Improvements in Maternal Depression as a Mediator of Child Behaviour Change

doi:10.4236/psych.2012.329120

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Psychology

2012. Vol.3, Special Issue, 79 5-801

Published Online September 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.329120

Improvements in Maternal Depression as a Mediator of Child

Behaviour Change

Judy Hutchings1, Tracey Bywater2, Margiad Elen Williams1, Eleanor Lane1,

Christopher J. Whitaker3

1Centre for Evidence-Based Ea rly Intervention, Bangor University, Bangor, UK

2Institute for Effective Education, University of York, York, UK

3North Wales Organisation of Ran domised Controlled Trials in Health & Social Care, Bangor University,

Bangor, UK

Email: [email protected]

Received June 5th, 2012; revised July 8th, 2012; accepted August 2nd, 2012

Depression is a common and debilitating illness and there is a strong association between maternal de-

pression and childhood Conduct Disorder (CD). This paper examines the impact of maternal depression

on the outcome of treatment for the prevention of CD. Data from the Hutchings et al. (2007) Randomised

Controlled Trial (RCT) of a parenting programme for parents of high-risk three and four year olds are

used to explore the potential role of change in maternal depression as a mediator of child behaviour out-

come. The role of positive parenting as an additional mediator was also examined due to previous re-

search findings. Improvement in maternal depression was found to be a significant partial mediator of

improvement in child behaviour. Maternal depression continued to be a partial mediator when positive

parenting was included in the mediation model. Parenting interventions for the prevention of CD are more

likely to result in improved child behaviour when they also address the skill deficits known to be associ-

ated with maternal depression.

Keywords: Maternal Depression; Child Behaviour Problems; Parenting Intervention/Training; Mediator

Introduction

Maternal De pression and Childhood C onduct

Problems

There is substantial literature showing the co-occurrence of

maternal depression and Conduct Disorder (CD) in children

(Goodman et al., 2011; Gross, Shaw, & Moilanen, 2008). More

than 50% of mothers of children with CD have clinical levels of

depression (Alpern & Lyons-Ruth, 1993; Webster-Stratton &

Hammond, 1988; Hutchings, 1996) and among parents of older

CD children (aged eight and above) Hutchings et al. (2011)

found that 79% of 300 parents reported clinically significant

levels of depression.

Some evidence suggests that maternal depression is causal in

the development of CD (Patterson, 1982; Rutter, 1996). De-

pressed mothers exhibit low rates of praise and failure in moni-

toring their child’s behaviour, which are both associated with

the development of CD (Webster-Stratton & Herbert, 1994).

Even shortly after birth, coded videos of mother-infant interact-

tions show differences in behaviour between depressed and

non-depressed mothers (Field, 1995a, 1995b). Other research

suggests that problematic child behaviour can precipitate ma-

ternal depression, particularly if the child displays characteris-

tics that make parenting difficult, such as temperament prob-

lems and poor sleep patterns (Webster-Stratton & Spitzer, 1996).

There can also be external predictors for both conditions such

as socio-economic disadvantage that have been shown to be

independently associated with both problems (Silberg & Rutter,

2002; Mensah & Kiernan, 2010).

There are a number of skill deficits commonly associated

with depression that have also been shown independently to

describe parents of conduct problem children. These include

poor problem solving and inability to recall specific events. De-

pressed people display over-general rather than specific memo-

ries (Williams et al., 2007; Williams, 1996) and this has been

shown to be associated with poor problem solving (Evans, Wil-

liams, O’Loughlin, & Howells, 1992; Pollock & Williams,

2001; van Vreeswijk & Wilde, 2004). Wahler and colleagues

(Wahler & Dumas, 1989; Wahler & Sansbury, 1990), and Mc-

Mahon & Frick (2005), found that, while mothers of children

with CD tended to focus on their children’s deviant behaviours,

their descriptions of behaviour were lacking in detail and over-

general. Similarly, Hutchings et al. (1998) found that, compared

to a non-referred sample, mothers of children referred to a child

and adult mental health service with behavioural problems had

significantly lower ability to recall specific events in relation to

their child’s life.

