Maternal Depression, Maternal Expressed Emotion, and Youth Psychopathology

Transcription

1 J Abnorm Child Psychol (2010) 38: DOI /s Maternal Depression, Maternal Expressed Emotion, and Youth Psychopathology Martha C. Tompson & Claudette B. Pierre & Kathryn Dingman Boger & James W. McKowen & Priscilla T. Chan & Rachel D. Freed Published online: 20 August 2009 # Springer Science + Business Media, LLC 2009 Abstract Across development, maternal depression has been found to be a risk factor for youth psychopathology generally and youth depression specifically. Maternal Expressed Emotion (EE) has been examined as a predictor of outcome among youth with depression. The present study explored the associations between youth psychopathology and two predictors maternal depression within the child s lifetime and maternal EE in a study of children at risk for depression. One hundred and seventy-one youth, ages 8 12, and their mothers participated. To assess maternal and youth psychopathology, dyads were administered structured diagnostic assessments, and mothers and children completed self-report measures of their own depressive symptoms. In addition, mothers completed the Achenbach Child Behavior Checklist Parent Report Version (CBCL) for their children. Maternal EE was assessed based on the Five Minute Speech Sample. History of maternal depression was associated with high maternal EE, and the combination of maternal depression history and maternal EE was associated with children s own reports of higher depressive symptoms. Current maternal depressive symptoms were associated with mothers reports of children s Internalizing scores on the CBCL, and maternal depression history, current maternal depressive symptoms, and maternal EE were strongly associated with mothers reports of children s Externalizing and Total Problem scores on the CBCL. History of maternal depression and a rating This research was supported by a grant to the first author from the National Institute of Mental Health (NIMH MH066077). M. C. Tompson (*) : C. B. Pierre : K. D. Boger : J. W. McKowen : P. T. Chan : R. D. Freed Department of Psychology, Boston University, 648 Beacon Street, 4th Floor, Boston MA 02215, USA mtompson@bu.edu of high or borderline Critical EE (characterized by maternal critical comments and/or reports of a negative relationship) were independently associated with children s depression diagnoses. Keywords Child depression. Maternal depression. Families. Expressed emotion Diathesis-stress models emphasize the interaction between vulnerability factors and negative life events/circumstances in the development of psychopathology (for a review, see Ingram and Luxton 2005). Neither vulnerability nor stress alone may be adequate for producing symptoms of psychopathology; however, in combination, they may lead to manifest disorder. While investigating risk of schizophrenia in adopted offspring of mothers with schizophrenia, Tienari and colleagues (2004) found that only when at-risk individuals were exposed to stressful family environments did they develop schizophrenic disorders. Examining a different measure of vulnerability, Caspi and colleagues (2003) found that genetic risk for depression among young adults, defined by having two short alleles on the 5-HTT gene, was only associated with the development of depression when at-risk individuals were exposed to stressful life events. In both studies, individuals at low risk were not likely to develop psychopathology regardless of life stress. One major risk factor for youth psychopathology generally, and youth depression specifically, is the presence of parental depression. Given the high rates of depression among women and the fact that mothers have traditionally been more available to participate in research than fathers, most of the research on parental depression in families has focused on maternal depression (Hammen et al. 1987). Further, current work suggests that risks for negative outcome are greater for maternal depression than for

2 106 J Abnorm Child Psychol (2010) 38: paternal depression (Foley et al. 2001). Maternal depression is associated with increased risk for depression and other psychopathology in youth (Beardslee et al. 1998; Goodman and Gotlib 1999). Children of depressed parents are 2 5 times more likely to develop a psychological disorder (Cummings and Davies 1992) and three times more likely to develop depression than are children whose parents are not depressed (Downey and Coyne 1990). Studies of child symptoms also confirm findings of greater distress among children of depressed mothers (Breslau et al. 1988; Hirsch et al. 1985; Langrock et al. 2002; Lee and Gotlib 1991). Five longitudinal studies, in particular, have included standardized diagnostic assessments and longitudinal methods to examine stability of outcomes. Hammen and colleagues (1990) followed 92 children of mothers with depression for up to three years. Compared to children of nonpsychiatric women and children of medically ill women, those with depressed mothers had high rates of diagnosis, recurrence, and chronicity of depression. Weissman and colleagues (Weissman et al. 1987, 1992; Wickramaratne and Weissman 1998) followed 125 offspring of parents with depression for over 10 years. Compared to children of mothers without depression, children of mothers with depression had an eight-fold increase in childhood-onset depression, as well as higher rates of substance abuse, impaired psychosocial functioning, psychiatric treatment, and academic difficulties. Beardslee and colleagues (1993) conducted a 4-year follow-up of 105 children of parents with mood disorders, including unipolar and bipolar depression, finding that 26% of children of parents with mood disorders met criteria for a mood disorder, compared to 14% of children whose parents had a non-mood disorder and 10% of those with parents who had no psychiatric disorder. Billings and Moos (1985) followed 83 children of parents with depression for 1 year and found that, even when parental depression remitted, these children were functioning more poorly than children with never-depressed parents. In a 10- month follow-up of 44 children of mothers with depression, Lee and Gotlib (1989a, b) found that children whose mothers depression had remitted showed more internalizing symptoms than those whose mothers had never been depressed. Overall, these studies underscore the risk conferred by parental depression, and