Academic and social outcomes

Parental depression has been associated with a number of poor outcomes in children across a variety of important domains. Current and past depression in parents is associated with lower cognitive and academic performance and poorer interpersonal functioning in offspring (England and Sim, 2009; Goodman and Tully, 2006). Infants of depressed mothers have been found to exhibit more withdrawn behaviors, insecure attachment, negative affect with nondepressed adults, and lower cognitive performance than other infants (Canadian Paediatric Society, 2004). Toddlers of depressed mothers also have higher rates of insecure attachment (England and Sim, 2009), and exhibit less interaction with other children, less creative play, and lower cognitive-linguistic skills than their peers (Canadian Paediatric Society, 2004). School-age children have been found to have significantly higher rates of low social competence if their mothers were currently or postnatally depressed, compared with children of nondepressed mothers (Luoma et al., 2001). Children whose mothers were depressed during the postpartum period also have been found to have lower average IQ scores, more difficulties in mathematical reasoning, and more special education needs by the time they reach school age, independently of the current status of parental depression (Hay et al., 2001). These findings of impairment from early exposure to parental depression are consistent with the social and cognitive deficits observed in very young children of depressed mothers.

Physical health outcomes

The physical health of children can also be affected by parental depression. Studies suggest that parental depression plays a role in increased healthcare utilization, emergency room use, and lower rates of child medication compliance (Bartlett et al., 2001, 2004; Olfson et al., 2003). Parental depression is also associated with increased physical health problems, such as frequent headaches, stomach aches or indigestion, and risky health behaviors, including tobacco, alcohol, and drug use (Timko et al., 2002). One study found that children of currently depressed parents compared to control children had significantly higher rates of physical health problems (including colds and asthma) and risky behaviors 10 years after baseline (Timko et al., 2002). Children of depressed parents have been found to have higher rates of health problems even when entering middle age (Weissman et al., 2006).

The physical health of very young children may be particularly at risk, as infants and toddlers are completely dependent on their caregivers to maintain their health and well-being. Toddlers of depressed mothers are more likely to be rated as being in poor health, and to be seen by a medical professional for somatic symptoms, such as headaches, stomach aches, and fainting (England and Sim, 2009). In addition, infants and toddlers of depressed mothers have lower rates of vaccination and well-child visits and higher rates of emergency room visits, and are more likely to ride in improperly used car seats (McLennan and Kotelchuck, 2000; Minkovitz et al., 2005).

It should be noted that, not only is parental depression directly associated with poor physical health, but it also can be indirectly associated with poor physical health by increasing the risk of depressive illness in the child, which is associated with increased risk of physical health problems (Birmaher et al., 1996; Fergusson and Woodward, 2002).

Psychological outcomes

Parental depression is a major risk factor for the development of internalizing and externalizing symptoms in children (Goodman et al., 2011). With regard to nonaffective disorders, children of depressed parents are more likely than children of nondepressed parents to develop substance-use disorders and disruptive behavior disorders (Biederman et al., 2001; Lieb et al., 2002). Increased rates of externalizing and internalizing symptoms in children of depressed parents have been evident even in toddlers and very young children (Canadian Paediatric Society, 2004; Goodman, 2007). The risk of affective disorders in children of depressed parents is particularly salient. Children are three times more likely to have an affective disorder if they have a parent with MDD (Weissman et al., 2006). High rates of anxiety symptoms and disorders have been reported in children of depressed parents (England and Sim, 2009).

Perhaps the most concerning risk to children of depressed parents is the risk that they will develop a depressive illness themselves. Having a parent with depression is one of the most potent risk factors for developing MDD, and children of depressed parents are at a two- to fourfold risk of developing a depressive disorder compared to children without a depressed parent (England and Sim, 2009). Risk of depression in offspring can be transmitted through genetic, epigenetic, neuroregulatory, environmental, and parental factors, including parental behavior and cognition (Beardslee et al., 2011). The significant risk in children of depressed parents is worthy of concern, as depressive illness can have a profound and lasting impact on young lives. MDD in youth is associated not only with significant emotional distress, disrupted academic and social function, and increased risk of substance abuse and suicide but also with long-lasting impairment in interpersonal functioning, educational attainment, and lifelong disorder and associated disability (Birmaher et al., 1996; Fergusson and Woodward, 2002). Depression in children of depressed parents, compared to the depression in children of parents who are not depressed, is associated with earlier onset, longer duration, and greater functional impairment and likelihood of recurrence (Goodman and Tully, 2006). Given the high risk of developing the disorder in children of depressed parents and the serious associated outcomes, much of the literature on the impact of parental depression focuses specifically on factors associated with increased child depression risk.