Parents of children with CD and depressed individuals also

both show insensitivity to the cues of others and have poor

observation skills (Cummings & Davies, 1994; Meunier, 2007).

Hutchings, Smith, and Gilbert (2000) showed that their meas-

ures of maternal observational style, autobiographical memory,

and parental problem solving were highly correlated and dif-

ferentiated well between the parents of children referred for

treatment of CD and parents of non-referred children.

Studies for the Treatment and Prevention of CD

Intervention programmes that have been most effective with

parents of children with CD address skill deficits that are com-

J. HUTCHINGS ET AL.

mon in this population (Hutchings, Gardner, & Lane, 2005). In

a review of parenting programmes, Barlow, Coren, and Stew-

art-Brown (2009) found them to be effective at improving both

child behaviour and a range of parental factors, including ma-

ternal depression, anxiety, and self-esteem. While some studies

have found that maternal depression can predict poor outcomes

for interventions to address CD (Beauchaine, Webster-Stratton,

& Reid, 2005; Forehand, Furey, & McMahon, 1984; Hinshaw,

2002) others have demonstrated that not only can gains be

made for the child, despite maternal depression, but also that

the depression itself improves significantly as a result of parent

training (Hutchings, Appleton, Smith, Lane, & Nash, 2002;

Hutchings et al., 2007; Hutchings, Lane, & Kelly, 2004). In one

of the few studies to provide long-term data, Hutchings et al.

(2002, 2004) compared the results of providing standard Child

and Adolescent Mental Health Service (CAMHS) management

advice with an intensive treatment programme involving coach-

ing and rehearsing parents in relevant skills and incorporated

observational skills training and realistic goal setting. While the

CAMHS treatment resulted in short-term improvements in

child behaviour, it did not impact on maternal mental health

and the improvements in child behaviour were not maintained

beyond the six-month follow-up. By contrast, the intensive

treatment group significantly improved both child behaviour

and maternal mental health at six months and these improve-

ments were both still significantly better at a four-year follow

up compared to baseline. Hutchings, Lane et al. (2004) suggest

that the long-term improvements were due to the intensive

treatment’s focus on helping parents to learn and practice effec-

tive observation and problem solving skills as well as specific

child management strategies. They concluded that for parents

experiencing depression, without improvement of maternal

depression, the benefits of parenting interventions may not be

sustained.

Maternal depression may be a mediating variable between

intervention and child behaviour. That is, some, or all, of the

effect of the intervention on child behaviour may be a result of

a change in maternal depression. The identification of mediat-

ing variables is important in gaining a better understanding of

how parent programmes work, so that, in developing and im-

proving interventions, special attention can be given to factors

shown to have a significant effect on outcome (Laurenceau,

Hayes, & Feldman, 2007; Goodman et al., 2011).

The aim of this study is to examine the potential mediating

effect of maternal depression on the outcome of a parent pro-

gramme to reduce child behaviour problems using data from a

Randomised Controlled Trial (RCT) of the Incredible Years (IY)

Parent programme (Hutchings et al., 2007). In a recent evalua-

tion of the IY Parent programme delivered as a preventive in-

tervention to parents of children at risk of developing CD, sig-

nificant improvements in parental depression, parenting skills

and child behaviour were found at the six-month follow-up (see

Table 1) (Hutchings et al., 2007). Improvements in parental de-

pression, parenting skills, and child behaviour were maintained

at 12-month and 18-month follow-up (Bywater et al., 2009).

Additionally, a similar study using the same data set found that

observed positive parenting partially mediated the relationship

between intervention status and child behaviour problems,

therefore this study aims to investigate whether maternal de-

pression and positive parenting are joint mediators.

Method

Participants

The RCT was conducted in 11 Sure Start areas in north and mid

Wales. These areas had been identified by Local Authorities as

having high levels of social and economical disadvantage and

received government funding to support services for children

under five years of age. Baseline characteristics of the children

in the sample are presented in Table 2.

