4
Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning

SUMMARY

Parenting Practices

  • Depression is significantly associated with more hostile, negative parenting, and with more disengaged (withdrawn) parenting, both with a moderate effect size. Findings are primarily related to mothers rather than to fathers.

  • Depression in mothers is significantly associated with less positive parenting (warmth), with a small effect size. Findings are primarily related to mothers rather than to fathers.

  • The poorer parenting qualities may not improve to levels comparable to those of never-depressed parents, despite remission or recovery from episodes of depression.

  • These patterns of parenting have been found in depressed mothers of infants and young children as well as in depressed mothers of school-age children and adolescents.

  • Less is known about parenting in depressed fathers relative to mothers, but most of the findings from the smaller number of studies are consistent with the findings about mothers.

Child Functioning

  • Depression in parents is associated with children’s poorer physical health and well-being. Infants and young children of mothers with



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4 Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning SUMMARY Parenting Practices • Depression is significantly associated with more hostile, negative parenting, and with more disengaged (withdrawn) parenting, both with a moderate effect size. Findings are primarily related to moth- ers rather than to fathers. • Depression in mothers is significantly associated with less positive parenting (warmth), with a small effect size. Findings are primarily related to mothers rather than to fathers. • The poorer parenting qualities may not improve to levels com- parable to those of never-depressed parents, despite remission or recovery from episodes of depression. • These patterns of parenting have been found in depressed mothers of infants and young children as well as in depressed mothers of school-age children and adolescents. • Less is known about parenting in depressed fathers relative to mothers, but most of the findings from the smaller number of stud- ies are consistent with the findings about mothers. Child Functioning • Depression in parents is associated with children’s poorer physical health and well-being. Infants and young children of mothers with 9

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20 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depression are more likely to use a variety of acute health care ser- vices. For older children and adolescents, there is limited evidence to suggest that depression plays a role in visits for stress-related health conditions and increased health care utilization. Adverse health outcomes of accidents, childhood asthma, child maltreat- ment, and adolescent tobacco and substance use occur more often when a parent is depressed. • Maternal depression symptoms (and stress) levels are high among caregivers of children with chronic conditions. • Depression in parents is associated with maladaptive patterns of health care utilization for children. Infants and young children of mothers with depression are more likely to use a variety of acute health care services. For older children and adolescents, there is limited evidence to suggest impact on health care utilization. • Depression in parents has been consistently found to be associated with children’s early signs of (or vulnerabilities to) more “difficult” temperament; more insecure attachment; affective functioning (more negative affect, more dysregulated aggression and heightened emotionality, more dysphoric and less happy affect, particularly for girls; lower cognitive/intellectual/academic performance, cogni- tive vulnerabilities to depression (more self-blame, more negative attributional style, lower self-worth); poorer interpersonal func- tioning; and abnormalities in psychobiological systems, including poorer functioning stress response systems (neuroendocrine and autonomic) and cortical activity. • Depression in parents has been consistently associated with a num- ber of behavior problems and psychopathology in children, includ- ing higher rates of depression, earlier age of onset, longer duration, greater functional impairment, higher likelihood of recurrence, higher rates of anxiety, and higher rates and levels of severity of internalizing and externalizing symptoms and disorders in children and adolescents. Mediators and Moderators • Depression in parents is more likely to be associated with adverse outcomes in children with the presence of additional risk factors (e.g., poverty, exposure to violence, marital conflict, comorbid psy- chiatric disorders, absence of father when the mother has depres- sion, and clinical characteristics of the depression, such as severity and duration) than with depression that occurs in the context of more protective factors.

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2 ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING • Parental functioning, prenatal exposure to stress and anxiety, ge- netic influences, and stressful environments appear to play a role in the development of adverse outcomes in children. ____________________ This chapter reviews what is known about the associations among de- pression in parents and parenting, child health, and child functioning, based on the large number of epidemiological and clinical studies that have docu- mented these associations. Throughout our work, the committee recognized that depression exists in a broader context of comorbidities, correlates, and contexts. In addition, there has been a growing body of research that sug- gests that parenting styles and processes are not necessarily universal and may differ and have differential impact on children’s behavior based on culture and ethnic group variations (Deater-Deckard et al., 1996). Thus, the literature was approached with a caution against interpreting outcomes as owing solely to the depression in the parent as a single risk factor. With this in mind, the committee’s task was to review the literature that focused on (1) direct association between depression in parents and parenting, child health, and child functioning; (2) conditions that may make the association stronger or weaker (i.e., moderators); and (3) mechanisms or intermediate steps (i.e., mediators) through which depression in the parent becomes as- sociated with parenting or with outcomes in children. Although a review of the effects of parents’ depression on the family (e.g., marital conflict) is not within the study scope, such effects are integrated into the literature sum- maries when findings bear on moderation (e.g., when maternal depression is more strongly associated with adverse child outcomes in the presence of high marital conflict rather than low marital conflict) or mediation (e.g., when maternal depression is associated with an increase in marital conflict, which is then associated with adverse child outcomes). PARENTING PRACTICES AND THE DEPRESSED PARENT Skills in parenting are key to facilitating healthy development in chil- dren. Qualities of parenting that have been found to be related to healthy development vary by age of the child. They range from the sensitive, re- sponsive caregiving especially needed by infants to the monitoring that is particularly needed by adolescents. Important aspects of effective parenting across development include providing age-appropriate levels of warmth and structure to help children feel safe and to help regulate their emotions (e.g., Cole, Martin, and Dennis, 2004). Children also are dependent on their par- ents to facilitate their education and to obtain their medical care.