the latter two suggest that difficulties do not necessarily subside with parental recovery from depression. Although genetic and biological risk mechanisms may contribute to the association between parental and youth mood disorder, psychosocial factors in families may also be operative (Goodman and Gotlib 2002). Parental depression is associated with a host of family stressors which may impact children s well-being, including divorce (Harlow et al. 2002), marital conflict (Coyne et al. 2002), spousal psychopathology (Fendrich et al. 1990; Merikangas and Spiker 1982), and parenting patterns that are negative, inconsistent, unpredictable, and unsupportive (Compas et al. 2002). Thus, the presence of parental depression may be associated with both genetic and psychosocial factors that contribute to the enhanced risk for mood disorders in youth (Goodman and Gotlib 2002). It is unclear whether parental depression has a direct effect on depression outcomes in children, whether it moderates the impact of psychosocial factors on depression outcomes, or whether psychosocial factors mediate the association between parental depression and child depression. For example, Fendrich et al. (1990) found that while family risk factors (e.g., parental marital adjustment, parent-child discord, affectionless control, low family cohesion, and divorce) were associated with parental depression, they were only associated with higher rates of depression in children of non-depressed parents. Indeed, parental depression was the strongest predictor of child outcomes. Alternatively, work by Hammen and colleagues (Hammen 1997; Hammen et al. 2004) suggests that, rather than maternal depression directly predicting youth depression, the relationship between maternal and youth depression may be mediated by life stress and negative family relationships. Overall, this work underscores the need to understand the complex web of risk factors often accompanying parental depression. In their review of possible pathways by which maternal depression may impact children s outcomes, Goodman and Gotlib (2002) outline a pathway in which depressed mothers may expose their offspring to negative and/or maladaptive cognitions, behaviors, and affect (p. 315). Depression is often associated with more negative cognitions about the self, world, and future (Beck 1976) and a tendency toward negative attributions (Alloy et al. 2006). These negative cognitions may be expressed in more critical and intrusive parent-child interactions (Tompson et al. 2008), and critical interactions are associated with children s higher self-criticism and lower self-esteem (Kuperminc et al. 1997). Thus, symptoms of maternal depression may have a strong negative impact on parentchild relationships (Shelton and Harold 2008). Family member Expressed Emotion (EE), a measure of critical, hostile, and/or emotionally over-involved attitudes in the family, has long been studied as a risk factor for negative outcomes among individuals with mental disorders, including schizophrenia, bipolar disorder, unipolar depression, and eating disorders (for reviews see, Hooley and Gotlib 2000; Tompson et al. 2003). Indeed, a metaanalysis suggests that family member EE may be particularly predictive of outcome among individuals with mood disorders (Butzlaff and Hooley 1998). While family member EE has been examined more fully in adult populations, some efforts have been made to investigate it in child populations. Most studies in the adult literature and

3 J Abnorm Child Psychol (2010) 38: a few in the child literature have used the traditional Camberwell Family Interview (CFI; Vaughn and Leff 1976) to measure EE in parents and/or spouses (e.g., Bolton et al. 2003; Hooley and Campbell 2002); yet, the majority of studies in the child literature have used the Five Minute Speech Sample (FMSS; Magaña et al. 1986) to estimate parental EE (e.g. Asarnow et al. 2001; Jacobsen et al. 2000; Rogosch et al. 2004). While the specificity of EE to particular diagnostic groups continues to be investigated, some studies indicate that children with depression may be particularly likely to be exposed to high parental EE attitudes. Among children in an outpatient setting, those with depression were more likely to have a high EE mother than were children with ADHD or with no psychiatric disorder (Asarnow et al. 2001). Among children in an inpatient setting, those hospitalized with depression were more likely to have at least one high EE parent than those hospitalized with schizophrenia-spectrum disorders and children without a psychiatric disorder (Asarnow et al. 1994). In addition, depressed children living with high EE parents may be at increased risk for relapse and non-recovery. Among children hospitalized for Major Depression and/or Dysthymia, high parental EE predicted depression relapse and/or continuing depression one year following hospital discharge (Asarnow et al. 1993). Another study of depressed adolescents indicated that high parental EE was predictive of youths lower social functioning over time and, in a subgroup of youth without comorbid ADHD, low parental EE was predictive of depression remission (McCleary and Sanford 2002). Although a potentially important predictor of outcome, the EE construct still remains somewhat ambiguous. One contributing factor is the fact that research on EE was initially empirically, rather than theoretically, derived. Although EE is construed as an index of the dyadic relationship, it is rated on the basis of the thoughts and feelings that a parent expresses toward his/her child in an individual interview. Thus, a parent is described as being high EE toward the child, and parents may be high EE toward one offspring and not another. Hooley (2007) observes that EE may reflect relationship problems that are bidirectional. Thus, EE is a characteristic of a particular dyad; however, Miklowitz (2004) emphasizes that EE may reflect disturbances in the organization, emotional climate, and transactional patterns of the entire family system. While EE demonstrates stability over time (Hooley 2007), it is also changeable, and interventions have been successfully designed to reduce EE (see Miklowitz and Tompson 2003). EE can be a stressor but also may contribute to the context in which the child develops and copes with other stressors. A few studies indicate that parental depression may increase the likelihood of high parental EE (Bolton et al. 2003; Rogosch