One hundred and fifty three children and their primary care-

givers were recruited to the trial and were randomised on a 2:1

basis to intervention or waiting list control conditions. Health

visitors administered the Eyberg Child Behaviour Inventory

(ECBI: Robinson, Eyberg, & Ross, 1980) to parents of pre-

school children aged between 36 and 59 months. The ECBI

measures levels of child behaviour problems. Participants were

eligible if the child scored above the clinical cut-off on the

ECBI problem or intensity scale, lived with the primary care-

giver and the caregiver was able to attend an IY parenting

group (Hutchings et al., 2007).

Intervention

The participating caregivers attended 12 weekly group ses-

sions lasting 2 to 2.5 hours per week. The IY BASIC Parent

programme (Webster-Stratton & Hancock, 1998) was delivered

to each group by two trained leaders. Control families were

offered the programme after the six-month follow-up.

Measures

The following measures were collected for the original

evaluation during two home visits at each time point, at base-

line and one at six-month follow up, by which time the inter-

vention parents had received the programme. All measures are

standardized measures typically used in the evaluation of par-

enting interventions. Full details of all measures, scoring, ra-

tionale for use, normative data, reliability and validity can be

seen in the protocol of measures (Hutch i n g s , E a de et al., 2004).

Measures of Child Problem Behaviour

The Eyberg Child Behaviour Inventory (ECBI; Robinson et

al., 1980). A 36-item inventory of child behaviours measured

on two scales: a 7-point intensity scale and a Yes/No scale of

whether the behaviour is viewed as a problem. The Yes/No

problem scale was used for data analysis in this study. The

ECBI demonstrates good stability and homogeneity, with reli-

ability coefficients from .86 (test-retest) to .98 (internal consis-

tency). The scale has also shown good convergent validity, with

ECBI scores being significantly correlated with scores on the

Child Behaviour Check List (CBCL; Achenbach & Edelbrock,

Table 1.

Baseline and six-month follow- u p measures.

Intervention (n = 86)

Mean (SD) Control (n = 47)

Mean (SD)

Measure Baseline F-up Baseline F-up

ECBI-problem score16.6 (6.9)9.5 (7.9)*** 14.7 (7.7) 13.7 (8.3)

BDI-II 17.7 (10.8)10.3 (10.2)*** 15.0 (9. 7) 13.7 (10.3)

Positive parenting§23.0 (19.3)32.4 (19.3)** 21. 9 (15.4)21.7 (16.8)

Note: §Frequency count in 30 minutes; **p < .01, ***p < .001, results of paired t

tests to compare baseline and follow-up scores.

796

J. HUTCHINGS ET AL.

1983) and the Parenting Stress Index (PSI; Abidin, 1995).

Measures of Maternal Depression

The Beck Depression Inventory II (BDI-II; Beck et al., 1961).

A 21-item inventory measuring the severity, on a scale of 0 to 3,

of symptoms associated with depression. The BDI-II demon-

strates high internal consistency with a mean coefficient alpha

of .92 reported for psychiatric groups and .93 for college stu-

dents (Beck, Steer, & Brown, 1996). The test-retest reliability

correlation is .93. Various types of analysis were used to esti-

mate the convergent validity of the BDI-II. The correlation

between the BDI-II and BDI-I was .93 (p < .001).

Observational Measure

The Dyadic Parent-Child Interaction Coding System (DPICS;

Eyberg & Robinson, 1981) was used to code positive parenting

behaviour in a 30-minute home observation. Observers were

blind to group allocation and inter-reliability was tested and

maintained through regular training. The DPICS has shown

good reliability with mean reliability between raters of .91 for

parent behaviours and .92 for child behaviours. Kappa coeffi-

cients for the current study showed high reliability amongst

raters (an average of  = .91 over the two time points) on 20%

of the total visits. The discriminant validity of the DPICS has

been established through a number of studies (e.g. Eyberg &

Matarazzo, 1980).

Statistical Procedure

Since the hypothesis concerns maternal depression, data for

fathers was not included in the analysis. Complete data (both

baseline and six-month follow-up) from 130 mothers and their

children was available for analysis. Of these families, 85 took

part in the intervention and 45 were waiting-list control fami li e s.

Control families were offered the IY Parent programme after

the six-month follow-up visit had been completed. Fifty-seven

(44%) mothers were in the clinical range for depression at

baseline.