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22 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Parenting practices that do not meet infants’ or children’s needs to sustain healthy development are one of the primary mechanisms through which parental depression exerts its effects on children (Goodman and Gotlib, 1999). As reviewed by Avenevoli and Merikangas (2006), there is evidence to support broad (e.g., stress), specific (e.g., parenting skills), and structural (e.g., divorce) family factors that explain or modify the associa- tion between depression in parents and children’s development of depres- sion or other problems. Although more research is needed to determine the effects of specific types of parent behaviors, it is evident that parenting behaviors associated with depression affect children’s adjustment. Indeed, a few studies have tested and found support for a mediation role of parenting in associations between depression and outcomes in children. For example, in a large, longitudinal, population-based study of Canadian youth ages 10 to 15, children’s reports of both positive parenting behaviors (i.e., nurturance and monitoring) and negative parenting behav- iors (i.e., rejection) mediated the relationship between parental depressive symptoms and children’s internalizing (e.g., anxiety, depressive symptoms) and/or externalizing (e.g., aggression, noncompliance) problems (Elgar et al., 2007). Also supporting mediation, Cummings et al. (2008) found that a community sample of 6-year-old children’s representations of their attachment to their parents and of interparental conflict partially mediated the relation between parental depressive symptoms and the children’s ex- ternalizing problems that emerged over the following 3 years. Lim, Wood, and Miller (2008), in a study of mothers with depressive symptoms and their children (n = 242, ages 7–17) with asthma symptoms recruited from pediatric emergency departments, also found evidence consistent with nega- tive parenting as a partial mediator of the relation between maternal depres- sive symptoms and children’s internalizing problems. However, despite the many strengths of this study, the reliance on a cross-sectional design limits conclusions that can be drawn about mediation. In addition to this support for parenting as a mediator, others have found that parenting serves as a moderator of associations between depression in parents and outcomes in children. Among research supportive of moderation is the finding that more positive outcomes in youth with depressed mothers were found among the subset of depressed mothers who used less psychological control, more warmth, and less overinvolvement (Brennan, Le Brocque, and Hammen, 2003). Researchers have accumulated strong evidence directly linking depres- sion in parents with problematic parenting practices, primarily based on studies using direct observations of parents and children in families of depressed parents. In a meta-analysis of this research, Lovejoy et al. (2000) found significant and moderate effect sizes for the association between both maternal depressive symptoms and disorder and hostile negative parenting

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2 ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING (e.g., negative affect, coercive, hostile behavior; mean d = 0.40), disengaged (withdrawn) parenting (e.g., neutral affect, ignoring; mean d = 0.29), and a small but significant adverse association with positive parenting behaviors (engaging a child in a pleasant or affectionate way; mean d = 0.16). These studies reflect the significance of disrupted parenting when a parent suf- fers from depression and underscore the usefulness of direct observations of parent-child interactions in these families. The authors conclude that depressed mothers who are preoccupied are more likely to become angry when children misbehave or make normal demands on them. Lovejoy et al. (2000) argue that the “findings support the need for intervention with depressed mothers, as their parenting behaviors are a component of the risk associated with living with a depressed mother” (p. 588). Despite the strength of findings linking depression and parenting, the analyses were limited by the literature’s focus on younger children. Only 17 percent of the studies in the meta-analysis (n = 8) included children ages 6 or older, and none of the studies focused specifically on the high-risk period of early adolescence, a developmental period associated with increasing rates of depression and increasingly stressful parent-child interactions (Hankin and Abramson, 2001). A few more recent studies, however, have similarly supported links between depression and parenting even among parents of adolescents, as reviewed later in this chapter. Parenting practices are also of concern because they are associated with depression not only during periods of elevated symptom levels or during episodes that meet diagnostic criteria for depression but also when parents who have experienced depression may be relatively symptom free. Negative parenting has been found to persist even after controlling for the presence of major depressive disorder, suggesting that depressed parents continue to parent poorly following a depressive episode (Seifer et al., 2001). Depression and Parenting During the Prenatal Period, Infancy, Toddlerhood, and Early Childhood Although it is not common to consider that one engages in parenting behaviors during pregnancy, in fact there are multiple behaviors associated with depression during pregnancy that are relevant to children’s outcomes. These include obtaining prenatal care early and regularly, engaging in healthy patterns of eating (weight gain) and sleeping, and avoiding drugs, alcohol, and cigarettes. Both the symptoms of depression, such as anhe- donia (lack of pleasure in everyday experiences) and low energy, and the often correlated stressors may contribute to pregnant women neglecting their physical health and to engaging in behaviors that might provide im- mediate relief from distress, such as smoking, drinking, or unhealthy eating. Also, pregnant women with depression-related low energy or lethargy may

