Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. e792-e800 (doi:10.1542/peds.2005-1841)
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ARTICLE

Maternal Depression and Violence Exposure: Double Jeopardy for Child School Functioning

Michael Silverstein, MD, MPHa, Marilyn Augustyn, MDa, Howard Cabral, PhD, MPHb and Barry Zuckerman, MDa

a Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
b Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. The goal was to determine how violence exposure affects the relationship between maternal depression, cognitive ability, and child behavior.

METHODS. A multivariate regression analysis of data for a nationally representative sample of kindergarten students was performed. Maternal depression and violence exposure were measured with standardized parent interviews. Standardized T scores were derived from direct testing of children in reading, mathematics, and general knowledge; child behavior was reported by teachers.

RESULTS. A total of 9360 children had neither maternal depression nor violence exposure, 779 violence only, 1564 depression only, and 380 both. Maternal depression alone was associated with poorer mean T scores for reading, mathematics, and general knowledge. However, this effect was attenuated by nearly 25% for reading and general knowledge with adjustment for violence. Children with concurrent exposure to depression and violence had lower mean T scores for reading, mathematics, and general knowledge, as well as more-concerning behaviors, than did those exposed to either factor alone. Across all outcome measures, boys seemed more affected than girls.

CONCLUSIONS. Violence compounds the effect of maternal depression on school functioning and behavior. Research and intervention planning for children affected by maternal depression should consider violence exposure.

Key Words: maternal depression • violence • school readiness • child development

Abbreviations: ECLS-K—Early Childhood Longitudinal Survey, Kindergarten Cohort • CES-D—Center for Epidemiologic Studies Depression Scale • OR—odds ratio • aOR—adjusted odds ratio • CI—confidence interval

The negative impact of maternal depression on children has been well documented. Children of depressed mothers suffer a variety of developmental, behavioral, and mental health problems, compared with children whose mothers are not depressed.1–4 Evidence also suggests that children who witness violence or whose mothers are victimized by violence have problems with social competence, temperament, internalizing behavior, and aggression.5–7 Clinical experience supports these early studies.8,9

The 2 categories of violence exposure that have been studied most comprehensively, namely, intimate partner violence and community violence, have both been associated with high rates of trauma symptoms.10 Between 62% and 81% of female domestic violence victims meet criteria for posttraumatic stress disorder11,12 and, although the effect of community violence is less well understood, it is estimated that nearly one third of individuals exposed to community violence exhibit trauma symptoms.13 Depression and trauma symptoms coexist frequently,14–19 and depression accompanied by trauma symptoms has been found to be more complicated, less remitting, and less responsive to treatment than depression alone.20–22 There is also evidence that depression in the presence of trauma has distinct symptoms, compared with depression in the absence of trauma,23–27 and may even be different at the biochemical level.28

Because of the modulating influence of trauma on depression and because domestic violence and community violence so often lead to trauma symptoms, it is reasonable to postulate that maternal depression accompanied by these types of violence may be more harmful to children than depression occurring alone. To date, however, studies of maternal depression have not considered the consequences of concurrent violence exposure on child outcomes; coincidentally, many interventions aimed at ameliorating the negative effects of maternal depression on children have failed to demonstrate significant effects.29 Filling this knowledge gap is important not only to ensure that the negative impact of violence is not misattributed to maternal depression but also to maximize the effectiveness of future interventions for maternal depression.

The aim of this investigation was to determine the impact of violence exposure on the relationship between maternal depression and childhood cognitive performance and behavior. We hypothesized that controlling for violence as a potentially confounding phenomenon would lessen substantially the magnitude of association between maternal depression and these outcomes and that the cooccurrence of violence and maternal depression in the same family would be associated with poorer cognitive functioning and behavior, beyond the main effect of either exposure alone.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data Source and Study Sample
We extracted data from the base year of the Early Childhood Longitudinal Survey, Kindergarten Cohort (ECLS-K). The ECLS-K draws from a nationally representative sample of children who attended kindergarten in 1998 to 1999 and monitors these children through the fifth grade with regular face-to-face parent interviews, teacher surveys, and direct cognitive assessments.30 Because of the many reasons why children cease to be cared for by their biological parents (and the possible cooccurrence of depressive symptoms and violence with these reasons), we restricted our study to biological mother-child dyads for which the mother served as the primary survey respondent.