Mediator Analysis

To examine the effect of the mediator variable a series of re-

gression analyses were conducted using SPSS 17.0. A total of

four regression parameters were estimated as described by

Baron and Kenny (1986): 1) the parameter for the mediator

regressed on the predictor variable; 2) the parameter for the

mediator regressed on the outcome variable; 3) the parameter

for the outcome variable regressed on the predictor variable;

and 4) the parameter representing the indirect effect of the pre-

dictor on the outcome via the mediator. Bootstrap procedures

described by Preacher and Hayes (2008) was used to estimate

the indirect effect of intervention status on change in child be-

haviour due to the small sample size (Preacher & Hayes, 2004,

2008). It is also the recommended procedure for testing media-

tion models in developmental psychology (Dearing & Hamilton,

2006). The reported results are based on 5000 bootstrap sam-

ples and both child age and child gender were included as co-

variates. Change scores were calculated using simple subtract-

tion, such that a higher change score represents greater im-

provement in the desired therapeutic direction. Using change

scores ensures that baseline levels of positive parenting and

maternal depression are controlled for in the analysis and has

been used in similar mediation analyses (e.g. Gardner et al.,

2007, 2010).

Results

Simple Mediation Model

Figure 1 shows a schematic of the simple mediation model

in which change in maternal depression is a proposed mediator

of the relationship between intervention status and changes in

child behaviour. Results of the mediation analysis using boot-

strap procedures are displayed in Table 3.

Results show that the indirect effect of maternal depression

was significant (b = 3.89, p = .011). Bias corrected and acceler-

ated (BCa) confidence intervals (CI) indicate that maternal

depression is a partial mediator of the relationship between in-

tervention status and child behaviour since the CI do not cross

zero.

Multiple Mediation Model

Since previous research has shown improvements in positive

parenting to mediate the relationship between intervention

status and child behaviour problems (see Gardner et al., 2010;

Figure 1.

Simple mediation model of the effect of intervention status on child

behaviour through maternal depression (controlling for child age and

gender).

Table 2.

Characteristics of the families in the sample at baseline.

No follow-up*

Intervention

n = 86 Control

n = 47 Intervention

n = 18 Control

n = 2

No. (%) of boys 49 (57) 31 (66) 7 (39) 29(100)

No. (%) Welsh speaking10 (12) 9 (19) 3 (17) 0(0)

Child age in months (SD)46.4 (6.6) 46.2 (4.2) 43.9 (4.8)52 (1.4)

No. (%) single parent 38 (44) 16 (34) 9 (50) 1 (50)

Total weekly income <

£64/person 76 (88) 42 (89) 17 (94) 2 (100)

Mean (SD) age of mother

at birth of first child 21.4 (5.0) 20.5 (4.2) 21.4 (4.4)17 (0)

Scores (SD):

Conduct problems (EC BI)16.5 (7.0) 14.8 (7.7) 15.7(5. 1)28 (4.2)

Hyperactivity (SDQ) 6.2 (2.7)6.9 (2.2) 5.9(1.9)8.5 (.7)

Self Control (SCRS) 127.9 (29.8) 130.2 (27.7) 119. 2(24.2)130.5 (27.6)

Note: *A two sample t test found no significant differences between int ervention

families who remained in the study and those lost to follow up. This was not

tested for control families; ECBI = Eyberg child behaviour inventory; SDQ =

Strengths and Difficulties Questionnaire; SCRS = Self-control rating scale.

J. HUTCHINGS ET AL.

Shaw et al., 2009), a multiple mediator analysis, using macros

written by Preacher and Hayes (2008), was conducted to ex-

amine whether both maternal depression and positive parenting

are mediators. Figure 2 shows the schematic of the multiple

mediator model in which both maternal depression and positive

parenting skills were proposed to mediate the relation ship betwe en

intervention status and change in child behaviour. The total

indirect effect for both proposed mediators was significant with

BCa CI of 1.05 - 4.20, indicating that both maternal depression

and positive parenting skills mediated the relationship between

intervention status and change in child behaviour (see Table 3).

The specific indirect effect of each mediator was 1.57

through maternal depression and .60 through positive parenting.