et al. 2004; Schwartz et al. 1990). Given that depression is frequently associated with ongoing negative perceptions and beliefs (Alloy et al. 2006) and negative interpersonal interactions (Tompson et al. 2008), depression may increase risk for high EE. This study focused on the relationship between two risk factors for depression in youth maternal depression and maternal EE and their cross-sectional association with measures of child psychopathology generally and child depression specifically. There were three major hypotheses. First, given findings of the deleterious impact of depression on interpersonal relationships in general and evidence of maternal critical behavior in interactions between depressed mothers and their children, we predicted that maternal depression would be associated with high EE, particularly high critical EE. Second, we predicted that maternal depression would be associated with child psychopathology overall, and critical EE would be associated specifically with children s depressive symptoms. Third, we predicted that the interaction between maternal depression and critical EE would be associated specifically with depressive symptoms and diagnoses of depressive disorder in youth. Method Participants The sample included 171 mother-child dyads of whom 69 (40%) were mothers with a depression-spectrum disorder during the child s lifetime. Among those with a depression-spectrum disorder, 51 (74%) had Major Depressive Disorder (MDD); one (1.5%) had Dysthymic Disorder (DD); one (1.5%) had Adjustment Disorder with Depressed Mood (AdjDep); and 16 (23%) had Depressive Disorder Not Otherwise Specified (DDNos). Table 1 includes demographic information for the sample. The sample was diverse with regard to children s ethnicity (32% ethnic minorities) and reflective of the larger region from which this sample was drawn (U.S. Bureau of the Census 2007a). Mothers were 42.4 years old on average (sd=5.86). Median family income was reported as $80,000 or above per year (range $10,000 to $80,000 or above), consistent with census data for the region (Median=$78,497; U.S. Bureau of the Census 2007b). Thirty families (17%) were at or below federal poverty level for a family of four; and 51 (29%) had at some time received public assistance (e.g., Food stamps, WIC, Medicaid, etc). Mothers had a mean of years of education (sd=2.60), 125 (73%) were currently married or living with a romantic partner, 30 (18%) were separated, widowed or divorced, and 16 (9%) had never married.

4 108 J Abnorm Child Psychol (2010) 38: Table 1 Children s Demographics (n=171) Maternal depression history Negative Positive Total The two groups did not differ on demographic variables Gender Male 58 (34%) 41 (24%) 99 (58%) Female 44 (26%) 28 (16%) 72 (42%) Ethnicity Caucasian 70 (41%) 46 (27%) 116 (68%) African-American 12 (7%) 10 (6%) 22 (13%) Hispanic 9 (5%) 2 (1%) 11 (6%) Asian 3 (2%) 0 3 (2%) Multi-Racial 8 (5%) 11 (6%) 19 (11%) Age Mean (SD) (1.40) (1.30) (1.36) Procedure This study consists of cross-sectional analyses of Wave 1 data from an NIMH-funded longitudinal (three Wave) study of psychosocial factors associated with the development of psychopathology in pre-adolescent children of mothers with and without depression. A non-referred sample of mothers was identified through several sources. First, mothers were identified through a Veterans Administration (VA) research study focusing on normative aging in men (NAS; Bell et al. 1972). Participating veterans were approached during other study visits and asked if they had grandchildren within the study s targeted age range (8 12); these veterans were then asked for permission to contact their offspring (the parents of their grandchildren within our targeted age-range); these veterans offspring were then approached and asked to participate in the study. There were 25 mothers recruited through the VA-NAS study. Second, 35 mothers who had participated in the Harvard Moods and Cycles (HMC) study (which examined depression in the peri-menopausal years; Harlow et al. 2004) and who had children ages 8 12 were invited to participate. Third, the remaining mothers (n=111) were identified through a mass mailing procedure. Publically-available census data were obtained for several ethnically-diverse neighborhoods and suburbs of Boston. Women within the age range of (judged as the range for potentially having children ages 8 12) were identified. In all cases, women received a letter by mail briefly describing the study, along with a self-addressed stamped postcard to be returned if they were interested in being contacted for further information. Those who returned the postcards indicating interest were contacted by phone and screened for inclusion. The three recruitment sources were not different with regard to presence/absence of maternal depression history; however, the groups differed with regard to maternal age, marital status, ethnicity, and receipt of public assistance. Mothers recruited through HMC were significantly older on average (M=47.3, sd=3.4) than mothers recruited through the VA-NAS (M=41.64, sd= 2.50) or the mass mailing procedure (M=41.05, sd=6.25; F (2,165) =16.61, p<.001). There was a trend for mothers recruited through the mass mailing procedure and HMC to be more likely than those recruited through VA-NAS to be divorced, separated, widowed, or never married (32%, 26%, 8% respectively; Contingency Coefficient (171) = 0.18, p<0.06). Mothers recruited through the mass mailing procedure were significantly more likely to be members of ethnic minority groups (32%; Contingency Coefficient (171) =0.29, p<0.001) and to have received public assistance at some point in their lives (43%; Contingency Coefficient (163) =0.34, p<0.001) than mothers recruited through the VA-NAS (0%, 10% respectively) or HMC (11%, 6% respectively). In order to participate, mothers had to meet the following criteria: (1) biologically related to index child; (2) a history of DSM-IV Major Depressive Disorder, Dysthymic Disorder or Depressive Disorder NOS, or a history of no depression (those meeting criteria for Bipolar Disorder were excluded); (3) no history of psychosis or brain injury. Children had to meet the following criteria: (1) ages 8 to 12 (at time of first scheduled participation); (2) living with biological mother at least half of the time for the past year; (3) English-speaking; (4) no history of psychosis, brain injury or chronic/life-threatening medical condition; (5) no history of Autism; (6) living within 100 miles of Boston. Finally, willingness and ability of both the child and parent to participate and informed consent were required for each dyad to participate. Families were invited to be interviewed in the research laboratory at Boston University or in their homes. Families largely preferred home-based interviews. Mothers signed IRB approved informed consents, and children signed IRB approved assents prior to any data collection. Pairs of trained interviewers administered a series of interviews, self-report measures, and video-taped interactions. Assessment batteries were divided between diagnosticians, with

