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Maternal Depression, Changing Public Assistance, Food Security, and Child Health Status

Patrick Casey, MD^*, Susan Goolsby, MS^*, Carol Berkowitz, MD, Deborah Frank, MD, John Cook, PhD, Diana Cutts, MD^||, Maureen M. Black, PhD^¶, Nieves Zaldivar, MD^#, Suzette Levenson, MEd, MPH, Tim Heeren, PhD, Alan Meyers, MD, MPH the Children’s Sentinel Nutritional Assessment Program Study Group

^* Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
Boston University School of Medicine/Public Health, Boston, Massachusetts
Harbor-University of California Los Angeles Medical Center, Los Angeles, California
^|| Hennepin County Medical Center, Minneapolis, Minnesota
^¶ University of Maryland, School of Medicine, Baltimore, Maryland
^# Mary’s Center for Maternal and Child Health, Washington, District of Columbia

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
Objective. To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged 36 months at 6 urban hospitals and clinics.

Methods. A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, child’s history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded.

Results. PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33–1.88) and hospitalizations during the child’s lifetime (AOR: 1.20; 95% CI: 1.03–1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03–2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06–2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33–3.11) than mothers without PDS.

Conclusion. Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

Key Words: welfare reform • food insecurity • child health status • maternal depression

Abbreviations: C-SNAP, Children’s Sentinel Nutritional Assessment Program • PDS, maternal depression screen • ED, emergency department • OR, odds ratio • AOR, adjusted OR

Depression is common in women of all ages, particularly among women who are mothers of young children.¹ Depressive symptoms are noted more commonly in women in clinical, particularly nonscheduled, settings,^2,3 in ethnic minorities, and in low-socioeconomic-status families.^1,4–7 Related risk factors include marital disharmony, housing dissatisfaction, and financial distress.

Since 1996, all states in the United States have implemented welfare reform in response to federal legislation (Personal Responsibility and Work Opportunity Reconciliation Act), which has resulted in the loss of cash assistance, food stamps, or both in many families.⁸ From 1994 to 1999, the national caseload of Aid for Dependent Children declined by 8 million recipients,^9–11 and the average monthly food stamp program caseload declined by 9.3 million recipients. Welfare-reform activities have progressed even more aggressively in most states since 1999. The potential impact of welfare reform on families may be positive due to greater self-esteem associated with joining the workforce. However, this advantage may not result in increased financial security. If the potential for increased financial distress in families is realized, one would expect an increased prevalence of depression in the mothers of these families.

From a pediatric perspective, maternal depression is associated with increased probability of problems in behavior, emotion, and development in their children across the developmental age span.^1,12–15 These associations likely result from ineffective parent-child interaction^16,17 and problematic parenting approaches¹⁸ along with the negative effects of related environmental factors such as marital disorder.^14,19 To date, however, little is known about the association of maternal depression or depressive symptoms with child health or on family characteristics such as food insecurity that may influence child health.

Household food security has been defined by national experts as the consistent access at all times to enough food for an active, healthy life by all household members. Two hallmarks of food security are 1) ready availability of nutritionally adequate and safe foods and 2) an assured ability to acquire acceptable foods in socially acceptable ways.^20,21 Food insecurity, like maternal depression, is more common in impoverished families. Although there are few published studies describing the impact of nutrient intake and health and developmental status in children who live in households that report food insecurity, some reports have found negative health and development effects on children in such families.^22,23 There are no reports that assess the potential association of maternal depression and household food insecurity.

The Children’s Sentinel Nutritional Assessment Program (C-SNAP) is a multisite collaborative study designed to monitor the impact of changing economic conditions and public policy resulting from federal welfare reform on children’s health and growth status. This study provided the opportunity to screen for the presence of maternal depression in a large multiethnic group of mothers living in 6 metropolitan communities in 5 regions of the United States while their children were being assessed in a clinical care setting. The maternal depression screen was added to the C-SNAP survey 1 year after its inception for the specific purpose of assessing the association of maternal depressive symptoms to child health status in the context of welfare reform. Specifically, this study assessed the relationship of self-reported depressive symptoms to reported child health status, frequency of child hospitalizations, child growth status, reported regular access to adequate food supply (food security), and loss of welfare and food stamps.