Maternal Depression and Violence Exposure
Respondent mothers answered a 12-item version of the Center for Epidemiologic Studies Depression Scale (CES-D), a valid reliable measure of depressive symptoms.31 Following convention, we combined responses to individual CES-D items to create a raw symptom score. The National Center for Education Statistics categorizes this raw score as no, mild, moderate, or severe depressive symptoms,32 and we considered only those with moderate/severe symptoms (raw scores of >9) to be depressed. We chose this cutoff point because it corresponds to the most commonly used clinical cutoff point (raw score of >15) for the full CES-D and because the proportion of mothers considered to have clinically significant depressive symptoms with this measure (19%) was consistent with previously published estimates for mothers with young children.33–35 We determined the cutoff point for the dichotomous measure before exploratory data analyses.

Exposure to violence was defined by using 2 ECLS-K survey items. First, respondents were asked, "When you have a serious disagreement with your partner, how often do you end up hitting or throwing things at each other?" We considered any response other than "never" to represent in-home violence. Second, respondents were asked how much of a problem violent crime is in their neighborhood. We considered any response other than "no problem" to represent community violence. We developed a composite violence exposure variable that represented a combination of in-home and community violence. If the family was affected by either type of violence and data on the other type were missing, then we considered the composite variable positive. If data on both in-home violence and community violence were missing, then the composite variable was coded as missing.

Each mother-child dyad was assigned to 1 of 4 mutually exclusive exposure categories, namely, neither maternal depression nor violence, violence only, depressive symptoms only, or both depressive symptoms and violence. Dyads for which data on either depression or violence were missing were excluded from analyses involving both exposures.

Child and Family Characteristics
We extracted the child's age and gender, the mother's age, and the number of other siblings in the home. In addition, socioeconomic status was quantified with a continuous measure constructed by the National Center for Education Statistics to represent parental education, income, and social prestige of parental occupations. Child race was classified as white, black, Hispanic, Asian/Pacific Islander, or other.

Outcome Measures
We divided our outcome measures into 2 categories, namely, school functioning and child behavior. To measure school functioning, we extracted standardized T scores (population mean: 50; SD: 10) for directly administered tests in reading, mathematics, and general knowledge. T scores provide normative value-referenced measurements of achievement, that is, estimates of achievement level relative to the population as a whole. Because the ECLS cohort is nationally representative, the T scores provide an indicator of the extent to which an individual or a subgroup ranks higher or lower than the national average. Reading assessments measured basic skills, vocabulary, and comprehension; mathematics assessments measured knowledge and problem-solving; and general knowledge assessments measured conceptual knowledge of science and social studies.

We assessed child behavior through teachers' responses to the Social Rating Scale, an adaptation of the valid reliable Social Skills Rating System,36 which characterizes child behavior with a variety of thematic subscales. Teachers were chosen for this role by a school-based coordinator, who interacted directly with personnel from the National Center for Education Statistics. For this study, we assessed 2 positive child behavior sets (self-control and interpersonal skills) and 2 negative sets (externalizing behavior and internalizing behavior). Within the ECLS-K cohort, teacher responses to Social Rating Scale subscales demonstrated high split-half reliabilities between 0.79 and 0.90.37 For each subscale, children were scored between 1 and 4, with higher numbers indicating a greater tendency to demonstrate the behavior. To make our results more clinically relevant and to follow the precedent of previous studies,38 we dichotomized responses at either the 5th percentile (self-control and interpersonal skills) or the 95th percentile (internalizing behavior and externalizing behavior). To corroborate these findings, we also analyzed these behavior outcomes as continuous variables.

Data Analyses
We used individual-level weights from ECLS-K to yield valid national estimates. With weighted data, we used the {chi}2 test to study associations for categorical outcome data and the t test for continuous data. With weighted cross-sectional data, we used multivariate logistic regression to estimate odds ratios (ORs) and linear regression to model differences in interval data. We used the Taylor series estimation to accommodate the complex sampling design of the ECLS-K.

Variables were selected for inclusion in the models because of their documented or theoretical relevance to the outcomes of interest. Our base multivariate models were adjusted for mother's age, child's age and gender, number of siblings in the home, and family socioeconomic status.

Using the techniques described above, we constructed a series of multivariate analyses. First, to confirm the comparability of our data with previous studies, we tested the association between maternal depression and our outcomes, adjusting for the potential confounders listed above. Second, to test the hypothesis that controlling for violence would decrease the measured association between maternal depression and our outcome measures, we also adjusted these models for violence exposure.

