Maternal Depression and Child Adjustment - American Psychological ...

Journal of Abnormal Psychology 1989, Vol. 98, No. 1,78-85

Copyright 1989 by the American Psychological Association, Inc. 0021-843X/89/S00.75

Maternal Depression and Child Adjustment: A Longitudinal Analysis

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Catherine M. Lee and Ian H. Gotlib University of Western Ontario, London, Ontario, Canada This study examined the relation between maternal depression and child adjustment. Two major issues were addressed. First, to assess the specificity to depression of observed child adjustment difficulties, four groups of female subjects were included: clinically depressed psychiatric patients, nondepressed psychiatric patients, nondepressed medical patients, and nondepressed nonpatients. Second, to assess the stability of the observed effects, data were collected early in the patients' treatment and again approximately 8 weeks later. The results indicated that the depressed mothers described their children as having various behavior problems; interestingly, interviewers also rated these children as demonstrating disturbed behavior. Although the offspring of the depressed mothers were the most impaired children in the sample, the lack of significant differences between children of the depressed and the nondepressed psychiatric patients suggests that child adjustment is more strongly related to the presence of maternal psychopathology than it is to diagnostic status. Finally, children of the psychiatric patients continued to demonstrate problems at the second assessment. Implications of these results for models of depression are discussed, and directions for future research are offered.

In recent years there has been mounting concern that the children of depressed parents may be at risk for a range of emotional adjustment difficulties (e.g., Beardslee, Bemporad, Keller, & Klerman, 1983; Billings & Moos, 1983, 1986; Weissman et al., 1984, 1987). Indeed, a number of investigators have found that depressed parents report a higher incidence of difficulties in their children than do nondepressed parents (e.g., Billings & Moos, 1983; Holahan & Moos, 1987; Weissman et al., 1984, 1987). Because depressed individuals may be characterized by a tendency to view themselves and their environment negatively (cf. Beck, Rush, Shaw, & Emery, 1979; Gotlib, 1983), however, it is possible that these parental reports of child difficulties are a function of elevated depressed mood, rather than accurate appraisals of impaired child adjustment. To circumvent this concern, it is necessary to obtain corroborating data from other sources, such as external raters, clinicians, or the children themselves. Addressing this issue, several investigators have conducted clinical interviews directly with the children of depressed parents. Typically, these researchers have focused on children of bipolar depressed parents, comparing them either with children of parents with nonaffective psychiatric disorders (e.g., Klein, Depue, & Krauss, 1986; Klein, Depue, & Slater, 1985, 1986), or with children of nondepressed nonpatient parents (e.g., Decina et al. 1983; Welner, Welner, McCrary, & Leonard, 1977). These studies have consistently demonstrated a higher inci-

dence of affective disturbance in children of bipolar depressed parents than in children of either nondepressed psychiatric or normal control parents. One issue that requires further examination concerns the generalizability of these results to unipolar depression. Although the results of some studies suggest that there may be significant differences between children of bipolar depressed parents and offspring of unipolar depressed parents (e.g., Radke-Yarrow, Cummings, Kuczynski, & Chapman, 1985; Zahn-Waxier, Cummings, lanotti, & Radke-Yarrow, 1984), both Winters, Stone, Weintraub, and Neale (1981) and Cytryn, McKnew, Bartko, Lamour, and Hamovitt (1982) found that children of unipolar depressed parents were more disturbed than were children of bipolar depressed parents. Interestingly, despite the greater prevalence of unipolar than bipolar depression, there are relatively few well-controlled studies of the effects of unipolar depression on child adjustment. In one recent study, Turner, Beidel, and Costello (1987) reported that children of dysthymic parents were less disturbed than were children of anxiety-disordered parents, although both groups of children were more severely impaired than were children of nonpatient control parents. Note, however, that the more serious dysfunction in the children of the anxiety-disorder parents may have been due to a relatively greater severity of parental psychiatric disturbance in this group (cf. Turner, McCann, Beidel, & Mezzich, 1986). In a similar study, Hirsch, Moos, and Reischl (1985) found both children of depressed parents and children of arthritic parents to report a greater number of symptoms themselves than did children of nonpatient control parents. Again, however, given the high incidence of reactive depression in rheumatoid arthritis patients (cf. Anderson, Bradley, Young, McDaniel, & Wise, 1985), it is possible that the lack of differences in this study between the children of depressed and arthritic parents was attributable to the presence of depressive symptoms in the arthritic parents rather than to the effects of general disability.

