RUNNING HEAD: EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
1
Abstract
Objective: This study focused on whether a brief family-based intervention for toddlers, the Family
Check-Up (FCU), designed to address parent management skills and prevent early conduct
problems, would have collateral effects on maternal depressive symptoms and subsequent child
emotional problems. Method: Parents with toddlers were recruited from the Women, Infants, and
Children Nutritional Supplement Program based on the presence of socioeconomic, family, and child
risk (N= 731). Families were randomly assigned to the FCU intervention or control group with yearly
assessments beginning at child age 2. Maternal depressive symptoms were measured using the
Center for Epidemiological Studies Depression Scale at child ages 2 and 3. Child internalizing
problems were collected from primary caregivers, alternative caregivers, and teachers using the Child
Behavior Checklist at ages 7.5 and 8.5. Results: Structural equation models revealed that mothers in
families randomly assigned to the FCU showed improvements in depressive symptoms from child
age 2 to 3, which in turn were related to lower levels of child depressed/withdrawal symptoms as
reported by primary caregivers, alternative caregivers, and teacher at ages 7.5-8.5. Conclusions:
Findings suggest that a brief, preventive intervention improving maternal depressive symptoms can
have enduring effects on child emotional problems that are generalizable across contexts. As there is
a growing emphasis for the use of evidence-based and cost-efficient interventions that can be
delivered in multiple delivery settings serving low-income families and their children, clinicians and
researchers welcome evidence that interventions can promote change in multiple problem areas. The
FCU appears to hold such promise.
Keywords: maternal depressive symptoms; child emotional problems; Family Check-Up; parenting
intervention
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
Public Health Significance: This study suggests that a brief, home-based, preventive intervention
such as the Family Check-Up can have meaningful long-term effects on children’s emerging
emotional problems. Although initially designed to improve children’s conduct problems by
improving parenting practices, in the current study the Family Check-Up contributed to both
improvements in maternal depressive symptoms during the toddler years and subsequent reductions
in school-age emotional problems.
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EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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Introduction
Maternal depression is among the most robust and well-replicated risk factors for depressionspecific and more general psychopathological symptoms in offspring (Goodman et al., 2011).
Maternal depression during early childhood has been linked to greater risk for concurrent (Murray &
Cooper, 1997; Weinberg & Tronick, 1998) and long-term (Luoma et al., 2001) emotional problems.
However, only a few studies have been carried out among school-age children and longitudinal
studies spanning from early to middle childhood are even rarer (Bagner, Pettit, Lewinsohn, Seeley, &
Jaccard, 2013; Luoma et al., 2001). Further research is needed to explore the association between
early exposure to maternal depression and children’s long-term risk for emotional problems during
the school-age period.
There is an established literature on the effectiveness of parenting interventions aimed at
preventing emotional and behavioral problems in early childhood (Baydar, Reid, & WebsterStratton, 2003; Olds, 2002). An example of a successful parenting intervention of this type is the
Family Check-Up (FCU). The FCU is a family intervention and treatment designed to improve
children’s adjustment across settings by motivating parents to address family management practices.
The FCU was originally designed to address early child conduct problems, but has been shown to
have positive collateral effects on inhibitory control and verbal skills (Lunkenheimer et al., 2008) and
emotional problems in early childhood (Shaw, Connell, Dishion, Wilson, & Gardner, 2009).
Parenting-focused interventions such as the FCU might facilitate collateral child outcomes by
improving maternal well-being. Several theorists have noted how maternal depression might
compromise a parent’s ability to be contingently responsive and actively engaged to their children’s
socioemotional needs (Belsky, 1984). In one of the few studies to examine maternal depression as a
mediator of intervention effects, Hutchings, Bywater, Williams, Lane, and Whitaker (2012) found
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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that improvements in maternal depressive symptoms mediated improvements in child behavior
following attendance in the Incredible Years Parenting program. However, the sole reliance on
maternal reports for reporting of both maternal depression and later child problem behavior may have
inflated associations because of reporting bias.
