 6–11 years old (girls (n = 726); boys (n = 726))


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Independent variables

Externalizing symptoms Girls

Boys

1. Age

Main effect only***

Main effect only***


ns

Main effect only*


ns

0.513 [0.022, 1.004]*


ns

ns

5. Parent-child relationship: mother’s caring behaviours

ns

ns

6. Parent-child relationship: mother’s punitive behaviours

Main effect only*

Main effect only***


ns

ns

8. Social support

ns

ns


ns

ns

Adjusted R2

0.029

0.061

Analyses According to Gender Physical or sexual abuse in interaction with mother’s lifetime depressive/anxiety disorders, was found to be associated with externalizing symptoms in boys aged 6–11 years (t = 2.053, P = 0.040) (Table 3). Among boys whose mothers had a lifetime depressive/anxiety disorders, those who were victims of physical/sexual abuse reported more externalizing symptoms than those who weren’t victims (b = 0.513). Table 3 shows main effects for (1) age (older vs. younger) (b = 0.077, t = 4.056, P \ 0.001), (2) school progression (irregular vs. regular) (b = 0.226, t = 2.241, P = 0.025) and (3) mother’s punitive behaviors (low score vs. average score) (b = 0.025, t = 3.493, P = 0.001). Among girls aged 6–11 years, no interaction effects were found between mother’s lifetime depressive/anxiety disorders and other psychosocial variables. However, main effects were found for (1) age (older vs. younger) (b = 0.066, t = 3.655, P \ 0.001) and (2) mother’s punitive behaviors (low score vs. average score) (b = 0.015, t = 2.259, P = 0.024) (Table 3).

Discussion Our findings highlight four main contributions. First, results support the hypothesis of interaction effects between mother’s lifetime depressive/anxiety disorders and other psychosocial variables suggested by the developmental integrative models of intergenerational transmission of psychopathology (Goodman and Gotlib 1999; Van Doesum et al. 2005). Indeed, two variables interacted with mother’s lifetime depressive/anxiety disorders, to statistically predict children’s externalizing symptoms: physical

or sexual abuse and mother-child relationship (mother’s caring behaviors). Second, results suggest an important contribution of mother-child relationship, thus converging with previous findings (Elgar et al. 2007; Fendrich et al. 1990; Harnish et al. 1995) and theoretical models (Van Doesum et al. 2005). However, in this study, mothers’ caring behaviors but not punitive behaviors, were associated with a higher score of self-reported externalizing symptoms in children of lifetime depressed/anxious mothers. This was particularly true among children aged 9–11 years. It suggests that mother’s caring behaviors may be involved in the association between maternal depressive/anxiety disorders and children’s externalizing symptoms. This result adds new information to the literature. Indeed, it has been highlighted that depressed/anxious mothers engage in more punitive behaviors towards their children, and that this type of parenting behavior would make the child more vulnerable for developing externalizing symptoms (Cummings et al. 2002). However, until now, the importance of mother’s caring behaviors in the association between maternal depressive/anxiety disorders and children’s externalizing symptoms has rarely been proposed in the literature. The finding that maternal punitive behaviors does not interact significantly with mother’s lifetime depressive/anxiety disorders to predict children’s externalizing symptoms may remain questionable. We hypothesize that children of depressed/anxious mothers may be at a higher risk of developing externalizing symptoms only when their mothers display extreme levels of punitive behaviors (e.g., physical abuse). Indeed, our findings suggest that physical abuse interacts with mother’s lifetime depressive/anxiety disorders and may heighten children’s vulnerability to develop externalizing symptoms. Both younger children (aged 6–8 years) and boys who were victims of physical/