The research reported in this article was funded by Grant 923-85/87 from the Ontario Mental Health Foundation to Ian H. Gotlib. The authors wish to thank Cynthia Waugh and Patricia Peters for their assistance in collecting the data reported in this article. Catherine Lee is now at the University of Ottawa. Correspondence concerning this article should be addressed to Ian H. Gotlib, Department of Psychology, University of Western Ontario, London, Ontario, Canada N6A 5C2.

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MATERNAL DEPRESSION AND CHILD ADJUSTMENT Finally, Hammen et al. (1987) assessed the level of psychopathology in unipolar depressed, bipolar depressed, medically ill, and normal mothers and their children. These investigators found that children of depressed mothers had higher rates of psychiatric diagnoses than did children of normal mothers, with children of unipolar depressed mothers evidencing the highest rates. Interestingly, a number of medically ill parents also reported a history of psychopathology, and children in this group had moderate rates of psychiatric diagnosis, albeit lower than those found in children of affectively disordered parents. Considered collectively, these studies appear to provide persuasive evidence of a link between parental depression and child difficulties. The present study was conducted to extend these findings by addressing two major issues. First, as we noted earlier, the specificity to parental depression of difficulties in child adjustment is unclear. To address this issue, a number of relevant variables were assessed in four matched groups of mothers: depressed psychiatric patients, nondepressed psychiatric patients, nondepressed medical patients, and nondepressed nonpatients. The inclusion of these control groups permitted an evaluation of three subhypotheses. The depression-specificity hypothesis (e.g., Beardslee et al., 1983) predicted that child adjustment problems would be evident only in the offspring of depressed patients and their children. The psychological distress hypothesis (e.g., Gotlib, 1982; Lyons-Ruth, Zoll, Connell, & Grunebaum, 1986) predicted that child difficulties would be related to maternal psychopathology and psychological distress in general. Thus, children in the two psychiatric groups would not differ from one another, but would both demonstrate poorer adjustment than would children in the two nonpsychiatric control groups. Finally, the general disability hypothesis (e.g., Hirsch et al., 1985) predicted that child problems are associated with maternal physical and psychological disorder; therefore, child difficulties should be evident in all three patient groups. The second issue involves the stability of the obtained results overtime. Whereas Billings and Moos (1986) found that remitted depressed parents continued to describe their children as having difficulties, Weissman (1983) observed improvement in the behavior of adolescent children following alleviation of their mothers' depression. This issue was addressed in the present study by assessing mothers and children both early in the mother's treatment and again approximately 8 weeks later. The "transient disturbance" hypothesis predicted that child adjustment difficulties would be evident only when mothers are symptomatic; an alleviation of maternal symptomatology, therefore, would be related to an improvement in child adjustment. In contrast, the "prolonged disturbance" hypothesis predicted that child difficulties would endure following symptomatic improvement in the mothers. Method

Subject Selection The original subject sample in this study consisted of 75 motherchild dyads. Four groups of dyads were formed: (a) dyads in which the mother was currently receiving outpatient psychiatric treatment for major depression; (b) dyads in which the mother was currently receiving outpatient treatment for a psychiatric disorder other than depression; (c) dyads in which the mother was currently receiving outpatient treat-

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ment for a medical condition; and (d) dyads in which the mother was not receiving outpatient treatment for either emotional or physical problems (see Measures section later for group assignment criteria). Mothers in the three patient groups were recruited from medical and psychiatric treatment facilities in the London, Ontario area. Potential subjects were given a letter by their therapists or physicians outlining the study. The names of those women who expressed interest in the study were passed on to a research assistant, who telephoned the women to provide them with additional information about the project. Nonpatient control subjects were recruited through newspaper advertisements soliciting participants in a study of mother-child relationships. Given these recruitment procedures, which were designed to protect patient confidentiality and to avoid coercion to participate, it is not possible to calculate actual response rates. Nevertheless, it is our impression that the psychiatric patient mothers who agreed to participate may represent a less disturbed sample of the population of outpatient psychiatric women. If accurate, the probable consequence of such a selection bias would be to attenuate differences between psychiatric and nonpsychiatric groups. Finally, pain ratings collected from the arthritic women who participated in this study indicated that the severity of their discomfort was comparable to that of women from the same clinic who declined to participate. For a mother-child dyad to be considered for inclusion in the study, they had to have lived together for at least 1 year. In addition, mothers were excluded from the study if they demonstrated evidence of alcoholism, psychotic ideation, or brain damage. With the exception of the medical patient group, mothers were also excluded from the study if they were suffering from a chronic illness. Because we were interested in the stability of patterns of child adjustment over time, mother-child dyads were also excluded from the study if they were currently involved in child management training. Finally, the youngest child in the family whose age was between 7 and 13 was selected for participation in the study.