5 J Abnorm Child Psychol (2010) 38: the person conducting child assessments blind to suspected maternal diagnostic status. Participants were interviewed in separate rooms to protect confidentiality. Interviewers (doctoral students in Clinical Psychology and a B.S. level Research Assistant) were trained extensively by the Principal Investigator and/or Project Director on the administration and scoring of all measures. Measures Maternal Depression Maternal depression was assessed categorically and dimensionally. First, a diagnostic measure the Structured Clinical Interview for the DSM-IV (SCID; First and Gibbon 2004) was administered to each mother about herself to assess history of depression diagnosis and other forms of psychopathology. This measure generates DSM-IV based diagnoses covering most common disorders including Major Depression, Bipolar Disorder, Dysthymia, Generalized Anxiety Disorder, Posttraumatic Stress Disorder, Psychotic Disorders, Eating Disorders, etc. Mothers were divided into two groups based on their responses to the depression section of the interview: those with a history of depression within their child s lifetime versus those without a history of depression within their child s lifetime. Forty randomly selected interviews were co-rated to assess inter-rater reliability for depression-spectrum disorder diagnoses, and inter-rater agreement was high (98%; kappa=0.95, p<0.001). Second, the total score (range 0 63) on the Beck Depression Inventory (BDI; Beck et al. 1961) was used to assess current depressive symptoms. The BDI has acceptable internal consistency and test-retest reliability (Bumberry et al. 1978), and internal consistency in this sample was high (α=0.89). Third, depression can differ greatly in its severity and chronicity. Thus, to capture the range of severity/chronicity in this sample, we applied an index devised by Horowitz and Garber (2003). Among our depressed group, each participant was given a rating for depression severity/ chronicity. A mild rating was given to mothers with no more than two depressive episodes and a total duration of no more than one year of depression within their child s lifetime. In addition, individuals in this group had no history of suicidality, psychiatric hospitalization or psychotic features. A moderate rating was given to mothers with one to three depressive episodes and one to four years total duration of depression within their child s lifetime. Mothers who had been depressed for less than one year but had a history of hospitalization, suicide attempt or psychotic features within their child s lifetime also received a moderate rating. The severe rating was assigned to mothers with four or more episodes and/or four or more years of depression during their child s lifetime. Maternal Expressed Emotion The Five Minute Speech Sample (FMSS; Magaña et al. 1986) was used in this study as an indicator of maternal Expressed Emotion (EE) toward the child. Administered individually to the mother, the FMSS instructs the mother by saying I d like to hear your thoughts about (child s name) in your own words and without my interrupting you with any questions or comments. When I ask you to begin, I d like you to speak for 5 min, telling me what kind a person (child s name) is and how you get along together. After you ve begun to speak, I prefer not to answer any questions. Are there any questions you would like to ask me before we begin? Audiotaped recordings of the FMSS were scored by a trained rater who was blind to information about maternal and child diagnosis and to the study design. Criteria for scoring EE from the FMSS were developed by Magaña and colleagues (1986). A high FMSS-EE rating is based on a high score on either of two dimensions: criticism (CRIT) and emotional overinvolvement (EOI). Parents may also be high on both. A high CRIT score is assigned if the parent makes a negative initial statement about, describes a negative relationship with, or uses one or more criticisms toward the child. A borderline CRIT rating is made based on evidence of relationship dissatisfaction in the absence of the high CRIT criteria. A high EOI rating is assigned if the parent shows evidence of excessive self-sacrifice/overprotective behavior, cries during the FMSS, or has a combination (two or more) of: statements of love/devotion, five or more positive remarks and/or excessive detail about the past. Finally, a borderline EOI rating is assigned if the mother reports milder signs of self-sacrifice/overprotective behavior or one of the following: statements of love/devotion, five or more positive remarks, or describes excessive detail about the past. For the purposes of this study, and consistent with other investigations using the FMSS (Asarnow et al. 1994, 2001; Tompson et al. 1997), individuals scoring borderline CRIT or borderline EOI were categorized as low EE. Past work using this coder demonstrated high inter-rater reliability (Asarnow et al. 1994, 2001; Tompson et al. 1997), and the FMSS has predicted one-year outcome among depressed child psychiatric inpatients (Asarnow et al. 1993). Child Psychopathology Child psychopathology generally and depression specifically were measured categorically and dimensionally. Children s lifetime diagnoses were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-aged Children (K-SADS-PL; Kaufman et al. 1997), which has demonstrated good testretest reliability (Chambers et al. 1985) and inter-rater agreement (Gammon et al. 1983). It was administered to the mother about her child and then to the child about him/ herself. To establish inter-rater reliability, a rater blind to the