Thus we addressed the following research questions: 1) Do mothers who respond positively on the depression screen report lower food security and greater loss of food stamps and federal financial support from welfare? 2) Do children whose mothers respond positively on a depression screen have poorer child health as evidenced by lower growth status, poorer reported health status, and more hospitalizations? Both questions were addressed while controlling for confounding demographic variables.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
Setting
C-SNAP conducted household-level surveys and medical record audits between August 1998 and December 2001 at medical centers that serve children in Baltimore, Maryland, Boston, Massachusetts, Little Rock, Arkansas, Los Angeles, California, Minneapolis, Minnesota, and Washington, District of Columbia. Primary adult caregivers accompanying children 0 to 3 years old presenting at hospital emergency departments (EDs) and primary care clinics at the centers were interviewed in private settings during wait periods. Potential respondents were excluded if they did not speak English, Spanish, or Somali (Minneapolis only), if they were not knowledgeable about the child’s household, if the child’s caregiver had been interviewed within the previous 6 months, or if they refused consent for any reason. Institutional review board approval was obtained at each site. Respondents gave informed consent to study participation. They were told that they were free not to answer any questions that made them feel uncomfortable and to terminate participation at any time without jeopardizing their access to medical care.

Sample
The C-SNAP sample is a convenience sample obtained by scheduling interviewers in the EDs and clinics to coincide with peak patient flow times. The maternal depression screen questions were added to the maternal interview January 1, 2000, and the sample used in this article includes all interviews from then through December 31, 2001.

Of the 7811 caregivers approached in these 2 years, 6665 (85%) were eligible for interview. Of them, 6102 (92%) successfully completed the interview, whereas 458 (7%) refused to be interviewed and 105 (1%) did not complete the interview. Of the 6102 completed interviews, 626 were with nonmaternal respondents and excluded from the analyses. Of the 5476-person maternal sample, 170 (3%) were missing information from the depression screen and were excluded from the analyses. The final analytical sample includes 5306 maternal respondents with complete data. Mothers who completed interviews were compared with those who did not and showed no statistical differences in maternal education, marital status, employment, child gender, or reported household food security. Mothers with noncompleted interviews were more likely to have no insurance, to be non-US-born, and to describe their ethnicity as other than white, Hispanic, or African American.

Measures
The interview questionnaire included items on household sociodemographic characteristics, federal assistance program participation, changes in federal program benefit levels, child health status, whether the child had been hospitalized since birth, food security, and maternal depression screen questions. Based on receipt of federal food stamps and federal financial assistance (Temporary Assistance to Needy Families) during the 12 months preceding the interview, families were categorized as: 1) sanctioned: terminated or reduced by full family or partial sanctions for failure to comply with behavioral requirements; 2) decreased: benefits decreased administratively due to increased income or decreased expense (eg, from employment or changes in marital status); 3) not decreased: benefits either increased or did not change; or 4) never on federal financial assistance/food stamps.²⁴

At 3 study sites, caregivers were interviewed in conjunction with ED visits. Overall, 3216 (61%) of the 5306 interviews in the analytic cohort were obtained from 3 ED sites: Boston (n = 1545; 48%), Little Rock (n = 934; 29%), and Los Angeles (n = 737; 23%). Separate analyses were conducted by using data from this subsample, with admission the day of the visit as the outcome.

The number of times each child in the analytic cohort had been hospitalized since discharge after birth was obtained from caregiver interview. This information was used to create a second hospitalization variable (yes or no) indicating whether the child had been hospitalized since birth (excluding the day of the interview). The caregiver’s report of the child’s overall health status was asked in standard form as used in the Third National Health and Nutrition Examination Survey.²⁵ Household food security status was measured by the US Department of Agriculture’s 18-item Food Security Scale and categorized as "food secure" or "insecure" in accordance with established procedures.^20,21 The 3-item maternal depression screen developed by Kemper et al²⁶ was used to screen for maternal depression. This instrument had a sensitivity of 100%, a specificity of 88%, and a positive predictive value of 66% when compared with the 8-item Rand screening instrument. As recommended by the author, the 3-item instrument was considered positive if a respondent had a positive response to any 2 of the 3 items. The child’s weight and length and whether the child was admitted to the hospital at the time of the clinical visit were obtained from medical record review. Low growth status was defined as weight for age <5% and weight for length <10% by using National Center for Health Statistics norms.