Measures Maternal functioning. A number of studies have demonstrated a low degree of concordance between clinical ratings and self-report measures of depression (e.g., Oliver & Simmons, 1984). In the current study, therefore, subjects' depression was assessed on the basis of multiple measures. Group assignment for the psychiatric patients was based on a Diagnostic and Statistical Manual of Mental Disorders (DSM-IH) diagnosis of depression, and on scores on the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960). The HRSD is a clinician-rated measure consisting of 17 items chosen to reflect the presence and severity of depression. During a structured interview with the patient, the clinician scores each item on a 0-2 or 0-4 scale. The sum of these ratings is used as a score of global severity of the depressive symptoms. Both the interrater reliability (Bech et al., 1975) and the criterion validity (Carroll, Fielding, & Blashki, 1973) of the HRSD have been demonstrated to be acceptable. A psychiatric outpatient was classified as depressed if she (a) met DSM-III criteria for a diagnosis of major depressive episode or dysthymic disorder, and (b) evidenced moderate to severe levels of depression, denned as a minimum score of 14 on the HRSD. This HRSD cut-off score of 14 is the same as that used in previous studies of psychotherapy outcome in depression (e.g., Elkin, Parloff, Hadley, & Autry, 1985; Murphy, Simons, Wetzel, & Lustman, 1984; Rush, Beck, Kovacs, & Hollon, 1977). Of the 16 depressed patients, 7 met DSM-III diagnostic criteria for dysthymic disorder, and 9 met criteria for major depressive episode. A psychiatric outpatient was classified as nondepressed if she (a) failed to meet DSM-III criteria for a diagnosis of affective disorder, (b) obtained scores of 10 or less on the HRSD, and (c) had no history of previous psychiatric treatment for depression. The nondepressed psychiatric


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outpatients were diagnosed as manifesting symptoms of anxiety disorder (n = 3), personality disorder (n = 3), and adjustment disorder (without depressed mood; n = 4). Criteria for inclusion in the study for the medical outpatient subjects, who were typically being treated for rheumatoid arthritis, included (a) failure to meet DSM-III criteria for a diagnosis of major affective disorder, (b) an HRSD score of 10 or less, and (c) no reported current or past treatment for a psychiatric disorder. Nonpatient mothers were included in the study if they (a) obtained scores of 10 or less on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), and (b) reported no current or past psychiatric problems or treatment. All potential patient-subjects who expressed an interest in participating in the study were assessed in a semistructured interview, based on the Schedule for Affective Disorders and Schizophrenia (Endicott & Spitzer, 1978), by a clinical psychology doctoral student. The assessment interviews yielded information relevant to both the DSM-III and HRSD criteria. The interviews were audiotaped, and a subset of 15 interviews was subsequently rated independently by a clinical psychologist to establish diagnostic reliability. Perfect agreement was attained in diagnosing subjects as depressed or nondepressed; correlation coefficients of the concordance between raters revealed a correlation of .58 for the HRSD. These data indicate that the diagnoses were made reliably. The relatively low correlation for HRSD scores may be partially accounted for by the fact that several HRSD items rely on direct observations of the patient and cannot adequately be assessed by audiotape. Mothers in all four groups also completed the BDI (Beck et al., 1961), a 21-item self-report measure of the depth or intensity of depression. The BDI has been demonstrated to have high internal consistency and acceptable discriminant validity (cf. Gotlib & Cane, in press), making it a particularly useful instrument for screening purposes. Child functioning. In light of increasing recognition that important information concerning child adjustment can be gleaned from different sources (e.g., Shoemaker, Erickson, & Finch, 1986), child functioning was assessed with a semistructured clinical interview and a report from the mother. Children were interviewed with the Child Assessment Schedule (CAS; Hodges, 1983), a semistructured protocol designed to be administered to children 7 years and older. The interviewer using the CAS records the child's responses to a set of questions assessing the child's functioning in different domains. The interview yields an overall disturbance score, as well as scores on 11 subscales. In the present study, the CAS was administered by trained interviewers with extensive research experience with children. The interviewer was blind with respect to the group membership of the family. Interrater reliability was determined by coding audiotapes of a subset of 25 interviews by a second trained rater. The CAS has demonstrated adequate content, construct, and discriminant validity (Hodges, Kline, Stern, Cytryn, & McKnew, 1982; Hodges, McKnew, Cytryn, Stem, & Kline, 1982; Turner et al., 1987). In the present study, kappa coefficients calculated on the total symptom scores for each subscale of the CAS ranged from .96 to 1.00, indicating a very high degree of reliability between raters. Finally, mothers also completed the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983), which contains 118 items, each scored on a scale from 0 to 2. The CBCL yields scores on broad band syndromes of "internalizing" and "externalizing" problems, as well as on social competence. Adequate construct criterion validity has been demonstrated for the CBCL (Achenbach & Edelbrock, 1983).