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sexual abuse in their lifetime and exposed to maternal lifetime depression/anxiety disorders reported more externalizing symptoms. Physical abuse is known to be a correlate of externalizing disorders in children in the literature (Burke et al. 2002; Jaffee et al. 2002; Loeber et al. 2000), particularly in boys (Jaffee et al. 2002; MalinoskyRummell and Hansen 1993; Scannapieco and ConnelCarrick, 2005). Some researchers also suggest considering physical abuse as an extreme form of parental punitive behavior (Deater-Deckard and Dodge 1997). Our findings suggest that boys may externalize more than girls in reaction to physical abuse. It is possible that this major stressful event may have a cumulative effect with maternal lifetime psychiatric disorder, to heighten boys’ vulnerability to develop externalizing symptoms. Fourth, significant main effects observed for age, gender and progression in school generally confirm results from previous studies investigating correlates of externalizing disorders (Bergeron et al. 2000; Ford et al. 2004; Tremblay et al. 1992). These variables are thus shown to remain important in the development of externalizing symptoms, independently of mother’s lifetime depression/anxiety disorders. Conclusions of this study must be interpreted by considering the four following limits (Bergeron et al. 2000). First, as the QCMHS is a cross-sectional study, the aim of the research into correlates was to formulate hypotheses regarding risk factors. Second, some variables possibly implicated in the etiology of externalizing symptoms in children and adolescents (e.g., genetic, neurobiological, neuropsychological) were not studied, for lack of feasibility. Yet, the pre-selection of a subgroup of children with biological mothers controls for the biological link between mother and child. Third, the large number of statistical tests performed may increase Type I errors, reduce power by increasing Type II errors, and generate results which may, in certain cases, be artefacts. Fourth, as this study measures the mother’s lifetime depressive/anxiety disorders, no conclusion can be made regarding the mother’s current psychiatric status. Bagner et al. (2010) underlined the importance of timing of maternal depression for the development of internalizing problems in children. Maternal depression during the child’s first year of life was significantly associated with mothers’ ratings of internalizing problems in children. Yet, empirical data from previous studies suggested that the most severe period of mother’s depressive/anxiety disorders may be considered a relevant index of adversity for current internalizing symptoms in children (Bergeron et al. 2000). Implications Although the generalization of these findings to a clinical population is somewhat limited, some implications for

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clinicians may be suggested. First, results highlight the importance for clinicians to pay special attention to one potential high-risk subgroup who seem particularly vulnerable to reporting psychiatric symptoms: boys of depressed/anxious mothers who were physically or sexually abused. It seems that being victimized physically or sexually and being exposed to maternal lifetime psychiatric disorder heightens boys’ vulnerability to develop externalizing symptoms. Thus, professionals seeing children exposed to lifetime maternal depression/anxiety disorders should be aware of the possible pervasive influence of physical/sexual abuse for boys. Second, clinicians may wish to consider careful early screening of psychiatric symptoms and other important child and family variables such as parent–child relationship, among children of lifetime depressed/anxious parents. Third, it is suggested that preventive intervention programs oriented towards high-risk groups of children, such as children of lifetime depressed/anxious parents and exposed to relational difficulties, be developed and integrated in the public health and social care system. In this regard, results of this study support the relevance of family and systemic interventions, to help prevent the intergenerational transmission of psychiatric disorders, by diminishing depressive/anxiety symptoms in parents and increasing the quality of parent-child relationships (e.g., parental caring behaviors) or parental social support. In recent years, several programs aiming to prevent the development of depressive/anxiety disorders in children of depressed/anxious parents have been developed, showing some positive short and long term effects (Beardslee et al. 2007; Gladstone & Beardslee, 2009; Van Doesum et al. 2008). Fourth, it is suggested that future research consider including both fathers and mothers in their sample. In past years, the importance of taking into account father-child relationship in children’s development and more specifically in the intergenerational transmission of psychiatric disorders has been highlighted in the literature (Bogels and Phares 2008; Brennan et al. 2002; Connell and Goodman 2002; Cummings et al. 2005). In this study, only biological mothers were selected for statistical analyses. Since 92.5% of parent respondants were biological mothers in the QCMHS (vs. 5.8% of biological fathers), this decision was made in order to maintain sufficient statistical power. Fifth, these exploratory findings need to be replicated using different research designs (i.e., longitudinal) and measurement instruments, as well as with samples of adolescents and young adults. From a developmental perspective, investigating the continuity of the interplay between maternal lifetime depressive/anxiety disorders and family characteristics across the early lifespan is highly relevant.

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Conclusion Our results support the hypothesis that mother’s depressive/anxiety disorders interact with other psychosocial characteristics to predict children’s externalizing symptoms. An original methodological contribution of this research is that these interaction effects were found for symptoms reported by the child, in a representative sample of children aged 6–11 years from the general population. This study also clearly highlights the contribution of the family context in the process of intergenerational transmission of psychopathology. Indeed, our results suggest that externalizing symptoms can be associated with both dimensions of parent-child relationship, caring and punitive behaviors, which supports a theoretical hypothesis presented relatively recently. Maternal caring behaviors were found to be involved in the association between maternal lifetime depressive/anxiety disorders and children’s externalizing symptoms. Findings from this study thus underscore the importance of taking into account mother’s caring behaviors, as well as evaluating if children are exposed to extreme forms of punitive behaviors (e.g., physical abuse) in early preventive interventions, and in systemic or family interventions, targeting families of depressed/anxious parents (Goodman and Gotlib 2002; Van Doesum et al. 2005).

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