Statistical Analyses
Bivariate associations between positive maternal depression screen (treated as a categorical variable) and other categorical variables used ² tests; t tests were used for bivariate associations with continuous variables. Separate sets of logistic regression models were specified to model the association of PDS with loss or reduction in Temporary Assistance to Needy Families assistance and food stamp benefits, child health variables, and household food security while controlling for multiple potentially confounding variables as identified by bivariate analyses. These variables controlled in regression analyses included study site, low birth weight (<2500 g), maternal race, health insurance type, and maternal education status.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
Table 1 depicts sample demographics of the interviewed sample and the percent who scored positive on the maternal depression screen. Of the interviewed sample, 51.4% were African American, 76.3% had public medical assistance, 39.6% had not graduated from high school, and 52.1% were single or divorced. Thirty-five percent of the mothers who completed the interview scored positive on the maternal depression screen.

Table 2 depicts the unadjusted odds ratio (OR) comparing those positive or not on the maternal depression screen on food security status and change in federal financial and food stamp support. There were statistically significant differences in the frequency of positive PDS and those with changed federal financial support, greatest in families with decreased benefits (OR: 1.5; P < .05). Forty-five percent of mothers who reported decreased financial benefits scored positive on the depression screen (data not shown). Positive depression screen was also associated with change in food stamp support, highest in families who were sanctioned (OR: 1.89; P < .0001). Positive maternal depression screen was strongly associated with food insecurity (OR: 2.6; P < .0001). Almost 53% of mothers who reported food insecurity scored positive on the maternal depression screen (data not shown).

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
Thirty-five percent of the mothers in this sample were positive on the maternal depression screen. This prevalence is very similar to that found in other inner-city pediatric clinical populations^2,4 and a Head Start sample.²⁷ PDS is associated with changes in federal financial assistance and food stamp support (while controlling for many independent confounding demographic variables). In addition, while controlling for these same variables, PDS is associated with household food insecurity status, lower maternal reported child health status, and more hospitalizations during the child’s lifetime.

Although there are several theoretical discussions regarding the potential impact of welfare reform on families, mothers, and their children, empirical data are more sparse.^28–31 Recent reports demonstrate the negative effect of loss of financial support on children’s development.^32,33 In a recent review, it was noted that many families will likely face decline in income from direct loss of benefits and also from related barriers to employment such as poor physical and mental health, inadequate past employment experience, and low education.⁸ This income decline, of course, may affect child health and development status in many ways including reduced access to health care or quality child care. In these families, mental health problems such as depression and substance abuse may be associated with difficulty in obtaining and maintaining an adequate job, whether as a cause or effect.³⁴ Depression may compromise a mother’s ability to benefit from interventions, whether directed toward their employment and education³⁵ or their parenting skills.³⁶ In both experimental interventions, improvements were found only in those mothers who were not depressed at the beginning of the intervention, whereas depressed mothers showed no benefits from the intervention.^35,36 Mothers’ emotional state has been shown to be associated with material circumstances. Worry about debt was the strongest independent socioeconomic predictor of maternal depression in a separate longitudinal study of 271 families with young children.³⁷ Our results, which demonstrate associations with positive PDS and loss or reduction of food stamps and financial assistance, suggest that maternal affect as well as loss of resources may be mechanisms by which welfare reform impacts children’s well being.

Food insecurity is found more commonly in families who live in poverty. In 1999, 10.9% of all families reported food insecurity, whereas 46% of those with income below the poverty line reported food insecurity.³⁸ A higher percentage of families who report food insecurity receive food stamps and other nutritional assistance as compared with those who report food security, indicating the nutritional fragility of these families.³⁹ Experts have anticipated negative effects of welfare reform on food security, because almost 50% of federal savings resulted from reduction in food stamps and other child nutrition support programs.⁴⁰ We recently demonstrated increased probability of reported household food insecurity in families whose federal support or food stamps were sanctioned or reduced.²⁴ Families who live below the poverty line, who typically have no "savings" to fall back on, have little or no discretionary money for spending when "income shocks" of any type occur, such as increase in rent, cost of gasoline, or cost of household heating/cooling or, even worse, loss of income or food stamps.⁴¹ Purchasing adequate quality and quantity of food may be compromised in favor of these other necessities.⁴² Loss of food stamps is of particular concern, because food stamps have been shown to increase the intake of nutrients in children of impoverished families.⁴³ Maternal depression thus is predictable in times of financial distress and food shortage. PDS in our sample was strongly associated with household food insecurity, independent of many confounding variables. This finding is of particular concern, because food insecurity has been shown to have a negative effect on child health and development status (while controlling for family income and related demographic variables).^22,23,44