Procedure In all groups, potential subjects were asked to participate with one of their children in a study of mother-child interaction. Subjects were paid $15 to cover transportation and babysitting expenses. Patient subjects who met inclusion criteria were contacted by a research assistant (who remained unaware of the subject's group assignment), and arrange-

ments were made for mothers and children to attend a research session within 1 week of the subjects' assessment interviews. Upon arrival at the laboratory, the mothers were given a detailed written overview of the procedures of the study and were assured of confidentiality. The procedures were also described to the child in language appropriate to the child's age, and data collection began only after both the mother and child consented to the procedures. The mother was taken to a separate room to complete a packet of questionnaires, including the BDI and the CBCL. During this time the child was assessed on the CAS by a trained interviewer who was unaware of the group assignment of the dyad. Finally, the research assistant thanked and paid the mother, answered any questions, and made arrangements for a second, identical session to be held 6-8 weeks later.

Results Overview of Sample Characteristics Of the 75 mothers who agreed to participate, one medical patient was excluded because she met criteria for a DSM-III diagnosis of dysthymic disorder, one nondepressed psychiatric patient mother was excluded because she was too agitated to complete the questionnaires, and two community mothers were excluded because they had elevated scores on the BDI. Of the 71 mothers who met inclusionary criteria, 61 returned for a second session. One medical patient mother and one nondepressed psychiatric patient mother withdrew from the study because of scheduling difficulties; two depressed mothers were unable to participate because they no longer had custody of their children; and six nondepressed psychiatric patient mothers had discontinued therapy and had either moved or had their phones disconnected. The subjects who completed both Sessions 1 and 2 included 16 depressed psychiatric patient mothers (8 boys and 8 girls), 10 nondepressed psychiatric patient mothers (3 boys and 7 girls), 8 medical patient mothers (5 boys and 3 girls), and 27 nonpatient mothers (14 boys and 13 girls). The grade levels of children in all groups ranged from Grade 1 to Grade 8, with an overall mean of 3.81; there were no significant group differences with respect to this variable. Demographic Characteristics Group means and standard deviations for mother's age, income, years of education, number of children, age of child, and length of interval between sessions are presented in Table 1. To compare subjects on demographic variables, a one-way multivariate analysis of variance (MANOVA) was conducted on subjects' age, income, years of education, number of children, and age of child participating in the study. Using Wilks's criterion, a significant main effect for group was obtained, P(l%, 131) = 2.33,p .1, nor the group by session interaction, F(3, 57) = 1.69, p > . 1, was significant. Tukey-Kramer comparisons revealed that none of the between-groups differences were of sufficient magnitude to attain statistical significance (all ps > .05). In sum, therefore, although interviewers found group differences in children's externalizing problems, these were not as robust as were the differences observed for internalizing problems. No group differences were evident in maternal ratings of externalizing behavior. Finally, across all groups, mothers rated their children as having fewer problems at Session 2 than at Session 1. Social competence. In contrast to the analyses for internalizing and externalizing problems, preliminary analyses on maternal perceptions of child social competence indicated that income exerted a significant effect, F(3, 42) = 3.46, p < .05. Consequently, child competence was assessed by a repeatedmeasures multivariate analysis of covariance (MANCOVA) conducted on the three social competence T scores derived from the Child Behavior Checklist (activity T score, social T score and school T score), with income as a covariate. A significant main effect for group was not obtained, F(9, 102) < 1, indicating that any group differences in maternal ratings of child competence could be accounted for by disparities in income. No significant main effect was obtained for session, F(3, 43) < 1, nor was there a significant group by session interaction, F(9, 105) < 1. Interviewer ratings of child social competence were assessed by a repeated-measures MANOVA conducted on symptom ratings from the CAS in the areas of school, activities, and friends. The MANOVA revealed no main effects for either group, F(9, 134) < 1, or session, F(3, 55) = < 1, and no group by session interaction, F(9, 134) = 1.26, p> . 10. Thus, interviewer ratings of child difficulties in school, in activities, or with friends did not discriminate among children in the various groups, nor was children's functioning in these areas found to change significantly across sessions. This finding is consistent with maternal ratings indicating no differences in child competence over and above the effects of family income. Discussion The present study was designed to assess the specificity and stability of adjustment difficulties of children of depressed mothers. With respect to the issue of specificity, both maternal and interviewer ratings indicated that the children of depressed mothers exhibited a significantly greater number of internalizing problems than did the children of either community or medical patient mothers. There was, however, significant overlap between the children of the depressed and the nondepressed psychiatric patient mothers. These two groups of children did