The current study was conducted to determine if the FCU would be directly or indirectly
associated with lower levels of school-age emotional problems by improving maternal depressive
symptoms in early childhood. Early childhood (ages 2 and 3) is a sensitive period of vulnerability to
effects of maternal depression and a critical phase in which to examine its interplay with child
emotional problems. Additionally, child’s adaptation to the demands of school represents an
important area of investigation, as successful adjustment in these early school years is associated
with avoidance of psychosocial problems in adulthood, such as drug and alcohol use disorders (Crum
et al., 2006; Fothergill et al., 2008). We hypothesized that there would only be a modest direct effect
of the intervention on school-age emotional problems, but an indirect effect on children’s school-age
emotional problems for those mothers showing an improvement in depressive symptoms. To extend
the methodological rigor of past research ((Barker, Copeland, Maughan, Jaffee, & Uher, 2012;
Hutchings et al., 2012), the two hypotheses were tested using three informants of child behavior and
two different contexts when children were in middle childhood.
Methods
Participants
Participants included 731 mother–child dyads recruited between 2002 and 2003 from WIC
programs in the areas of Pittsburgh, PA, Eugene, OR, and Charlottesville, VA (Dishion et al., 2008).
Families were approached at WIC sites and invited to participate if they had a son or daughter
between 2 years 0 months and 2 years 11 months of age, following a screen to ensure that they met
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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the study criteria by having socioeconomic, family, and/or child risk factors for future behavior
problems. Two or more of the three risk factors were required for inclusion in the sample. The flow
of participants through the recruitment and randomization procedures is shown in Figure 1.
Retention
Of the original 731 families, 659 (90%), 629 (86%), 622 (85%), 568 (78%), and 565 (77%)
participated at the follow-up at ages 3, 4, 5, 7.5, and 8.5 respectively. Selective attrition analyses
revealed no significant differences in attrition by project site, children’s race, ethnicity, income,
gender, children’s emotional problems, or intervention status.
Procedures
Home observation assessment protocol. Caregivers (i.e., predominantly mothers and, if
available, alternative caregivers, such as fathers or grandmothers) and children who agreed to
participate in the study were scheduled for a 2.5-hour home visit. During the assessment, caregivers
completed questionnaires and children engaged in a series of structured tasks with their parents or the
examiner. Similar procedures were repeated at ages 3, 4, 5, 7.5, and 8.5, with modifications made to
adjust for the child’s developmental status. For purposes of the current study, data from the ages 2, 3,
7.5, and 8.5 assessments were used.
The Family Check-Up in the current study. The intervention model used in this study is
the Family Check-Up (FCU), a brief, ecologically-based program based on motivation interviewing
techniques (also see Dishion et al., 2008). The key components of the FCU that differentiate it from
standard clinical care are: it (a) utilizes a health maintenance model, (b) derives much of its power
from a comprehensive assessment, and (c) emphasizes motivating change.
Following the initial assessment at age 2, primary caregivers and the target child were
randomly assigned to the intervention condition (n = 367, 50.2%) assessments using a computer-
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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generated sequence. Randomization was balanced by gender to assign an equal number of boys and
girls in each group. Those in the control condition received WIC services (e.g., food vouchers) but no
intervention from therapists. Primary caregivers assigned to the FCU were scheduled to meet with a
parent consultant for two or more sessions, depending on the family’s preference. The three meetings
in which the primary caregiver and/or alternate caregiver were typically involved include an
assessment meeting, an initial contact meeting, and a feedback session. Families assigned to the
FCU received a $25 gift certificate for completing the feedback session.
Measures
Demographics questionnaire. A demographics questionnaire was administered to the
mothers during the age 2, 3, 4, 5, 7.5, and 8.5 visits. For purposes of the present study, we used data
on parent income, parent education, project site, and child gender collected at age 2 as covariates.
Maternal depressive symptoms. The CES-D (Radloff, 1977) is a 20-item measure of
depressive symptomatology that was administered at each assessment. For purposes of the current
study, CES-D reports were used from the age 2 and 3 home assessments. Participants report how
frequently they have experienced a list of depressive symptoms during the past week on a scale
ranging from 0 (less than a day) to 3 (5–7 days). For the current sample, internal consistencies were
.76 and .75 at the respective age 2 and 3 assessments.