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN seek less prenatal care or begin their care later in pregnancy than women without depression. Furthermore, depression symptoms, such as appetite or sleep disturbances, suggest that pregnant women with depression may get inadequate nutrition or sleep. All of these behaviors raise concern for fetal development. Among the empirical findings, depression during preg- nancy has been associated with more smoking, greater consequences from alcohol use, and poorer overall health (Marcus et al., 2003; Zuckerman et al., 1989). Also, greater total sleep time during the third trimester predicted elevated depression symptoms postpartum (Wolfson et al., 2003). Among adolescent parents with depression, the poorer health behaviors are espe- cially strong (Amaro and Zuckerman, 1991). A much larger literature has shown depression, especially in moth- ers, to be associated with qualities of parenting of infants and toddlers. Researchers who observed mothers in face-to-face interaction with their babies or toddlers found higher levels of depressive symptoms to be associ- ated with less maternal responsiveness or sensitivity, less verbal and visual interaction, and more intrusiveness (Campbell et al., 2004; Civic and Holt, 2000; Easterbrooks, Biesecker, and Lyons-Ruth, 2000; Ewell Foster, Gar- ber, and Durlak, 2007; Horwitz et al., 2007; Marchand and Hock, 1998; Murray et al., 1996a; NICHD Early Child Care Research Network, 1999; Oztop and Uslu, 2007). Goodman and Brumley (1990), in a home obser- vation study, found that depressed mothers were emotionally unavailable and withdrawn to the extent that they were less sensitive to their children’s behavior, relative to women with no depression. Palaez et al. (2008) found that mothers with elevated depressive symptoms were more likely to be classified as authoritarian or disengaged in their interactions with their toddlers in comparison to mothers with low levels of depressive symptoms. Although mostly limited to small samples and to studies of elevated depres- sion symptom levels rather than diagnoses, and with typically moderate ef- fect sizes, these findings provide consistent support for associations between depression in mothers and patterns of interaction with their infants or young children that are intrusive/harsh or withdrawn/disengaged or both. Each of these parenting styles presents significant risks to the development of infants and toddlers. Parenting of infants is particularly of concern given its essential role in children’s development of secure attachment (Sroufe et al., 2005). Sen- sitive, responsive caregiving has been found to be the strongest predictor of secure attachment, which raises concerns given findings on depressed parents being less responsive and sensitive. Even beyond infancy, a sense of “felt security” has been found to be essential for healthy development and for preventing the development of psychopathology (Davies, Winter, and Cicchetti, 2006). Other aspects of parenting of young children that have been found