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not differ significantly on any of the internalizing problems. Although children of the depressed mothers were rated as being most troubled by internalizing problems, the absence of a significant difference between the two psychiatric groups in either interviewer or maternal ratings raises doubts about the specificity of this effect to depression. Rather, the present data suggest that maternal psychological disturbance affects children's internalizing behavior. The results of this study are consistent with those reported by Turner et al. (1987), who also identified a greater number of fears and more mood disturbance in children of affectively disturbed parents than in children of community parents. Considered in light of other findings indicating that severity of parental psychopathology is related to child adjustment (e.g., Harder, Kokes, Fisher, & Strauss, 1980; Keller et al., 1986), it is possible that in both the current study and in Turner et al.'s study, the degree of impairment found in children was related to the severity of parental impairment rather than to parental diagnostic status. In future research, it will be important to compare parents who have different diagnoses but are equated explicitly in terms of the severity of their psychopathology. The results of the mother-completed CBCL revealed no differences among the four groups of children with respect to externalizing problems. In contrast, interviewers using the CAS did find group differences in terms of externalizing problems, although none of the between-groups comparisons were of sufficient magnitude to attain statistical significance. These findings are also consistent with those obtained by Turner et al. (1987), in that no differences were found with respect to children's acting-out problems identified on the CAS. As a caveat, however, it should be noted that because mothers who were currently involved in child management training were excluded from this study, the obtained rates of externalizing problems may be an underestimate of the population rate for children of depressed mothers. Maternal ratings also revealed no group differences in social competence over and above the effects of family income. Similarly, no differences among groups were found with respect to the clinicians' ratings of children's competence. These findings corroborate those reported by Turner et al. (1987) and Hammen et al. (1987), and suggest that the effects of disturbance in maternal functioning are limited to behavior problems. Another possibility that should be considered, however, is that because the CBCL social competence scales assess only overt aspects of competence (e.g., participation in activities, amount of time spent alone), they may not be comprehensive measures of this construct. It will be important in future research to examine school-age children's competence in greater detail through the use of developmentally relevant tasks. For example, children could be assessed in terms of their problem-solving abilities, peer interactions, affective expression, or ability to cope with stressors. With respect to the issue of stability, although both mothers and clinicians identified fewer internalizing problems in children at the second session, no group by session interactions were obtained. Furthermore, despite the improvement in depressed mothers' reported severity of depression, group differences in children's adjustment were still evident across sessions. Thus, although maternal symptomatology had abated to mild