To test the hypothesis that violence exposure augments the adverse effects of maternal depression, we disaggregated maternal depression and violence, deriving regression coefficients for depression and violence independently as well as together, a technique that yields regression coefficients identical to those obtained with the use of an interaction term. We assessed formally effect modification by violence exposure by adding depression-violence interaction terms to the base regression models. Because of evidence indicating that boys and girls are affected differently by violence exposure,39 we stratified our analyses according to child gender and assessed formally the effect modification by child gender by adding 3-way (depression-violence-gender) interaction terms to the models. Lastly, because of recommendations regarding the role of race in epidemiologic studies,40–42 we stratified all analyses according to race. Because we considered the analysis according to race exploratory, and because of sample size limitations, we did not perform a formal assessment of effect modification by race. We performed each of these analyses by using the aforementioned composite violence measure, as well as by using the in-home violence and community violence measures separately.

We performed all analyses with Stata 8.0 software (College Station, TX). Because the ECLS-K is a public-use data set devoid of unique identifiers, the Boston University Medical Center granted official exemption from institutional board review.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Maternal Depression and Violence Exposure
Among the 21260 kindergarten students included in the ECLS-K cohort, 15386 biological mother-child dyads were eligible for our study (348 dyads were excluded because the mother was not the biological mother). Among the eligible dyads, 2806 (19%) of 15227 mothers had CES-D scores indicating moderate to severe depressive symptoms; 145 mothers (1%) had missing CES-D scores. A total of 675 (6%) of 11910 mothers reported that domestic disagreements involved hitting or throwing things, and 540 (4%) of 15341 reported neighborhood violent crime. Data on in-home violence were missing in 22% of cases, but in the vast majority of these cases (21%), data were missing because of nonapplicability of the question (most commonly, the mother did not have a partner), as opposed to nonresponse. Data on community violence were missing in 0.2% of cases. Because of overlap between in-home violence and community violence, a total of 1166 (10%) of 12123 mother-child dyads were considered exposed to violence. All estimates were consistent with previously published data.43–45

A total of 12083 dyads were assigned to 1 of 4 mutually exclusive exposure categories, 9360 (77%) to neither depression nor violence, 779 (7%) to violence alone, 1564 (13%) to depression alone, and 380 (3%) to both. Depressive symptoms were more than twice as common among mothers exposed to violence, compared with mothers not exposed (33% vs 15%; P < .0001). However, among mothers with moderate/severe depressive symptoms, there was no clinically significant difference in raw CES-D scores between those exposed and not exposed to violence (15.5 vs 14.2).

Sample Description According to Exposure Group
Overall, 51% of our cohort was male, the mean child age was 75 months (SD: 4 months), the mean maternal age was 32.8 years (SD: 5.9 years), and the mean number of siblings in the home was 1.5 (SD: 1.1). Across exposure groups, there was no significant difference in child age or ratio of girls to boys. However, maternal age and family socioeconomic status decreased, whereas the mean number of siblings increased, among those exposed to violence and/or affected by maternal depression. Mean T scores in reading, mathematics, and general knowledge were lower and the prevalence of concerning child behaviors was greater among those with depression and violence exposure (Table 1).


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  		TABLE 1 Sociodemographic Characteristics, School Functioning, and Child Behavior According to Exposure Group

 
Effects of Maternal Depression on School Functioning and Child Behavior
We first tested the association between maternal depression and our outcomes by intentionally not adjusting for violence exposure. In these multivariate models, maternal depression was associated with decreases in mean T scores for reading (–2.11; 95% confidence interval [CI]: –3.06 to –1.17), mathematics (–1.45; 95% CI: –1.94 to –0.95), and general knowledge (–2.04; 95% CI: –2.75 to –0.1.32) (Table 2). Regarding child behaviors, maternal depression alone had a statistically significant association only with interpersonal skills (adjusted OR [aOR]: 0.66; 95% CI: 0.46–0.93); its relationship to self-control (aOR: 0.71; 95% CI: 0.48–1.06), externalizing behavior (aOR: 1.56; 95% CI: 0.97–2.51), and internalizing behavior (aOR: 1.47; 95% CI: 0.86–2.50) did not reach statistical significance.