6 110 J Abnorm Child Psychol (2010) 38: original diagnoses, rated 20% of a randomly selected sample of interviews. Agreement for depression-spectrum diagnosis was 97% (kappa=0.90, p<0.001) and was 91% (kappa=0.82, p<0.001) for any childhood disorder, including mood disorders, anxiety disorders (Generalized Anxiety Disorder, Separation Anxiety Disorder, Obsessive Compulsive Disorder, Panic Disorder, Posttraumatic Stress Disorder, and Phobic Disorders), disruptive behavior disorders (ADHD, Oppositional Defiant Disorder, and Conduct Disorder), elimination disorders (Enuresis and Encopresis), and tic disorders (transient and chronic vocal and motor tics and Tourette s Disorder). The 118-item Child Behavior Checklist (CBCL; Achenbach 1991) was administered as a continuous measure of child emotional and behavioral symptoms as reported by mother. The CBCL has good test-retest reliability, inter-parental agreement (McConaughy 1993), and internal consistency, as well as convergent and discriminant validity (Clarke et al. 1992). Internalizing scale scores successfully differentiate children with and without diagnosable depressive disorder, and Externalizing scale scores successfully differentiate children with and without Attention Deficit Disorder (Biederman et al. 1996). Children completed the 27-item self-report Child Depression Inventory (CDI; Kovacs 1981) as a dimensional measure of current depressive symptoms. For the CDI, item response scores range in severity from 0 (not at all)to2(alot),andtotalcdiscoresrangefrom0to54. Validity and test-retest reliability have been documented (Smucker et al. 1986). Cut-off scores for clinical severity vary; some studies suggest that an optimal cut-off of 16 be used to describe a child experiencing current depression (Timbremont et al. 2004), while others suggest that lower cutoffs (>12) may be indicative of a current mood disorder. Internal consistency in this sample was moderate (α=0.78). referral sources VA-NAS, HMC, mass mailing were compared on the BDI, CDI, and CBCL Internalizing, Externalizing, and Total Problem scales. Using Contingency analyses, the three referral sources were also compared on overall EE, CRIT EE, EOI, maternal depression history, and child depression diagnosis. There were no differences between the referral sources on any of the variables of interest. We examined distributions for the BDI, CDI, and CBCL. Only maternal BDI was positively skewed and, thus, a square root transformation was applied in all analyses; however, for ease of interpretation, means for the non-transformed BDI are reported. We then looked at the association between our measures of maternal depression. Among the 69 mothers with a depression history, 32 (46%) had a mild rating on severity/ chronicity, 19 (28%) had a moderate rating, and 18 (26%) were rated severe/chronic. In addition, and not surprisingly, a t-test revealed a highly significant difference in BDI scores between those mothers with a history of depression (M=8.89, sd =8.60) and those with no history of depression in their child s lifetime (M=3.70, sd=4.15, t (163) = 5.19, p<0.001). Further, when the four severity/ chronicity groups were compared using ANOVA, they differed significantly in terms of current BDI score (F (3,161) =14.02). Post-hoc tests specifically revealed that the mild and moderate groups had higher BDI scores (M=5.74, sd=5.94; M=8.89, sd=7.69, respectively) than the no history of depression group (M=3.70, sd=4.15) but did not differ from one another; the severe/chronic group had significantly higher scores (M=15.0, sd=11.10) than all other groups. Given the strong association between severity/chronicity ratings and transformed BDI scores, as well as the greater range of the BDI, we decided to examine the dichotomous overall maternal depression history variable and the dimensional maternal BDI score and not conduct separate analyses by severity/chronicity groups. Overview Results Preliminary Analyses Prior to testing the hypotheses, we conducted preliminary analyses to: (1) compare participants from our different recruitment sources on our key variables of interest; (2) examine distributions for our key dimensional variables; and (3) examine the associations between our various measures of maternal depression, including a diagnostic measure of the presence/absence of depression history, an ordinal measure of severity/chronicity, and a dimensional measure of current symptoms (BDI). Using one-way ANOVAs, the scores of the participants from our three This study examined two issues the association between maternal depression and EE and the association between these risk factors and children s symptoms and diagnoses. All analyses were conducted first for overall EE status and then for CRIT EE and EOI. Our first goal was to examine the association between history of maternal depression and maternal EE, and we conducted two sets of analyses. First, using chi-square analyses, we examined the association between the presence/absence of maternal depression history and maternal EE, including overall EE, CRIT EE, and EOI. Second, recognizing that those with a maternal depression history may vary significantly in terms of current symptoms, we then examined the association between current maternal

7 J Abnorm Child Psychol (2010) 38: BDI and maternal Expressed Emotion, including overall EE, CRIT EE, and EOI. Our second goal was to examine the association between the risk factors maternal depression history and maternal EE (overall EE, EE CRIT, and EOI) and children s symptoms and diagnoses. In predicting symptoms, we considered both children s reports of depressive symptoms on the CDI and mothers reports of Internalizing, Externalizing, and Total Problems on the CBCL. We conducted a series of 2-way ANOVAs with maternal depression history and maternal overall EE, CRIT EE, and EOI as independent variables and CDI scores and CBCL Internalizing, Externalizing, and Total Problems as dependent variables. To explore whether current maternal depressive symptoms might account for these associations, we also conducted a series of regressions with maternal BDI and maternal EE as independent variables predicting the child symptom measures. In predicting child diagnosis, we conducted a series of logistic regression analyses with maternal depression history and maternal overall EE, CRIT EE, and EOI as independent variables and a depression diagnosis specifically and any child mental health diagnosis generally as dependent variables. To again look at the fuller range of maternal depressive symptoms, the logistic regression