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levels at the second session, continued child difficulties were evident, indicating that there may be a substantial lag between alleviation in maternal depressive symptomatology and improvement in child functioning. These findings not only corroborate Billings and Moos's (1986) observations that remitted depressed parents continue to report adjustment difficulties in their children, but also replicate these results with ratings by clinicians. Considered collectively, the present data on child adjustment corroborate previous findings of impairment in the children of depressed parents (e.g., Billings & Moos, 1983; Cytryn et al., 1982; Weissman et al., 1984; Welner et al., 1977). Consistent with these findings, child difficulties spanned a range of adjustment difficulties but were most prominent in terms of internalizing problems. Observed impairments in the children of nondepressed psychiatric patient women call into question the specificity to maternal depression of problematic child adjustment. Furthermore, there was no evidence in the present study to support the hypothesis that child adjustment difficulties are related to general maternal disability. Indeed, despite the relatively small sample, children of the medical patient mothers differed significantly from children of the depressed mothers on most indexes. These results stand in contrast to those obtained by Hirsch et al. (1985) for a sample of adolescents. This discrepancy may be due to the exclusionary criteria used for the medical control groups in the two studies. In the present study, medical patients were excluded if they met criteria for a DSM-III diagnosis. In contrast, Hirsch et al. did not assess psychological adjustment in the medical group. It is possible, therefore, that the child adjustment difficulties observed by Hirsch et al. may be related to undiagnosed psychological problems in their arthritic parents. A final focus for further research concerns the nature of the relation between maternal psychiatric disturbance and child dysfunction. Having now identified adjustment difficulties in the children of psychiatric patient mothers, it is important that we turn our attention to the mechanisms by which such problems develop and to the processes underlying the relation between these two constructs. Two recent lines of study appear to be particularly promising in this regard. First, a number of investigators have found that individuals experiencing unipolar depression are characterized by a heightened state of self-focused attention (e.g., Ferster, 1973; Ingram, Lumry, Cruet, & Seiber, 1987). In fact, Lewinsohn, Hoberman, Teri, and Hautzinger (1985) and Psyzczynski and Greenberg (1987) have recently proposed that self-focused attention is a central process in the development and maintenance of unipolar depression. One obvious effect of this increased self-focus in depressed parents would be a relative lack of awareness and responsivity of the parents to the emotional needs of their children. Prolonged self-focus, therefore, and the consequent unavailability of the parent may be one mechanism through which difficulties in children's adjustment are established (cf. Lee & Gotlib, in press). Second, recent direct observations of families with depressed parents suggest that depressive symptoms may be functional in reducing aversive exchanges between family members (e.g., Hops et al., 1987; Kochanska, Kucynski, Radke-Yarrow, & Welsh, 1987). If this is in fact the case, children's mastery of appropriate conflict-resolution and affect-regulation skills

would be disrupted. It remains for future studies to examine more explicitly the viability of these explanations in accounting for the significant association of maternal psychiatric disorder and child dysfunction.

References Achenbaeh, T. M., & Edelbrock.C. (1983). Manual for the Child Behavior Checklist and revised Child Behavior Profile. Burlington: University of Vermont. Anderson, K. Q, Bradley, L. A., Young, L. D., McDaniel, L. K., & Wise, C. M, (1985). Rheumatoid arthritis: Review of psychological factors related to etiology, effects, and treatment. Psychological Bulletin, 98, 358-387. Beardslee, W. R., Bemporad, J., Keller, M. B., & Klerman, G. L. (1983). Children of parents with major affective disorder: A review. American Journal of Psychiatry, 140, 825-832. Been, P., Gram, L. E, Dein, E., Jacobsen, Q, Vitger, J., & Bolwig, T. G. (1975). Quantitative ratings of depressive states. Acta PsychiatricaScandanavica,51, 161-170. Beck, A. X, Rush, A. J., Shaw, B. R, & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Billings, A. G., & Moos, R. H. (1983). Comparisons of children of depressed and nondepressed parents: A social-environmental perspective. Journal of Abnormal Child Psychology, 11,463-486. Billings, A. G., &Moos, R. H. (1986). Children of parents with unipolar depression: A controlled one year follow-up. Journal of Abnormal Child Psychology, 14, 149-166. Carroll, B. J., Fielding, J. M., & Blashki, T. G. (1973). Depression rating scales: A critical review. Archives of General Psychiatry, 28, 361-366. Cytryn, L., McKnew, D. H., Bartko, J. J., Lamour, M., & Hamovitt, J. (1982). Offspring of patients with affective disorders: II. Journal of the American Academy of Child Psychiatry, 21, 389-391. Decina, P., Kestenbaum, C. J., Farber, S., Kron, L., Gargan, M., Sackeim, H. A., & Fieve, R. R. (1983). Clinical and psychological assessment of children of bipolar probands. American Journal of Psychiatry, 140, 548-553. Elkin, I., Parloff, M. B., Hadley, S. W, & Autry, J. H. (1985). NIMH treatment of depression collaborative research program. Archives of General Psychiatry, 42, 305-316. Endicott, J., & Spitzer, R. L. (1978). A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry, 35, 837-844. Ferster, C, (1973). A functional analysis of depression. American Psychologist, 28, 857-870. Gotlib, I. H. (1982). Self-reinforcement and depression in interpersonal interaction: The role of performance level. Journal of Abnormal Psychology, 91, 3-13. Gotlib, 1. H. (1983). Perception and recall of interpersonal feedback: Negative bias in depression. Cognitive Therapy and Research, 7, 399412. Gotlib, I. H., & Cane, D. B. (in press). Self-report assessment of depression and anxiety. In P. C. Kendall & D. Watson (Eds.), Anxiety and depression: Distinctive and overlapping features. New %rk: Academic Press. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56-62. Hammen, C., Gordon, D., Burge, D., Adrian, C., Jaenicke, C., & Hiroto, D. (1987). Maternal affective disorders, illness, and stress: Risk for children's psychopathology. American Journal of Psychiatry, 144, 736-741.