Child emotional problems at home. The CBCL is a 120 item parent questionnaire for
assessing emotional and behavioral problems in 4- to 18-year-olds (Achenbach & Rescorla, 2001).
Primary caregivers (PC) and alternative caregivers (AC) completed the CBCL at the age 7.5 and 8.5
assessments. For the purposes of the current study, the 9-item depressed/withdrawn subscale was
used in the analysis to measure child emotional problems at home. The internal consistency for PC
ratings was .77 and .76 at ages 7.5 and 8.5, respectively.
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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Child emotional problems at school. To measure teacher-reported child emotional
problems in the classroom, the depressed/withdrawn factor from the Teacher Report Form (TRF;
Achenbach & Rescorla, 2001) was used. The TRF was administered to the primary teacher of study
participants at ages 7.5 and 8.5. For the purposes of the current study, a very similar 8-item
depressed/withdrawn subscale utilized with parents was used in the analysis. Internal consistency for
the 8-item scale was .80 and .79 at ages 7.5 and 8.5, respectively.
Missing Data. Among the 731 participants included in the analysis, 17.1% had missing data
on primary caregiver reports of child internalizing problems (22.9% at age 7 and 24.4% at age 8),
30.2% on alternative caregiver reports of child internalizing problems (41.8% at age 7 and 43.5% at
age 8), and 38% on teacher reports of child internalizing problems (57.4% at age 7 and 48.6% at age
8). Missingness on these variables was not associated with the values of other study variables or each
other, and Little’s MCAR test yielded a nonsignificant chi-square statistic (χ2(91)=97.367, ns), which
suggests that these data were missing at random. Because of these high levels of missing teacher
reports, either report was used as the outcome when only one age teacher report was available. A
mean of the two scores was used when data were available at both time points. To remain consistent
across reporters, this approach was used for primary caregiver, alternative caregiver, and teacher
reports and yielded 609 (83%), 512 (70%), and 451 available cases (62%), respectively.
Results
Analytic strategy
Structural equation modeling (SEM) was utilized using maximum likelihood estimation with
robust standard errors (MLR) in Mplus 7.11 (Muthén & Muthén, 2013). MLR is robust to
nonnormality and adjusts for missing data by estimating parameters of all available data for the
estimation of a specific parameter (Muthén & Muthén, 2013). A model was first computed to
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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examine whether random assignment to the FCU would be associated with lower levels of child
depressed/withdrawn symptoms. We included all three informants in the same model to account for
the overlapping effects among reporters. Next, we explored whether random assignment to the FCU
would be associated with lower levels of child depressed/withdrawn symptoms as reported by
primary caregivers, alternative caregivers, and teacher at ages 7.5-8.5 through improvements in
maternal depressive symptoms from child age 2 to 3. A statistical test of the significance of the
indirect effect from the intervention to the change in maternal symptoms to the level of child
depressed/withdrawn symptoms was examined. Standard errors for indirect effects were calculated
using the delta method described by MacKinnon and colleagues (Mackinnon, Lockwood, Hoffman,
West, & Sheets, 2002). Based on the project’s preventive nature, this study used an intent-to-treat
design in all analyses. Thus, all participants randomly assigned to either the treatment (n = 367) or
control group (n = 364), regardless of their level of participation in the intervention, were included in
the analyses. Covariates used in the analysis were parent income, parent education, project site
(Eugene, OR, served as the reference group), and child gender (female = 1).
Descriptive Statistics
Table 1 provides means, standard deviations, and inter-correlations for the study’s primary
variables. Correlations between variables were largely in the expected direction.
Direct effect of intervention on child emotional problems
Our first goal was to test the direct effect of the FCU intervention on child
depressed/withdrawn symptoms. As shown in the full model in Figure 2, intervention group status
was not significantly related to primary caregiver (β = -0.02, ns), alternative caregiver (β = 0.08, ns),
or teacher reports (β = 0.03, ns) of child depressed/withdrawn symptoms.