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  		TABLE 2 Effects of Maternal Depression, With and Without Adjustment for Exposure to Violence, in Weighted Multivariate Analyses

 
With additional adjustment of the models for violence exposure (Table 2), the effect of maternal depression on reading scores was attenuated by 24% and the effect on general knowledge scores was attenuated by 25%. With additional adjustment for violence exposure, the effect of maternal depression on externalizing behavior decreased in magnitude by 31%.

Violence Exposure Augmentation of the Adverse Effects of Maternal Depression
Among children with dual exposure to maternal depression and violence, decreases in mean T scores for reading (–2.99; 95% CI: –3.99 to –1.99), mathematics (–3.23; 95% CI: –4.26 to –2.20), and general knowledge (–3.49; 95% CI: –4.63 to –2.35) were more than double in magnitude, compared with those among children exposed to either factor alone (Table 3). For these cognitive outcomes, depression-violence interaction terms demonstrated P values of .06 (reading), .08 (mathematics), and .06 (general knowledge), providing suggestive evidence of effect modification.


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  		TABLE 3 Compounded Effects of Maternal Depression and Violence Exposure in Weighted Multivariate Analyses

 
Regarding behavior, children with dual exposure had an aOR of 0.42 (95% CI: 0.29–0.60) for self-control, whereas the effects of violence (aOR: 0.65; 95% CI: 0.47–0.89) or maternal depression (aOR: 0.74; 95% CI: 0.57–0.97) alone were less substantial. Children's interpersonal skills, externalizing behavior, and internalizing behavior followed similar patterns. For these behavioral outcomes, however, depression-violence interaction terms did not demonstrate P values suggesting effect modification. Analyses of these behavioral outcomes as continuous variables in linear regression models yielded consistent results (data not shown). Although community violence seemed to exert a greater effect on our cognitive measures than did in-home violence, disaggregation of in-home violence and community violence did not change our results substantially (data available on request).

Stratification According to Gender and Race
In all categories of school functioning, the combined effect of depression and violence seemed greater for boys than for girls (Table 4). Boys exposed to both maternal depression and violence experienced an estimated decrease of 4.27 points (95% CI: 2.56–5.98 points) on standardized assessments of general knowledge, compared with those exposed to neither; for this outcome measure, effect modification by gender was statistically significant (P = .03). Regarding behavior, the gender difference was particularly apparent for externalizing and internalizing behaviors, for which boys with dual exposure had aORs of 2.59 (95% CI: 1.42–4.72) and 3.48 (95% CI: 1.94–6.27), respectively. For internalizing behavior, effect modification by gender was statistically significant (P = .003). Among the subjects whose mothers were not depressed, violence exposure was associated with statistically significant differences in our outcome measures more often among girls than among boys; however, the clinical significance of these differences did not seem substantial.


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  		TABLE 4 Different Effects Among Boys and Girls

 
Although limited by sample size, trends within races mirrored the overall trends for the cohort as a whole (data not shown). An exception to this was the decrease in cognitive scores among Asian children exposed to both maternal depression and violence, as follows: for reading, a loss of 3.74 points on average (95% CI: 0.73–6.75 points); for mathematics, 5.41 points (95% CI: 2.77–8.05 points); for general knowledge, 5.91 points (95% CI: 3.21–8.60 points).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
For this nationally representative sample of kindergarten students, we found that maternal depression was associated with decreased cognitive abilities and suboptimal interpersonal skills. When controlling for violence exposure, however, we demonstrated attenuation of the effect of maternal depression on children's abilities in both reading and general knowledge. When coexistent within the same family, maternal depression and violence were associated with poorer cognitive abilities and more-concerning child behaviors than when each was present individually. For measures of cognitive abilities, we found evidence suggesting an interactive effect.

Our results are consistent with previous reports on the prevalence of maternal depression, domestic violence, and community violence and the effects of adult depression on children. They are also consistent with previous studies on violence that documented modest but consistent associations between family violence exposure and psychological distress in children. However, our study adds to the field in 2 ways. First, it suggests that previous reports might have overestimated the association between maternal depression and child behavior by not controlling for violence exposure. Second, it suggests that maternal depression and violence, when coexistent within the same family, exert a more harmful effect on children than either exposure alone.