MATERNAL DEPRESSION AND CHILD ADJUSTMENT Harder, D. W., Kokes, R. E, Fisher, L., & Strauss, J. S. (1980). Child competence and psychiatric risk. IV. Relationships of parent diagnostic classifications and parent psychopathology severity to child functioning. Journal of Nervous and Mental Disease, 168, 343-347. Hirsch, B. J., Moos, R. H., & Reischl, T. M. (1985). Psychosocial adjustment of adolescent children of a depressed, arthritic, or normal parent. Journal of Abnormal Psychology, 94, 154-164. Hodges, K. K. (1983). The Child Assessment Schedule. Unpublished manuscript, University of Missouri. Hodges, K. K., Kline, J., Stern, L., Cytryn, L., & McKnew, D. (1982). The development of a child assessment interview for research and clinical use. Journal of Abnormal Child Psychology, 10, 173-189. Hodges, K. K., McKnew, D., Cytryn, L. Stern, L., & Kline, J. (1982). The Child Assessment Schedule (CAS) Diagnostic Interview: A report on and validity. Journal of the American Academy of Child Psychiatry, 21, 468-473. Holahan, C. J., & Moos, R. H. (1987). Risk, resistance, and psychological distress: A longitudinal analysis with adults and children. Journal of Abnormal Psychology, 96, 3-13. Hops, H., Biglan, A., Sherman, L., Arthur, J., Friedman, L., & Osteen, V. (1987). Home observations of family interactions of depressed women. Journal of Consulting and Clinical Psychology, 55, 341-346. Ingram, R. E., Lumry, A., Cruet, D., & Seiber, W. (1987). Attentional processes in depressive disorders. Cognitive Therapy and Research, 11, 351-360. Keller, M. B., Beardslee, W. M., Dorer, D. J., Lavori, P. W., Samuelson, H., & KJerman, G. R. (1986). Impact of severity and chronicity of parental affective illness on adaptive functioning and psychopathology in children. Archives of General Psychiatry, 43, 930-937. Klein, D. N., Depue, R. A., & Krauss, S. P. (1986). Social adjustment in the offspring of parents with bipolar affective disorder. Journal of Psychopathology and Behavioral Assessment, 8, 355-366. Klein, D. N., Depue, R. A., & Slater, J. F. (1985). Cyclothymia in the adolescent offspring of parents with bipolar affective disorder. Journal of Abnormal Psychology, 94, 115-127. Klein, D. N., Depue, R. A., & Slater, J. F. (1986). Inventory identification of cyclothymia. IX. Validation in offspring of bipolar I patients. Archives of General Psychiatry, 43, 441-445. Kochanska, G., Kucynski, L., Radke-Yarrow, M., & Welsh, J. D. (1987). Resolution of control episodes between well and affectively ill mothers and their young children. Journal of Abnormal Child Psychology, /5, 441-456. Lee, C. M., & Gotlib, I. H. (in press). Family disruption, parental availability, and child adjustment: An integrative review. In R. J. Prinz (Ed.), Advances in the behavioral assessment of children and families. Greenwich, CT: JAI Press. Lewinsohn, P. M., Hoberman, H., Teri, L., & Hautzinger, M. (1985). An integrative theory of depression. In S. Reiss & R. Bootzin (Eds.), Theoretical issues in behavior therapy'(pp. 331-359). New York: Academic Press. Lyons-Ruth, K., Zoll, D., Connell, D., & Grunebaum, H. U. (1986). The depressed mother and her one-year-old infant: Environmental context, mother-infant interaction and attachment, and infant development. In E. Tronick & T. Field (Eds.), Maternal depression and infant disturbance: New directions in child development (pp. 61-82). San Francisco: Jossey Bass.