Further examination of the specific contribution of each indirect

effect using BCa CI revealed that both are significant mediators

of the relationship between intervention status and change in

child behaviour (i.e. none of the CI cross zero). Maternal de-

pression seems to be the stronger mediator however contrasts

revealed no significant difference between the two mediators

since the CI crosses zero (Table 3).

Figure 2.

Multiple mediation model of the effect of intervention status on child

behaviour through maternal depression and positive parenting (control-

ling for child age and gender).

Table 3.

Mediation of the relationship between intervention status and child

behaviour through maternal depression and observed positive parent-

ing.

Bootstrap BCa 95% CI

Point

Estimate S.E. z LowerUpper

Model summary for maternal depression

Maternal Depression 1.6980 .6683 2.5405 .6056 3.5027

Model summary for maternal depression/positive parenting

Total 2.1631 .7651 2.8275** 1.05434.2017

Maternal Depression 1.5669 .6512 2.4062* .5850 3.3099

Positive Parenting .5963 .3899 1.5292 . 0591 2.0297

Contrast

MD vs. PP 1.0119 .7409 1.3658 –.52952.8889

Note: *p < .05; **p < .01. BCa, bias corrected and accelerated; MD, maternal

depression; PP, positive parenting. Estimates based on 5000 bootstrap samples.

Discussion

The first aim of this study was to establish whether im-

provements in maternal depression mediate improvements in

child behaviour following attendance on an IY Parent pro-

gramme. Results using a simple mediation model showed that

maternal depression was a partial mediator of the relationship

between intervention status and improved child behaviour. The

second aim of this study was to examine whether both maternal

depression and positive parenting together mediate this rela-

tionship. A multiple mediator analysis was conducted showing

that both variables were partial mediators with no significant

difference between their specific contributions to the indirect

effect.

These findings are important as they add to our understand-

ing of the mechanisms operating when child behaviour im-

proves as a result of parent training. Identifying mediators is

necessary if we are to understand the active ingredients of

treatment. These results extend previous findings by Gardner et

al. (2010) who found that an increase in observed positive par-

enting behaviour was a partial mediator for improved child

behaviour. The present findings suggest that both change in the

practice of positive parenting and change in maternal depres-

sion are key factors mediating change in child problem behav-

iour.

One explanation for why improvements in maternal depres-

sion were seen in mothers who attended a parent programme

dealing with their childrens’ behaviour problems is that im-

proving parents’ skills increases their confidence, which in turn

improves their mental health. DeGarmo et al. (2004) found that

improvements in parenting skills were followed by improve-

ments in child behaviour and which were subsequently fol-

lowed by improvements in maternal depression. Shaw et al.

(2009) found that maternal depression was a significant media-

tor of the relationship between a toddler intervention and child

behaviour problems when accounting for the effects of positive

parenting. The results of the current study corroborate these

findings.

The IY parent programme includes components and strate-

gies that promote effective parenting by addressing specific

skill deficits. Parents are taught accurate observation skills, goal

setting and problem solving skills, which are known to be defi-

cient in parents experiencing depression. It also provides the

opportunity for these skills to be practiced and reinforced, ini-

tially in group-based practice and subsequently by success in

home activities with children (Hut c h i n g s e t a l ., 2005).

Gaining experience of using new skills with success is par-

ticularly important for depressed parents. Early functional ac-

counts of depression such as those posited by Fester (1973) and

Seligman (1975) reasoned that a depressed individual’s inabil-

ity to deal with problems was due to the failure of past efforts

to be rewarded. Fester described the behavioural patterns that

characterised depression, as a low rate of positively reinforced

behaviours and a high rate of escape and av oida nce f rom st ress-

ful situations. These ideas were developed by Seligman in his

“learned helplessness” theory of depression (1975). His re-

search with animals and humans lead him to conclude that

when repeatedly confronted by situations that are outside their

control, people cease trying to do things that could potentially

improve their situation. As a reduction in activity reduces op-

portunities for their actions to be reinforced by success, it

serves to maintain feelings of helplessness and depression.