Although the mechanism of this effect cannot be determined from the present study, we hypothesize that maternal trauma symptoms are a key mediating factor. Because trauma victims often display diminished responsiveness to the external world (referred to in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, as "psychic numbing" or "emotional anesthesia"16), the nuances of a mother's depressive illness that is comorbid with violence exposure or trauma symptoms may suppress nurturing parent-child interactions more than depression existing on its own.

In the United States presently, increasing attention is being paid to measuring children's school performance. Much of this dialogue has focused on the No Child Left Behind legislation and schools' accountability for their students' performance. Less prominent, however, has been a sustained focus on other family and community factors that influence children's ability to learn. In our study sample, kindergarten boys whose mothers reported both depressive symptoms and exposure to violence scored 7% to 10% lower on standardized tests of mathematics, reading, and general knowledge than did otherwise similar boys, an effect similar in magnitude to that of lead intoxication46–48 or low birth weight.49–51 Considering the suboptimal behavior patterns noted, it is reasonable to postulate that maternal depression and violence exposure may account for substantial school difficulties among US children.

Our study was limited by a number of factors, foremost among which were our violence exposure measures. We restricted these measures to the 2 most common types of violence, namely, community violence and intimate partner violence, which we assessed with 2 questions. The psychometric properties of these questions are unknown, however, and we must assume misclassification error. Specifically, the limited range of violent behaviors covered by these measures and the in-home measure's presumption of bidirectional violence both represent a bias in the direction of underreporting and limit the extent to which our results can be generalized to other types of violence. Our measure of violence exposure does have internal validity, however, because its associated outcomes are similar in magnitude to, but independent of, those for maternal depression and because our results are consistent across virtually all outcomes.

Although the effect of maternal depression and violence exposure on child development is worth studying on its own, our theoretical construct invokes trauma symptoms as a key mediating factor in this relationship. However, because we did not have the means to assess trauma symptoms directly, we are unable to comment on the validity of this construct, and it is possible that other mechanisms (for example, children witnessing violence directly) may be responsible for the observed effects.

Our ability to demonstrate a statistically significant interaction between maternal depression and violence was also limited. Although our sample size was large, total sample size may not be the overriding driver of statistical power to detect interactions when the sample is parsed unevenly. Maternal depression and violence exposure are, statistically speaking, relatively uncommon events. Therefore, despite a large initial sample size, we actually faced small cell sizes when modeling interactions involving variables with uneven distributions. Largely on the basis of trends among the outcome measures presented and biological plausibility, we argue that an interaction between maternal depression and violence is likely; however, this will remain suspect until future confirmation.

Because our study was cross-sectional, we cannot assume causality or comment on the longitudinal effects of maternal depression and violence on child cognition or behavior. As in any observational study, the possibility of unmeasured confounding exists. Maternal health and child health represent likely sources of such biases in our study. Lastly, because of sample size limitations, we were unable to explore fully subanalyses among nonwhite races. Therefore, data on racial differences should be considered preliminary.

With these limitations in mind, we argue that our study has important research and clinical implications. First, interventions aiming to ameliorate the adverse effects of maternal depression on children should consider the influence of violence exposure and should incorporate specific therapeutic strategies to address it. Second, pediatric providers should be aware that children whose mothers are both depressed and exposed to violence represent a group at particularly high risk for cognitive and behavioral problems. Because violence exposure commonly causes trauma, stress, or frank posttraumatic stress disorder in children and adults, the presence of these clinical symptoms and the effects of specific interventions to treat them need to be studied. The present study is not meant to be a definitive analysis of the potentially interactive effects of violence and maternal depression on childhood outcomes. Rather, it indicates that, from the perspective of child outcomes, considering maternal depression without considering violence potentially means ignoring a significant part of the problem.


   ACKNOWLEDGMENTS
 
We thank Howard Bauchner, MD, and Kari Hironaka, MD, MPH, for thoughtful review of the manuscript. We thank Terry Keane, PhD, for insight into the relationship between depression and violence exposure. We thank the Boston University School of Medicine ECLS-K Workgroup for input into our study. We thank the Weaver Family Foundation, the Harris Foundation, and the Maternal and Child Health Bureau for support of this project.

Dr Silverstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.


   FOOTNOTES
 
Accepted Apr 10, 2006.

Address correspondence to Michael Silverstein, MD, MPH, Boston Medical Center, Maternity Building, 4th Floor, 91 East Concord St, Boston, MA 02118. E-mail: michael.silverstein{at}bmc.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 METHODS
 RESULTS
 DISCUSSION
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