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Murphy, G. E., Simons, A. D., Wetzel, R. D., & Lustman, P. J. (1984). Cognitive therapy and pharmacotherapy. Archives of General Psychiatry, 41, 33-41. Oliver, J. M., & Simmons, M. E. (1984). Depression as measured by the DSM-HI and the Beck Depression Inventory in an unselected adult population. Journal of Consulting and Clinical Psychology, 52, 892898. Psyzczynski, T, & Greenberg, J. (1987). Self-regulatory perseveration and the depressive self-focusing style: A self-awareness theory of reactive depression. Psychological Bulletin, 102, 122-138. Radke-Yarrow, M., Cummings, E. M., Kuczynski, L., & Chapman, M. (1985). Patterns of attachment in two- and three-year-olds in normal families and families with parental depression. Child Development, 56, 884-893. Rush, A. J., Beck, A. T, Kovacs, M., & Hollon, S. (1977). Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and Research, 1, 17-37. Rutter, M. (1984). Stress, coping, and development: Some issues and some questions. In N. Garmezy & M. Rutter (Eds.), Stress, coping, and development in children (pp. 1-41). New York: McGraw-Hill. Shoemaker, Q S., Erickson, M. T, & Finch, A. J. (1986). Depression and anger in third and fourth grade boys: A multimethod assessment approach. Journal of Clinical Child Psychology, 15, 290-296. Turner, S. M., Beidel, D. C., & Costello, A. (1987). Psychopathology in the offspring of anxiety disorder patients. Journal of Consulting and Clinical Psychology, 229-235. Turner, S. M., McCann, B. S., Beidel, D. C., & Mezzich, J. E. (1986). DSM-HI classification of the anxiety disorders: A psychometric study. Journal oj'Abnormal Psychology, 95, 168-172. Weissman, M. M. (1983). The depressed mother and her rebellious adolescent. In H. L. Morrison (Ed.), Children of depressed parents: Risk, identification, and intervention (pp. 99-113). New \brk: Grune & Stratton. Weissman, M. M., Gammon, G. D., John, K., Merikangas, K. R., Warner, V., Prusoff, B. A., & Sholomskas, D. (1987). Children of depressed parents: Increased psychopathology and early onset of major depression. Archives of General Psychiatry, 44, 847-853. Weissman, M. M., Prusoff, B. A., Gammon, G. D., Merikangas, K. R., Leckman, J. E, & Kidd, K. K. (1984). Psychopathology in the children (ages 6-18) of depressed and normal parents. Journal of the American Academy of Child Psychiatry, 23, 78-84. Welner, Z., Welner, A., McCrary, M., & Leonard, M. A. (1977). Psychopathology in children of inpatients with depression: A controlled study. Journal of Nervous and Mental Disease, 164,408-413. Winters, K. C., Stone, A. A., Weintraub, S., & Neale, J. M. (1981). Cognitive and attentional deficits in children vulnerable to psychopathology. Journal of Abnormal Child Psychology, 9, 435-453. Zahn-Waxler, C., Cummings, E. M., lanotti, R. J., & Radke-Yarrow, M. (1984). Young offspring of depressed parents: A population at risk for affective problems. In D. Cicchetti & K. Schneider-Rosen (Eds.), Childhood depression: New directions for child development (pp. 81 105). San Francisco: Jossey Bass. Received July 15, 1988 Accepted August 9, 1988