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2 ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING to be associated with depression are behaviors related to the health and well-being of children. For example, a community study of 400 children entering kindergarten in New York (Kavanaugh et al., 2006) reported that mothers with high levels of depressive symptoms were less likely to take their children for dental care (odds ratio = 2.6), read to their children less (odds ratio = 2.6), and were less consistent in their use of discipline (odds ratio = 2.3) than mothers with normal results from depression screening. This theme is also reflected in reports of elevated depressive symptoms in mothers being associated with less use of well-child care by age 12 months, more infant hospitalization, less back positioning for sleeping, and fewer up-to-date vaccinations (Chung et al., 2004; Mandl et al., 1999; Minkovitz et al., 2005). Radke-Yarrow et al. (1993) conducted a landmark study of unipo- lar and bipolar depressed mothers and controls and their children, all of whom were under age 8 at study entry. To briefly summarize the findings, they found depression in a mother to be associated with (1) problems in functioning in essential and routine roles, (2) failure to help the child achieve self-regulation, (3) anger and irritability or enmeshing dependency or both, (4) less consistency of mother-child relationship over time, and (5) escalating negative qualities of interaction over time. Radke-Yarrow et al. concluded that psychopathology in a child was especially promoted when the mother’s behavior interfered with the child’s fundamental tasks, such as self-regulation; long-term dependable security, autonomy, and dependency needs; and positive attitudes about self. Middle Childhood and Adolescence Although direct observations of parent-child interactions in samples of depressed parents with older children and adolescents have been less common than with infants and younger children, a few studies have tested and found support for the hypothesis that depression is associated with parenting of adolescents and that the affected parent-child interactions may represent a crucial pathway for parental depression to the development of psychological problems in the adolescents (e.g., Gordon et al., 1989; Simons et al., 1993). Jaser and colleagues (2008) examined the associations between mater- nal mood and parenting behaviors through direct observations of mothers with and without a history of depression interacting with their adolescent children during a positive and a negative task. Mothers with a history of depression were significantly more likely to exhibit sad affect and disen- gaged and antisocial parenting behaviors than mothers with no history of depression across the two interactions, but these differences were largely ac- counted for by mothers’ current depressive symptoms. Mothers’ self-reports

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN of their current depressive symptoms were also related to higher levels of observed sadness and antisocial behaviors, as well as both children’s and mothers’ reports of maternal intrusive and withdrawn parent behaviors. Mothers’ prior history of depression and their current depressive symptoms were associated with higher levels of parent and self-reported internalizing problems in adolescents. Parenting associated with depression is thought to be experienced as stressful by children in middle childhood or adolescence, given that by middle childhood children have the cognitive capacity to perceive, interpret, and draw inferences about their parents’ behavior. The stress of living with a depressed parent, relative to living with a parent with no depression, is characterized by more negative and unpredictable parental behaviors (e.g., irritability, inconsistent discipline), less supportive parental behaviors (e.g., less warmth, praise, nurturance, monitoring), and heightened marital con- flict (Cummings, Keller, and Davies, 2005). Similar to the situation with younger children, depression leads to disruptions in parenting of older children and adolescents as a result of parental withdrawal (e.g., social withdrawal, avoidance, unresponsiveness to children’s needs), parental in- trusiveness (e.g., irritability toward children, overinvolvement in their lives), or alternating behaviors between the two (e.g., Field et al., 1996; Forehand, McCombs, and Brody, 1987; Gelfand and Teti, 1990). Depressed mothers exhibit both intrusive and withdrawn behaviors, and the alteration or un- predictability itself may be perceived as stressful by their children (Gelfand and Teti, 1990; Jaser et al., 2005; Palaez et al., 2008). Exposure to these types of parental behaviors contributes to a chroni- cally stressful environment for children. As noted by Hammen, Shih, and Brennan (2004), “Parenting quality, especially if perceived as being negative by the child, is itself stressful” (p. 512). A series of studies found that, ac- cording to parent and adolescent reports in a sample of adolescent children of depressed parents, adolescents were faced with the demands of moderate to high stress related to both parental withdrawal and parental intrusiveness in the past 6 months (Jaser et al., 2005, 2007; Langrock et al., 2002). Pa- rental withdrawal and intrusiveness were moderately positively correlated, indicating that children must cope with parents who exhibit both types of behaviors rather than with parents who are either withdrawn or intrusive. Stressful parent-child interactions characterized by parental withdrawal and parental intrusiveness were significantly correlated with higher levels of children’s symptoms of anxiety/depression and aggression. As with studies of younger children, studies of older children that were designed to test mediation have found that qualities of parenting at least partially mediate associations between depression in parents and the development of behavioral or emotional problems in their children. For example, Jaser et al. (2008) found that regression analyses indicated