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
Indirect effect of FCU on child emotional problems through improvements in maternal
depressive symptoms
As previously reported in Shaw et al. (2009), mothers in the intervention group reported a
significantly greater decrease in depressive symptoms than control mothers (d = .18). Next, we
examined whether this reduction in maternal depressive symptoms was linked to improvements in
child depressed/withdrawn symptoms at ages 7.5 and 8.5. As shown in Figure 2, higher levels of
maternal depressive symptoms at age 3 predicted higher levels of child depressed/withdrawn
symptoms at 7.5 and 8.5, reported by primary caregivers (β= .21, p < .01). We next examined the
significance of the indirect effect from intervention to changes in maternal depressive symptoms to
child depressed/withdrawn symptoms. These analyses confirmed an indirect effect of the
intervention on child depressed/withdrawn symptoms through improvements in maternal depressive
symptoms (β= -.02, p < .05). κ2, an effect size measure for mediation models, was .058 suggesting a
small effect size (Preacher & Kelley, 2011).
Next, we examined the pathway from the intervention to changes in maternal depressive
symptoms to alternative caregivers’ and teacher reports of child depressed/withdrawn symptoms. In
both models, higher maternal depressive symptoms predicted higher levels of child
depressed/withdrawn symptoms at 7.5 and 8.5, reported by alternative caregivers (β= .13, p < .01)
and by teachers (β = .16, p < .01). Additionally, there was a significant indirect effect of the
intervention on alternative caregiver (β= -.01, p < .05; κ2 = .01) and teacher (β= -0.01, p < .05; κ2 =
.02) reports of child depressed/withdrawn symptoms via changes in maternal depressive symptoms.
Discussion
The present study examined whether reductions in maternal depressive symptoms serve as a
mediator of intervention effects on children’s school-age emotional problems. In accord with our
9
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
10
hypothesis, reduction in maternal depressive symptoms was a significant mediator of intervention
effects on child emotional problems, reported by primary caregivers, alternative caregivers, and
teachers. Although these effects were indirect, it is notable that a brief preventive intervention
contributed to both improvements in maternal depressive symptoms and reductions in child
emotional problems during a formative developmental period. We have now shown that improving
maternal depressive symptoms during the toddler period has positive consequences not only for
child’s short-term behavioral health, but also for the child’s longer-term functioning across context.
These results are also consistent with prior findings linking remission of maternal depressive
symptoms with reductions in children's depression, anxiety, and disruptive behavior diagnoses and
symptoms (Weissman, Pilowsky, Wickramaratne, & et al., 2006). Similarly, in a review of treatment
and observational studies of depressed parents, Gunlicks and Weissman (2008) found reductions in
parental depression to be consistently linked to improvement in child outcomes across study types.
It is noteworthy that although the FCU was originally designed to reduce children’s
disruptive behavior problems, in the current study collateral benefits were found for children’s
emotional problems. While there is a rather modest indirect effect, the small effect sizes are also
consistent with some previous reports on collateral outcomes (e.g., Shaw et al., 2009). Despite the
small effect sizes, multi-impact interventions for children with emotional problems may be especially
important based on the high rate of co-occurring psychopathology among children with either
conduct or emotional problems (Connell et al., 2008). In addition, the main findings could have
important implications for reducing the likelihood of enduring emotional problems and cascading
effects of internalizing problems into other domains of adjustment (Masten et al., 2005)
Although the current results are promising, the findings must be tempered with an
appreciation of study limitations. First, the study was originally designed to test the effect of the
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
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intervention for children with conduct problems. It is unknown whether these findings will generalize
to other samples of children or to children who have emotional problems without elevated conduct
problems. Second, there was considerable loss of teacher report data at two of the three sites.
However, an analysis of the participants with missing data on teacher ratings does not suggest
selective attrition. Lastly, it is possible that genetics play a role in both improvements in maternal
depressive symptoms as well as the development of child emotional problems. However, the current
study involved biologically-related family members, thereby limiting understanding of the role of
genetic and/or environmental underpinnings of maternal depression and child psychopathology.
Alternative designs, such as adoption and children of twin studies, have the potential to disentangle
environmental effects of parental depression from genetic influences.