Parental factors

Parental gender can influence the degree to which parental depression affects the child. Both maternal and paternal depression have been associated with poor child outcomes (Dave et al., 2008), but far less is known about the impact of paternal depression, and what is known indicates that paternal depression may not affect children as strongly as maternal depression (Smith, 2004). For example, meta-analytic studies indicate that maternal psychopathology is more strongly associated with child internalizing (but not externalizing) problems than is paternal psychopathology (Connell and Goodman, 2002). It has been hypothesized that when the mother is the primary caregiver, the child is affected more by disruptions of maternal parenting caused by depression than by disruptions of paternal parenting caused by depression (Smith, 2004).

The degree to which a depressed parent can carry out daily life activities can affect the child and family. Functional limitations are characteristic of depression; it is often very difficult for depressed individuals to get out of bed in the morning, complete self-care routines, and perform daily tasks (Avery et al., 2008). This can directly affect children, as depressed parents may have more difficulty in meeting the tangible needs of the child, such as providing steady, adequate income, helping with homework, or providing transportation. These functional limitations can have short-term and long-term consequences for the child, affecting school performance, relationship functioning, and ability to attend psychological or physical health appointments (England and Sim, 2009).

Behaviors of depressed parents can have a tremendous effect on children and play a key role in transmitting risk of depression and other negative outcomes in offspring. Meta-analytic studies indicate that depression in parents is strongly associated with negative, hostile parenting, with depressed parents being less positive and more retaliatory, punitive, and intrusive in their behavior towards their children than nondepressed mothers (Lovejoy et al., 2000). Parenting practices are a primary mechanism through which parental depression affects children (Elgar et al., 2007). A population-based, longitudinal study of Canadian children (aged 10–15) found that both negative parenting behaviors and the lack of positive parenting behaviors mediated the relation between parental depression and child internalizing and externalizing symptoms (Elgar et al., 2007).

The behavior of depressed parents can increase the risk of emotional problems in offspring both by insufficiently providing for the social, emotional, and developmental needs of the child and by modeling parental depressive behaviors, cognitions, affect, and impaired coping and problem-solving skills (Hoffman et al., 2006; Sheeber et al., 2001). Negative parenting behaviors of depressed parents, such as critical parenting and psychological control behaviors (e.g., inducing guilt, using authoritarian parenting practices), have been associated with child negative cognitive and attribution styles and decreased problem-solving skills, which are all risk factors for depression (Sheeber et al., 2001). Negative, affectionless control in depressed parents also appears to be associated specifically with increased anxiety and depressive symptoms in children (Berg-Nielsen et al., 2002).

In line with the developmental principles highlighted in the Chapter 1 framework, younger children have different needs and vulnerabilities, and therefore are affected by different parental behaviors. Studies of depressed mothers and their infants and toddlers indicate that mothers with depression exhibit more withdrawn or intrusive behaviors towards their young children (National Research Council and Institute of Medicine, 2000). Infants of such mothers learn that their needs cannot be safely and reliably met, possibly resulting in difficulty forming secure attachment. Insecure attachment is associated with a number of negative long-term outcomes in children, such as cognitive delays, social withdrawal, and difficulties with emotion regulation, including permanent neurological changes in how the child’s brain responds to stress (National Research Council and Institute of Medicine, 2000). This lack of secure attachment due to depressive parental behaviors may explain some of the negative outcomes in very young offspring.

It is important to remember that depressed adults can still be good parents, and that certain behaviors, in healthy or depressed parents, can decrease the risk of depression in offspring. Children whose depressed mothers exhibit more warmth and less overinvolvement and psychological control behaviors have more positive outcomes than children whose depressed mothers do not exhibit these characteristics (Brennan et al., 2003). Behaviors that support the child functionally and emotionally, that encourage development of problem-solving and coping skills, and that promote open family communication, understanding of the parent’s depression, and building social supports outside the home can increase a child’s protective factors and decrease the likelihood of depression (Beardslee and Podorefsky, 1988). Depressed mothers of very young children can decrease the odds of negative outcomes in their children by altering their behaviors towards their children to be less intrusive and more attentive and interactive (Cohen et al., 1999). Of course, it is also vitally important that parents affected by depression receive effective treatment for their illness in order to promote good outcomes in their children, in addition to receiving interventions that might support them in improving their parenting behaviors.