Maternal depression and even subthreshold depressive symptoms have been associated with an array of childhood learning and behavioral problems and childhood psychopathology.^12–15,45 Few studies have demonstrated the effects of maternal depression on child health. A higher rate of accidents has been found in children of depressed mothers compared with children of nondepressed mothers.⁴⁶ In a group of asthmatic children, those whose mothers reported depressive symptoms were more likely to have higher morbidity.⁴⁷ In 2 different cohorts of neonates³ and school-aged children with childhood asthma,² those whose mothers had depressive symptoms were more likely to have ED or problem-oriented primary care visits (after controlling for demographic and other variables), including asthma morbidity. In our convenience sample, mothers who were positive on the maternal depression screen were more likely to report fair to poor child health status and increased likelihood of lifetime hospitalizations of the child (while controlling for demographic variables).

Our study has limitations that restrict the generalization and interpretation of the results. Ours is a geographically diverse sentinel population in which relatively high rates of clinical problems are expected to be found, which likely exceed the occurrence of problems in general populations. This is a nonepidemiologic sample studied cross-sectionally, and thus the relationship of cause and effect between variables cannot be evaluated. Almost all data in our study are self-reported in questionnaire format; the maternal responses may have been influenced by the environment of the clinical setting. It is possible that maternal depressive symptoms might lead the mothers to overstate their household’s food insecurity and their child’s ill health (although hospitalization since birth is a relatively objective measure). Finally, maternal depression was assessed by a brief, 3-question screen instrument. Although one cannot conclude that the respondents were depressed, such instruments that have been validated against other instruments are useful for screening and perhaps case-finding in primary care settings.^48,49

The relationship between the important variables in this study may be multidirectional and open to speculation. Within the context of poverty, depression is very common in women on welfare, and unsuccessful transition off of welfare and job acquisition may relate to preexisting depression. On the other hand, maternal depression may also result from the loss of welfare when sanctions have been imposed. Food insecurity and poor adult nutrition may be related to maternal depression and loss of federal financial assistance and food stamps either as a cause or effect. Finally, problems in child health and development status may result either from maternal depression, loss of financial support and food stamps, or food insecurity, each directly and independently or indirectly in a multifactorial causal pathway. Longitudinal research will be required to understand these causative pathways.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
Positive maternal depression screen in a pediatric clinical sample is associated with reports of poorer child health status, food insecurity, and loss of federal financial support and food stamps, independent of many confounding variables. Pediatricians and other child health providers should be aware of the potential importance of maternal depression on the status of their patients’ health, nutrition, development, and behavior in the context of welfare reform. Child health professionals might ask their state and local welfare agencies to make contact with the family to review their case before imposing a sanction that may jeopardize the physical or mental health of children or their parents. Some states have demonstrated the efficacy of evaluating families by identifying and treating barriers to successful transition such as maternal depression before the implementation of sanctions. Policy experts attempting to estimate the impact of welfare reform should consider maternal depression as one of the important cumulative risks for children and families.

	ABSENT PRESENCE

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS ABSENT PRESENCE REFERENCES

 
"A new plague of inattention is spreading. It’s called ‘surfer’s voice’—a habit of half-heartedly talking to someone on the telephone while simultaneously surfing the Web, reading e-mails, or trading instant messages. ... On one end of the phone is an annoyed colleague or family member discussing an important topic. On the other end, a party puts on a meager soundtrack of knowing participation: ‘OK ... uh-hum ... right ... OK.’ It is punctuated with surreptitious tapping of a keyboard."