Child emotional problems are a serious public health burden. A review of the evidence-base
of psychosocial treatment outcome studies for depressed youth concluded that cognitive-behavioral
therapy (CBT) is a well-established intervention approach for depressed children (David-Ferdon &
Kaslow, 2008). There has also been a growing emphasis for the use of evidence-based and costefficient interventions that can be delivered in multiple delivery settings and that can promote change
in multiple problem areas. The FCU appears to hold such promise and importantly in the current
study, was indirectly associated with improvements in children’s long-term emotional problems for
families that were not seeking treatment.
12
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
Table 1
Means, Standard Deviations, and Correlations Among Variables Used in Analyses
1.
Maternal Depressive Symptoms
(age 2)
2. Maternal Depressive Symptoms
(age 3)
3. Teacher Report of Child
Depressed/Withdrawn Symptoms
(age 7)
4. Teacher Report of Child
Depressed/Withdrawn Symptoms
(age 8)
5. PC Report of Child
Depressed/Withdrawn Symptoms
(age 7)
6. PC Report of Child
Depressed/Withdrawn Symptoms
(age 8)
7. AC Report of Child
Depressed/Withdrawn Symptoms
(age 7)
8. AC Report of Child
Depressed/Withdrawn Symptoms
(age 8)
Mean
SD
1.
-.42**
2.
3.
4.
5.
6.
.07
.19**
.03
.09
.35**
--
.16**
.19**
.23**
.30**
--
.17**
.23**
.16**
.28**
.63**
--
.13**
.14**
.11
.126*
.46**
.40**
--
.06
.14**
.25**
.25**
.44**
.47
.62**
57.95
8.13
57.30
7.71
56.98
7.82
16.75
10.66
8.
--
15.39
10.95
--
58.87
8.13
Note. t scores are provided in presenting descriptive statistics for the CBCL externalizing,
although raw scores were used for testing hypotheses in models to avoid potential age and
gender corrections. PC= primary caregiver; AC= alternative caregiver. * p < .05.
** p < .01.
7.
56.17
7.07
--
56.45
7.25
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
Figure 1. Participant Flow Chart
13
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
14
Figure 2. Indirect effect of Family Check-Up assignment on primary caregiver, alternative
caregiver, and teacher report of child internalizing behavior through improvements in maternal
depressive symptoms: χ2 (5) = 11.41, p = .04; comparative fit index = .97; root mean square error
of approximation =.04; standard root mean residual =.02. Covariates used in the analysis were
parent income, parent education, project site (Eugene, OR, served as the reference group), and child
gender (female = 1). Model estimates are standardized and provided for significant pathways
only. Nonsignificant modeled pathways are illustrated by gray dotted lines. * p < .05. ** p < .01.
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
15
References
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA School-age Forms &
Profiles: An Integrated System of Multi-informant Assessment: Research Center for
Children, Youth, & Families/Achenbach System of Empirically Based Assessment
(ASEBA).
Bagner, D. M., Pettit, J. W., Lewinsohn, P. M., Seeley, J. R., & Jaccard, J. (2013). Disentangling
the temporal relationship between parental depressive symptoms and early child behavior
problems: A transactional framework. Journal of Clinical Child & Adolescent
Psychology, 42, 78-90.
Barker, E. D., Copeland, W., Maughan, B., Jaffee, S. R., & Uher, R. (2012). Relative impact of
maternal depression and associated risk factors on offspring psychopathology. The
British Journal of Psychiatry, 200, 124-129. doi: 10.1192/bjp.bp.111.092346
Baydar, N., Reid, M. J., & Webster-Stratton, C. (2003). The role of mental health factors and
program engagement in the effectiveness of a preventive parenting program for Head
Start mothers. Child Development, 74, 1433-1453.
Belsky, J. (1984). The determinants of parenting: a process model. Child Development, 55, 8396.
Connell, A. M., Bullock, B. M., Dishion, T. J., Shaw, D., Wilson, M., & Gardner, F. (2008).
Family intervention effects on co-occurring early childhood behavioral and emotional
problems: a latent transition analysis approach. Journal of Abnormal Child Psychology,
36, 1211-1225. doi: 10.1007/s10802-008-9244-6
Crum, R. M., Juon, H. S., Green, K. M., Robertson, J., Fothergill, K., & Ensminger, M. (2006).
