Parental Prevention Practices for Young Children in the Context of Maternal Depression

DISCUSSION

As hypothesized, we found significant and consistent negative relationships between maternal depression and 4 parent-based prevention practices with only 1 subgroup exception. In general, depression at 2 time points demonstrated a stronger relationship with poor practice than 1 time point suggesting a type of dose response.

The rate of depression at time 1 is similar to those found for women in the original community studies using the CES-D (20.7%–29.6%),²⁸ although the rate at time 2 falls below this range. It is unclear why there would be such a decrease in depressive symptoms with time. Perhaps, over time, the joys of parenthood overcompensate for the stress of initially being a parent for some mothers. Of note, the mean age of the child at the first time point corresponds to the beginning of the notorious terrible 2s, while the second point falls beyond this period.

Overall, the rates of prevention behaviors are poor, leaving much room for improvement. The worst of the 4 practices was having syrup of ipecac in the home (39.7%), although the rate was higher than the 25% value found in the National Health Interview Survey of 1985.¹ (Note: charcoal may now be a preferred substance to have available in the home rather than syrup of ipecac.^29,,30) Car seat use was found to be somewhat higher than a report of 46% in 1984 noted in literature from the National Highway Traffic Safety Administration.³¹ Little information about the frequency of use of safety plugs is available. One study of Head Start programs noted that <60% of parents reported that they use safety plugs on outlets.³² Comparable rates of frequency of daily reading to children were not identified.

An unexpected finding was the conditional relationship between daily reading and depression depending on the cohabitation status. One might have suspected that depression would have had a more significant impact on the single mother, as a male partner would not be available to compensate for her lack of daily reading. However, in this analysis, the male partner does not seem to serve as a buffer for maternal depression. Perhaps he serves as a competitor with the child for the limited time and energy the depressed mother has for her family. This finding is consistent with the general trend found in stratified analysis (not shown) in which depression demonstrated a weaker relationship with the prevention practice under more difficult conditions (eg, lower income and lesser education). This pattern is not consistent with previous findings, where multiple stressors, including maternal mental illness measures, seem to have an additive or synergistic effect with each other.^33,,34

The only other variables demonstrating a consistent relationship across all 4 prevention practices were income and cohabitation status, where being poor and being without a significant male partner were related to poorer practice. As expected, a greater amount of maternal education was related to better practice, although electrical plug use was an exception. Being black was consistently related to poorer practices despite controlling for several other sociodemographic factors. This was particularly striking for presence of syrup of ipecac in the home. Car seat use was an exception, however. In contrast, birth order demonstrated an inconsistent relationship. This may reflect a balance of first time mothers being less knowledgeable but also more cautious with some aspects of caring for her child. Hence, the first time mother may be more vigilant in providing a safe environment, such as through the use of electrical plugs, but be unaware of syrup of ipecac, with the latter perhaps being learned about by mothers with more children through personal experiences with accidental poisonings. Not surprisingly, having more than 1 child negatively impacted on whether the index child was read to on a daily basis.

Although there are important strengths to the study, such as the large and representative nature of the sample, the use of a well-validated and commonly used depression screen, and the assessment of a variety of prevention practices; there are also several limitations. First, the study relies on self-reported prevention practices. This might lead to an overreporting of behaviors in the socially desirable direction.^35,,36 However, a large percentage of the sample was willing to report less than ideal practice patterns. Although this potential bias may impact on the accuracy of the overall prevalence of these practices, it is unclear whether this would preferentially impact on reports by mothers depending on their depression status. One could hypothesize that the depressed mother may underestimate her engagement in prevention behaviors as a part of an overall devaluation of her parenting practices. However, we are unable to assess this hypothesis with this dataset.

A second limitation is the dependence on the CES-D score as a measure of depression as opposed to a diagnostic instrument. A false-positive rate of 6.1% and a false-negative rate of 36.4% were found for this instrument in 1 study where major depression, diagnosed using a structured diagnostic interview, was used as the criterion.³⁷ However, it is unclear how this pattern of false-positives and false-negatives would impact the accuracy of the results of the current study. In addition, a measure of depressive symptoms, as opposed to a diagnosis of depression, has been found to be related to impaired mother–child interactions,³⁸ hence a nondiagnostic dimensional instrument may be appropriate in and of itself rather than serving solely as a proxy for diagnosis.

An additional limitation of the study is the cross sectional nature of the data. Despite having two data points, we are not able to determine the temporal relationship between the proposed criterion and predictor variables. Hence, we are not able to determine causality, that is, if maternal depression predicts poor prevention practices. However, that depression may impair engagement in prevention practice is plausible. Low energy and fatigue characterize depression,³⁹ making it difficult to put in the “extra effort” required to engage in various prevention behaviors, especially those that need to be repeated on a regular basis, such as the use of car seats. In addition to the physical manifestations of depression, there are distortions of cognition and beliefs.⁴⁰ People with depression often have outlooks that are colored by a sense of helplessness and hopelessness,⁴¹ which may discourage them from engaging in prevention behavior with their more distant outcomes. In addition, self-efficacy, a related construct, is often decreased in depressed persons.^42,,43 One manifestation of this may be that the depressed mother feels that she cannot make a difference in her child's health and development. Finally, the decreased interaction noted between depressed mothers and their children⁴⁴ might impact on prevention behaviors that require sustained interactions, such as reading to a child.

Finally, the selection of a variety of parent-based prevention practices was limited to only 4 items, because these were the only ones included in this survey. We had hoped to also assess the relationship between depression and the use of well-child visits and delays in immunization; however, this information is primarily available from a linked provider dataset, which is quite incomplete. Although these 4 items may not be representative of parent-based prevention practices in general, they do represent a broad spectrum of activities.

Overall, the frequency of engagement in prevention practices by mothers of young children is far from ideal. Maternal depression may be 1 factor among multiple factors contributing to this deficient pattern. Maternal depression should be considered in addition to more traditional barriers, such as knowledge deficits and low income. Child health practitioners should inquire about maternal depression when poor adherence to prevention practices has been detected, or better yet, they should address maternal depression prophylactically before poor adherence develops.

Although the suffering that mothers with depression experience warrants mental health treatment in and of itself, the potential impact on children broadens the net of professional responsibility to child health practitioners (eg, pediatricians). Zuckerman and Beardslee⁴⁵ have outlined several reasons for pediatricians to be concerned about maternal depression. Impairment in prevention practices may be 1 more reason for child health providers to be involved in universal screening and appropriate referrals for maternal depression.