798

J. HUTCHINGS ET AL.

Seligman (1975) suggested that “forced” exposure to success

was the most effective strategy to overcome learned helpless-

ness. The group based rehearsal and training for home activities

encouraged in the IY programme may be doing just that. The

emphasis on teaching observation, problem solving and realistic

goal setting skills and rehearsal of these new skills increases the

likelihood that the new behaviours will be reinforced by their

success. This also impacts on parental depression, giving par-

ents more confidence in their parenting abilities and their abil-

ity to manage other aspects of their life. In the present study, 25

(61%) of the intervention parents who scored in the clinical

range on the BDI-II at baseline, moved to the non-clinical range

at follow-up. This compared with five (31%) of those in the

control group.

It is likely that the extent to which the skill deficits are ad-

dressed contributes to the varying outcomes in both child be-

haviour and maternal depression that are reported in the litera-

ture. While some studies have found maternal depression to

predict poor intervention outcome, almost 30 years of research

of the IY programme using high quality RCT trials, has consis-

tently demonstrated significant improvements in both parental

mental health and outcomes for children. Evidence also sug-

gests that improvements in child behaviour are more likely to

be maintained over time when there are also improvements in

maternal mental health (Hutchings, Lane et al. 2004). The find-

ings of the present study add to the evidence that the aspects of

the IY programme (training in observation skills, rehearsal and

problem solving) that are also likely to impact on maternal

mental health are important ingredients in improving child be-

haviour.

An alternative explanation for the improvements in maternal

depression could be that the increased social support and access

to a trained group facilitator lead to improvement in maternal

mood. All the parents who attended the groups had children

who scored above the clinical cut-off for behaviour problems

and were considered to be socially disadvantaged based on

number of risk factors (e.g. single parents, teenage parents,

family poverty, history of drug/alcohol abuse, etc.). It is possi-

ble that having access to a group of people with similar chal-

lenges meant that parents no longer felt alone. Also having

access to a trained professional to help with their children’s

challenging behaviour may have lessened depressive symptoms

and enabled parents to feel more in control of their lives. Sev-

eral studies have found associations between poor maternal

mental health and low social support (Sheppard, 1994, 1997,

2009). However there are many parent programmes that report

that depressed people do less well in addressing child behaviour

problems so the evidence suggests that it is the specific com-

ponents of the IY programme described above that result in the

changes found (Gardner et al., 2006; Hutchings et al., 2007).

Limitations of the Study

One limitation of this study concerns the use of parent-report

for both child behaviour problems and maternal depressive

symptoms. It is possible that the improvement in maternal de-

pression changed mother’s view of their own parenting prac-

tices, their child’s behaviour and their impression that their

child’s behaviour was a problem. Previous research has found

larger effect sizes for studies that relied on mother-report of

child externalizing problems compared to child self-report,

others’ reports, or independent observations (Goodman et al.,

2011). However, a number of studies have shown the ECBI

parent report measure to correlate significantly with independ-

ent observation of child behaviour (Webster-Stratton, 1985;

Webster-Stratton & Hammond, 1998; Webster-Stratton & Lind-

say, 1999). Nevertheless, it is important for future research to

include objective measures of both child behaviour and mater-

nal depression.

Another limitation is that, due to the design of this trial, tem-

poral precedence for the mediators was not established. Both

mediators (maternal depression and positive parenting) and the

outcome variable (child behaviour) were assessed at the same

time point meaning that it is not possible to see whether these

potential mediators are actual causal agents or covariates of

change (Laurenceau et al., 2007). Future research using a more

appropriate design including several measurement time points

for both child behaviour and maternal depression would solve

this problem.

Conclusion

The co-occurrence of maternal depression and child conduct

problems is well established. While this may be explained by a

number of causal pathways, the findings of this mediator analy-

sis show that improvements in child behaviour following the

programme were partially but significantly mediated by im-

provements in maternal depression. Findings also showed that

both maternal depression and positive parenting together were

mediators of intervention status on child behaviour. This sug-

gests that, for interventions to be effective in reducing child

conduct problems, they need to emphasise those aspects of the

programme that are also likely to impact on maternal depres-

sion such as the training in specific observation, problem solv-

ing, realistic goal setting skills and rehearsal of effective be-

haviours, thereby contributing to i mprovement in, and the longer

term maintenance of, improvements in child behaviour.

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