analyses were then conducted using current maternal BDI score in place of maternal depression history. Maternal EE and Maternal Depression History Rates of high overall EE (25%) were relatively low in this sample, with 16% rated high on CRIT EE and 9% high on EOI; no mothers were rated high on both CRIT EE and EOI. Consistent with prior research (Schwartz et al. 1990), chi-square analyses revealed significant associations between maternal depression history and overall EE (χ 2 (1)= 8.64, p<0.003) and CRIT EE (χ 2 (1)=3.92, p=0.05) and a trend toward an association between maternal depression history and EOI (χ 2 (1)=3.60, p<0.06). Data for overall EE are displayed in Table 2. Second, we conducted two-way ANOVAs to examine associations between EE and current maternal BDI. In contrast to our findings with maternal depression history, overall EE was not associated with current maternal BDI; however, high CRIT EE was associated with higher maternal BDI (M=9.39, sd=8.40) than was low CRIT EE (M=5.04, sd=6.23, F(1,161)=7.92, p<0.006), and low EOI was associated with higher maternal BDI (M= 6.10, sd=7.05) than was high EOI (M=2.75, sd=2.72, F (1,161)=5.75, p<0.02). Thus, CRIT EE and EOI show different patterns of association with current maternal depression symptoms. Maternal Depression History, Maternal EE, and Child Symptoms As noted above, two-way ANOVAs were run to examine maternal depression history and maternal EE (overall, CRIT EE, and EOI) as predictors of children s symptoms on the CDI and on the Internalizing, Externalizing, and Total Problems scales of the CBCL. We first examined the CDI. In the model that included overall EE and maternal depression history, neither maternal depression history, overall EE, nor their interaction was associated with current CDI scores. However, in the model that included maternal depression group and CRIT EE, the interaction between high maternal CRIT EE and maternal depression group approached significance (F(1,167)=3.55, p=0.06). In the final model, neither maternal depression group, maternal EOI, nor their interaction was associated with children s CDI scores. We next examined CBCL Internalizing, Externalizing, and Total Problem scores. Means for these variables by maternal depression history and CRIT EE are shown in Table 3. For the Internalizing scale, none of the EE variables, maternal depression, or their interactions was associated with CBCL scores. Examining externalizing symptoms produced quite different findings. In a model that included both maternal depression history and overall EE, overall EE was associated with higher CBCL Externalizing scores (F(1,166) =8.14, p<0.005). In a model that focused on maternal depression history and CRIT EE, both maternal depression history (F(1,166)=4.62, p<0.05) and CRIT EE (F(1,166) =20.59, p<0.001) were associated with higher Externalizing scores. In a model that included maternal depression history and EOI, no significant effects were found for either variable or their interaction. Third, we examined the CBCL Total Problem scale. When maternal depression history and overall EE were entered, only overall EE was significantly associated with CBCL Total Problem scores (F(1,166) =6.02, p<0.02). Likewise, in a Table 2 Frequency of Maternal Depression History and Maternal Expressed Emotion (n=171) Maternal depression history Negative Positive Total χ 2 (1)2=8.64, p<0.003 Maternal Expressed Emotion High EE 18 (11%) 26 (15%) 44 (26%) Low EE 84 (49%) 43 (25%) 127 (74%) Total 102 (60%) 69 (40%) 171 (100%)

8 112 J Abnorm Child Psychol (2010) 38: Table 3 Means from ANOVA Examining Child Symptoms as Function of Maternal Critical EE and Maternal Depression History (n=171) a = interaction effect p>0.06 b = Critical EE<0.001 and maternal depression history p< 0.05 c = Crit EE p<0.001 Numbers in parentheses represent standard deviations. Maternal depression history Maternal critical EE Negative Positive Hi Lo Hi Lo n=12 n=90 n=16 n=53 Total CDI a 5.00 (4.00) 5.18 (3.96) 7.81 (7.60) 4.45 (4.20) CBCL: Internalizing (9.99) (9.75) (9.53) (10.47) CBCL: Externalizing b (7.76) (8.96) (10.40) (8.86) CBCL: Total Problems c (9.11) (9.82) (9.13) (10.83) model that included maternal depression history and CRIT EE, only CRIT EE was associated with CBCL Total Problems (F(1,166) =16.16, p<0.001). In a model that included maternal depression history and EOI, neither variable nor their interaction was associated with CBCL Total Problem scores. To examine current maternal BDI and the EE variables (overall EE, CRIT, and EOI) as independent variables predicting child symptoms, we conducted hierarchical linear regressions. For each analysis, the maternal BDI score and the respective EE variable were entered on Step 1, and their interaction term was entered on Step 2. As in the above analyses, dependent variables included CDI and CBCL Internalizing, Externalizing, and Total Problem scores. First, in the regression predicting CDI scores, the model including BDI and overall EE was significant only on Step 2, accounting for 5% of the variance in CDI (F (3,161) =2.91, p<0.05). As illustrated in Table 4, only the interaction between BDI and EE variables was significant (β=0.348, p<0.05). Models in which BDI was combined with CRIT EE or EOI were not significant in predicting CDI. Second, regressions examining maternal BDI and EE as predictors of CBCL scores showed a similar pattern of results to that obtained with the above ANOVA analyses including maternal depression history. As shown in Table 4, when maternal BDI and overall EE were entered as predictors of CBCL Internalizing scores on Step 1, the model was significant (F(2,161) =13.53, p<0.001) but only maternal BDI made a significant contribution; none of the EE variables contributed. In contrast, predicting CBCL Externalizing scores, the model including maternal BDI and overall EE was highly predictive at Step 1, predicting 22% of the variance; however, the interaction term at Step 2 was not significant. As shown in Table 4, both maternal BDI and overall EE were significant predictors. The model including maternal BDI and CRIT EE was also significant at Step 1, accounting for 25% of the variance in CBCL Externalizing scores (F(2,161)=26.56, p<0.001). Both maternal BDI (β=0.363, p<0.001) and CRIT EE (β= 0.260, p<0.001) were significant predictors; Step 2, including the interaction term, did not add to the model. Finally, we examined maternal BDI and the EE variables as