Educational achievement and early school behavior as predictors of alcohol-use
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
16
disorders: 35-year follow-up of the Woodlawn Study. Journal of Studies on Alcohol, 67,
75-85.
David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-Based Psychosocial Treatments for Child
and Adolescent Depression. Journal of Clinical Child and Adolescent Psychology, 37(1),
62-104. doi: 10.1080/15374410701817865
Dishion, T. J., Shaw, D., Connell, A. M., Gardner, F., Weaver, C., & Wilson, M. (2008). The
family check-up with high-risk indigent families: preventing problem behavior by
increasing parents' positive behavior support in early childhood. Child Development, 79,
1395-1414. doi: 10.1111/j.1467-8624.2008.01195.x
Fothergill, K. E., Ensminger, M. E., Green, K. M., Crum, R. M., Robertson, J., & Juon, H. S.
(2008). The impact of early school behavior and educational achievement on adult drug
use disorders: a prospective study. Drug and Alcohol Dependence, 92, 191-199.
Goodman, S. H., Rouse, M. H., Connell, A. M., Broth, M. R., Hall, C. M., & Heyward, D.
(2011). Maternal depression and child psychopathology: a meta-analytic review. Clinical
Child and Family Psychology Review, 14(1), 1-27. doi: 10.1007/s10567-010-0080-1
Hutchings, J., Bywater, T., Williams, M. E., Lane, E., & Whitaker, C. J. (2012). Improvements
in Maternal Depression as a Mediator of Child Behaviour Change. Psychology, 3, 795.
Lunkenheimer, E. S., Dishion, T. J., Shaw, D. S., Connell, A. M., Gardner, F., Wilson, M. N., &
Skuban, E. M. (2008). Collateral benefits of the Family Check-Up on early childhood
school readiness: indirect effects of parents' positive behavior support. Developmental
Psychology, 44, 1737-1752. doi: 10.1037/a0013858
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
17
Luoma, I., Tamminen, T., Kaukonen, P., Laippala, P., Puura, K., Salmelin, R., & Almqvist, F.
(2001). Longitudinal study of maternal depressive symptoms and child well-being.
Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1367-1374.
Mackinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A
comparison of methods to test mediation and other intervening variable effects.
Psychological Methods, 7, 83-104.
Masten, A. S., Roisman, G. I., Long, J. D., Burt, K. B., Obradović, J., Riley, J. R., . . . Tellegen,
A. (2005). Developmental cascades: linking academic achievement and externalizing and
internalizing symptoms over 20 years. Developmental Psychology, 41, 733.
Murray, L., & Cooper, P. (1997). Effects of postnatal depression on infant development.
Archives of disease in childhood, 77, 99-101.
Muthén, L. K., & Muthén, B. O. (2013). Mplus User's Guide: Statistical Analysis with Latent
Variables : User's Guide (Version 7.11): Muthén & Muthén.
Olds, D. L. (2002). Prenatal and infancy home visiting by nurses: From randomized trials to
community replication. Prevention Science, 3, 153-172.
Preacher, K. J., & Kelley, K. (2011). Effect size measures for mediation models: quantitative
strategies for communicating indirect effects. Psychological Methods, 16, 93.
Radloff, L. S. (1977). The CES-D Scale: A Self-Report Depression Scale for Research in the
General Population. Applied Psychological Measurement, 1, 385-401.
Shaw, D. S., Connell, A. M., Dishion, T. J., Wilson, M. N., & Gardner, F. (2009). Improvements
in maternal depression as a mediator of intervention effects on early childhood problem
behavior. Development and Psychopathology, 21, 417-439.
EFFECT OF MATERNAL DEPRESSIVE SYMPTOMS ON CHILD INTERNALIZING
18
Weinberg, M. K., & Tronick, E. Z. (1998). The impact of maternal psychiatric illness on infant
development. The Journal of Clinical Psychiatry, 59 Suppl 2, 53-61.
Weissman, M. M., Pilowsky, D. J., Wickramaratne, P. J., & et al. (2006). Remissions in maternal
depression and child psychopathology: A star*d-child report. JAMA, 295(12), 1389-1398.