Berman DK. Technology has us so plugged into data, we have turned off. Wall Street Journal. November 10, 2003

Submitted by Student

	ACKNOWLEDGMENTS

 
This study was supported by grant P0053897 from the W. K. Kellogg Foundation (Battle Creek, MI) and grants from MAZON: A Jewish Response to Hunger (Los Angeles, CA); the David B. Gold Foundation and the Minneapolis Foundation (Minneapolis, MN); Project Bread: the Walk for Hunger, the Anthony Spinazzola Foundation, and the Eos Foundation (Boston, MA); the Candle Foundation (El Segundo, CA); the Sandpipers Philanthropic Organization (Hermosa Beach, CA); the Abell Foundation and the Thomas Wilson Sanitarium for Children of Baltimore City (Baltimore, MD); the Claneil Foundation (Philadelphia, PA); and the Beatrice Fox Auerbach donor advised fund of the Hartford Foundation for Public Giving (Hartford, CT) on the advice of Jean Schiro Zavelas and Vance Zavelas.

We thank Zhaoyan Yng, MS, Maryse Roudier, MPH, Sharon Bak, MPH, and Tom Dauria, MS, for statistical analysis, data management, and web programming. We thank especially Joni Geppert, MPH, RD, LN, Luz Neira, PhD, Sally Montoya, Olga De Jesus, MPH, Susan Goolsby, MS, RD, LD, Jill Heckendorf, Alicia Saunders-Mobley, and Jessie Gerteis, for excellence in training, scheduling, and supervising interview staff. We also thank Lisa Blazejewski, MS, Jolene Bertrand and Nancy Rodriguez for diligence in coding, cleaning, and preparing questionnaires for data entry. Margaret Parker provided invaluable administrative support. We also thank Phaedre Yount and Jonathan M. Stein for helpful review of earlier drafts of this article.

	FOOTNOTES

 
Received for publication Jan 24, 2003; Accepted Jun 13, 2003.

Address correspondence to Patrick Casey, MD, 800 Marshall St, Little Rock, AR 72202. E-mail: caseypatrickh{at}uams.edu

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				J. Bronte-Tinkew, M. Zaslow, R. Capps, A. Horowitz, and M. McNamara Food Insecurity Works through Depression, Parenting, and Infant Feeding to Influence Overweight and Health in Toddlers J. Nutr., September 1, 2007; 137(9): 2160 - 2165. [Abstract] [Full Text] [PDF]

				R. C. Whitaker, S. M. Phillips, and S. M. Orzol Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children Pediatrics, September 1, 2006; 118(3): e859 - e868. [Abstract] [Full Text] [PDF]

				M. U. Shalowitz, T. Mijanovich, C. A. Berry, E. Clark-Kauffman, K. A. Quinn, and E. L. Perez Context Matters: A Community-Based Study of Maternal Mental Health, Life Stressors, Social Support, and Children's Asthma Pediatrics, May 1, 2006; 117(5): e940 - e948. [Abstract] [Full Text] [PDF]

				J. T. Cook, D. A. Frank, S. M. Levenson, N. B. Neault, T. C. Heeren, M. M. Black, C. Berkowitz, P. H. Casey, A. F. Meyers, D. B. Cutts, et al. Child Food Insecurity Increases Risks Posed by Household Food Insecurity to Young Children's Health J. Nutr., April 1, 2006; 136(4): 1073 - 1076. [Abstract] [Full Text] [PDF]

				B. A. Laraia, A. M. Siega-Riz, C. Gundersen, and N. Dole Psychosocial Factors and Socioeconomic Indicators Are Associated with Household Food Insecurity among Pregnant Women J. Nutr., January 1, 2006; 136(1): 177 - 182. [Abstract] [Full Text] [PDF]

				C. L. Connell, K. L. Lofton, K. Yadrick, and T. A. Rehner Children's Experiences of Food Insecurity Can Assist in Understanding Its Effect on Their Well-Being J. Nutr., July 1, 2005; 135(7): 1683 - 1690. [Abstract] [Full Text] [PDF]

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				M. M. Black, D. B. Cutts, D. A. Frank, J. Geppert, A. Skalicky, S. Levenson, P. H. Casey, C. Berkowitz, N. Zaldivar, J. T. Cook, et al. Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Infants' Growth and Health: A Multisite Surveillance Study Pediatrics, July 1, 2004; 114(1): 169 - 176. [Abstract] [Full Text] [PDF]

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