predictors of CBCL Total problem scores. Findings paralleled those for CBCL Externalizing scores. Specifically, as shown in Table 4, the model including maternal BDI and overall EE explained 26% of the variance in CBCL Total Problems (F(2,161)=27.76, p<0.001), with both maternal Table 4 Summary of Hierarchical Regression Predicting CDI and CBCL Scores (n=163) For CDI scores R 2 =0.022, ΔR 2 =0.029 (p<0.05); for CBCL Internalizing scores R 2 = (p<0.001); for CBCL Externalizing scores R 2 =0.218 (p<0.001); for CBCL Total Problem scores R 2 =0.256 (p< 0.001). Square-root transformed BDI used in all analyses. * p<0.05 Variable B SE B β Outcome: CDI Scores Step 1 Predictor: Maternal BDI Score Predictor: Overall EE Step 2 Interaction of Maternal BDI and Overall EE * Outcome: CBCL Internalizing Scores Step 1 Predictor: Maternal BDI Score * Predictor: Overall EE Outcome: CBCL Externalizing Scores Step 1 Predictor: Maternal BDI Score * Predictor: Overall EE * Outcome: CBCL Total Problem Scores Step 1 Predictor: Maternal Score * Predictor: Overall EE *

9 J Abnorm Child Psychol (2010) 38: BDI and overall EE as significant predictors and the interaction term not significant. The model including maternal BDI and CRIT EE was also highly significant (R 2 =0.28; F(2,161)=30.66, p<0.001), with both maternal BDI (β=0.43, p<0.001) and CRIT EE (β=0.21, p<0.005) significant and the interaction making no significant contribution. It should be noted that EOI was not a significant predictor in models predicting CBCL Internalizing, Externalizing, or Total Problem scores. Maternal Depression, Maternal EE, and Child Diagnosis In the overall sample, 22 (13%) children met criteria for a depression-spectrum disorder. We assigned primary depression diagnoses according to the following hierarchy: (1) Major Depressive Disorder (MDD; n=11; 6.5%), (2) Dysthymic Disorder (DD; n=1; 0.5%), (3) Depressive Disorder Not Otherwise Specified (DDNos; n=6; 3.5%) and (4) Adjustment Disorder with Depressed Mood (AdjDep; n=4; 2.5%). Of those children with a mother having a history of maternal depression, 17 (24%) had a depression-spectrum diagnosis, and of those with a mother without a history of maternal depression, 5 (5%) had a depression-spectrum diagnosis (χ 2 (1)=14.30, p<0.001). Separate hierarchical logistic regression analyses were conducted to statistically examine history of maternal depression in combination with each of the EE variables (overall EE, CRIT EE, and EOI) as independent variables predicting child depression-spectrum diagnoses (Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder NOS). For each analysis, maternal depression and the respective EE variable were entered in Step 1 and their interaction term was entered in Step 2. In the analysis including overall EE and maternal depression history, Step 1 was significant (Wald x 2 (2)=13.60, p<0.001); however, only maternal depression was a significant predictor (Wald x 2 (1)=10.28, p<0.001). The interaction between maternal depression and maternal EE did not improve prediction. Findings were similar in the logistic regression models that included CRIT EE and EOI maternal depression history was a significant predictor. However, CRIT EE, EOI, and their interaction terms were not significant predictors of child depression-spectrum diagnosis. Given our expectation that CRIT EE would be particularly associated with child depression, and literature suggesting that the FMSS may underestimate CRIT EE (Hooley and Parker 2006), we also conducted a logistic regression analysis in which the borderline high CRIT group was grouped with the high CRIT group to form a borderline/high CRIT EE group. As anticipated, the full regression model was highly significant (Wald x 2 (2)= 19.32, p<0.001) with both maternal depression (Wald x 2 (2)=11.17, p<0.001) and borderline/high CRIT EE (Wald x 2 (2)=4.24, p<0.05) strongly contributing to child depression diagnosis. The interaction of maternal depression history and borderline/high CRIT EE did not add significantly. The hierarchical logistic regression analyses were conducted using the dimensional measure of current depressive symptoms (maternal BDI) as an independent variable in place of the dichotomous maternal depression history variable. Interestingly, unlike maternal depression history, current BDI was not associated with child depression diagnosis in any of these analyses, and the combination of BDI and the EE variables (overall EE, CRIT, and EOI) was not significant. However, as in the above analyses, the model including maternal BDI and borderline/high CRIT EE significantly predicted child depression diagnosis (Wald x 2 (2)=6.67, p<0.05), but only borderline/high CRIT EE was significant (Wald x 2 (1)=4.83, p<0.05) in this model. Hierarchical logistic regression analyses were then conducted to predict the presence of any childhood mental health disorder. These analyses revealed that neither maternal depression history, the EE variables (overall EE, CRIT EE, EOI), nor their interaction terms was a significant predictor. However, as in the above analyses, when maternal depression history and the broader borderline/high CRIT group were entered as predictors of any childhood mental health disorder, the overall regression model was significant (Wald x 2 (2)= 6.84, p<0.01). In this model, the combination of maternal depression history and borderline/high CRIT EE was associated with a greater likelihood of any childhood mental health disorder (Wald x 2 (2)=6.61, p<0.01). When these hierarchical logistic regression analyses were conducted using the dimensional maternal BDI score in place of the dichotomous maternal depression variable, there was no association between the predictors and any childhood mental health disorder. Discussion This study yielded four primary findings. First, maternal depression history was associated with high overall Expressed Emotion (EE) and critical Expressed Emotion (CRIT EE) in mothers, as evidenced in other studies (e.g., Schwartz et al. 1990). Second, maternal CRIT EE and maternal depression history appear overall to make synergistic contributions to children s depressive symptoms. Third, maternal depression is overwhelmingly the strongest predictor of child depression diagnosis, with the EE variables alone not being predictive. Fourth, both history of maternal depression and presence of borderline or high CRIT EE in mothers were highly associated with offspring mental health diagnoses.

10 114 J Abnorm Child Psychol (2010) 38: In this study, maternal depression history was strongly associated with maternal Expressed Emotion. However, this masked a more complicated picture. An overall rating of high EE can be assigned based on evidence of either high criticism/negative relationship (high CRIT) or emotional overinvolvement/excessive self-sacrifice (EOI), and in this sample approximately two thirds were rated high EE based on high CRIT EE and one third based on EOI. CRIT EE and EOI were not correlated, as no participant was high on both CRIT EE and EOI. However, both high CRIT and high EOI were independently associated with maternal depression history, suggesting that maternal depression may increase the risk of a mother becoming more critical or alternatively more anxious and overprotective toward her offspring. CRIT EE and EOI may have differential associations with children s development and risk. Indeed, prior studies suggest that maternal EOI may be associated with child anxiety disorders; whereas high maternal CRIT EE may be more strongly associated with child depression and externalizing psychopathology (Hirshfeld et al. 1997; Stubbe et al. 1993). Notably, mothers with a history of depression were more than two times as likely to be high EE compared to mothers with no history of depression; however, only 37% of depressed mothers were high EE, and only 23% of mothers were high CRIT EE. Thus, although maternal depression is associated with high EE, both depressed and non-depressed mothers are far more likely to be low in Expressed Emotion. Further analyses examining factors that may increase EE in depressed mothers could potentially shed light on this issue. Interestingly, while history of maternal depression was associated with CRIT EE and EOI, current depressive symptoms were positively correlated with CRIT EE and inversely correlated with EOI. These findings are consistent with studies indicating that depressive symptoms are associated with social withdrawal and increased negativity (Lovejoy et al. 2000). In line with our prediction, current maternal depressive symptoms interacted with overall EE significantly, and the interaction of maternal depression history and CRIT EE approached significance in predicting children s selfreported depressive symptoms. However, only maternal depression (both history and current symptoms) was associated with mothers reports of internalizing symptoms on the CBCL. When predicting externalizing symptoms and total problems on the CBCL, both maternal depression history and maternal EE were, not surprisingly, associated with maternal reports of a range of child symptoms, including both internalizing and externalizing dimensions. Indeed, maternal EE may reflect a response to children s emotional/behavioral symptoms. Alternatively, and/or perhaps concurrently, maternal EE may fuel both internalizing and externalizing symptoms in youth. It should also be noted that maternal depression may lead to an increased likelihood of endorsing symptoms on the CBCL, as depression may lead to more negative perceptions. However, maternal depression history was only associated with higher CBCL externalizing symptoms and not total problems or internalizing symptoms. Thus, in this sample, mothers with a maternal depression history were not more likely to see their offspring as more generally symptomatic. On the other hand, current maternal depressive symptoms were associated with higher ratings on all CBCL scales. In this sample, 13% (n=22) of the youth met criteria for depression-spectrum disorders. This rate is somewhat higher than those reflected in epidemiologic studies of children during the preadolescent period of development, which report rates of depressive disorders around 3 4% (Costello et al. 1996; Kessler and Walters 1998). However, our study included a high-risk sample. Consistent with epidemiologic studies (Costello et al. 1996; Kessler and Walters 1998), the rate of depression-spectrum disorders among youth of mothers without a history of depression in the current sample was 5%. Similarly, paralleling other depression high-risk studies (Wickramaratne and Weissman 1998; Hammen et al. 1990; Beardslee et al. 1993), the rate of depression-spectrum disorders among youth of mothers with a history of depression in this sample was 24%. Maternal depression history was significantly associated cross-sectionally with child depression-spectrum diagnoses. However, in contrast to significant associations found between EE and child symptomatology, EE was not significantly associated with child diagnoses. The FMSS EE measure has been criticized as an insufficiently sensitive measure in comparison to the more traditionally used Camberwell Family Interview as an indicator of Expressed Emotion (Hooley and Parker 2006), and it has been further suggested that cases rated as borderline critical on the FMSS should be included in the high EE group. Indeed, our data suggest that both maternal depression history and the broader CRIT EE group (including both high and borderline critical EE) were highly significant predictors of child depression-spectrum diagnoses. Perhaps, preadolescent youth may be sensitive to more subtle maternal communications of dissatisfaction than are captured by the more restrictive high CRIT EE rating on the FMSS. Interestingly, maternal depression history was not significantly associated with this broader CRIT EE group. Earlier findings with clinically depressed youth indicate maternal EE, and maternal CRIT EE in particular, may be associated with depression outcomes in youth (Asarnow et al. 1993; McCleary and Sanford 2002). However, the current study suggests that lower levels of maternal negativity, as reflected in the combined borderline and critical EE group, may also be associated with increased child depressive symptoms and disorders.