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2 ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING that the relationship between current maternal depressive symptoms and adolescents’ internalizing and externalizing problems were mediated by the observed sadness in mothers’ interactions with their children. Similarly, in one of the few studies that included mothers and fathers, Du Rocher Schudlich and Cummings (2007) found that disrupted parenting (e.g., parental rejection, lax control, and psychological control) by mothers and fathers partially mediated the relations between maternal and paternal dysphoric mood and children’s internalizing and externalizing problems. As described previously, a large-scale study recently found support for parental behaviors (nurturance, rejection, and monitoring) as mediators in the association between depressive symptoms in both mothers and fathers and 10- to 15-year-olds’ emergence of emotional and behavioral problems (Elgar et al., 2007). These findings are strongly supportive of interventions to improve the quality of parenting in order to reduce the effects of parental depression on children. Maternal Depression Increases Risk for Punitive Parenting and Child Abuse As much as one needs to be concerned about depression in parents being associated with negative parenting qualities such as rejection, harsh- ness, and intrusiveness, it is of even greater concern that researchers find depression in parents to be associated with maltreatment of children. Much of the latter work has focused on the pathway from maternal history of child maltreatment to depression in the women and, ultimately, maltreat- ment of the children. Numerous studies demonstrate that a maternal his- tory of childhood maltreatment significantly increases a woman’s risk for major depression, substance abuse, and domestic violence (Edwards et al., 2003; Kendler et al., 2000; Lang et al., 2004; MacMillan et al., 2001; Spatz Widom, DuMont, and Czaja, 2007; Springer et al., 2007; Whitfield et al., 2003). These outcomes have, in turn, been clinically implicated as increasing the risk for subsequent maltreatment of the woman’s children, either by the woman herself or through her association with a perpetrat- ing partner (Collishaw et al., 2007; Hazen et al., 2006; Koverola et al., 2005; Thompson, Kingree, and Desai, 2004). Several studies have sought to empirically determine the relative contributions of maternal child abuse history and the longer term outcomes of maternal depression, substance abuse, and domestic violence to increased risk for maltreatment of children. Statistical models have focused on a variety of proxy outcome measures, including measures of parenting attitudes, punitive parenting, parental stress, or child abuse potential as quantified by the Child Abuse Potential Inventory (CAP), a 160-item measure of potential for physical abuse. Using path analysis with a sample of 265 predominately minority

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN women, Mapp (2006) found that the only route from experiencing mater- nal childhood sexual abuse to increased risk for committing child physical abuse, as quantified by the Parenting Stress Index, was through elevated maternal depression symptom levels as defined by a score of 16 or more on the Center for Epidemiologic Studies Depression Scale (CESD). In a sample of 107 sexually abused and 156 control first-time mothers recruited prenatally and followed up when their children were between 2 and 4 years of age, Schuetze and Eiden (2005) found that maternal depression (CESD ≥ 16) was significantly associated with harsh, punitive parenting when the mother was also experiencing domestic violence. They concluded that the relationship between maternal childhood sexual abuse and adverse parent- ing was indirect and was mediated by maternal depression and domestic violence. Comparing CAP scores in physically abused adolescent and adult mothers, de Paúl and Domenech (2000) found a significant interaction be- tween young maternal age, a history of severe physical abuse, and maternal depression that predicted significant risk for child maltreatment measured with the CAP. Using a structured clinical interview, Cohen, Hien, and Batchelder (2008) compared mothers diagnosed as substance abusing (n = 41), depressed (n = 40), and both depressed and substance abusing (n = 47) with control mothers (n = 48) and found that the combination of substance abuse and depression was significantly related to elevated CAP scores as well as to several other measures of aversive parenting. Banyard, Williams, and Siegel (2003), however, found that maternal depression was related only to poor parenting satisfaction but not to other measures of parenting dysfunction or to the actual incidence of child protection intervention in a sample of 174 low-income predominantly African American women, half of whom had documented histories of child sexual abuse. That finding may be explained by their use of a nonstandard measure of depression, a subscale of the Trauma Symptom Checklist, which may account for the lack of effect. Research thus indicates that maternal depression increases risk for child maltreatment when it occurs in some combination with other factors, such as a maternal history of maltreatment, maternal substance abuse, or domestic violence. Mediators and Moderators of Associations Between Depression and Parenting Given the strong and consistent evidence linking depression and parent- ing, it is important to ask what factors might mediate the relations between parental depressive symptoms and parenting behaviors. For example, as part of a larger study of parents of children with attention deficit hyperac-

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29 ASSOCIATIONS BETWEEN DEPRESSION IN PARENTS AND PARENTING tivity disorder (ADHD), Gerdes et al. (2007) found that the association of maternal depressive symptoms and lax parenting was mediated by maternal locus of control and maternal parenting stress, and the relation between maternal depressive symptoms and harsh, overreactive parenting was medi- ated by maternal parenting stress and maternal self-esteem. That is, beliefs about control over events in one’s life, perceived parenting stress, and self- esteem explained at least part of the association between high symptom levels in mothers and their parenting approaches. Similarly, many factors are likely to moderate the relationship be- tween depressive symptoms and parenting behaviors, although few studies have provided direct tests. General systems and social ecological mod- els (Bronfenbrenner, 1980) suggest that a model to explain associations between depression and parenting must include potential influences be- yond the individuals involved. Mothers, including mothers experiencing depression, are embedded in systems that have the capacity to enhance or disrupt their responsiveness to their infants. Theory suggests that social support networks may operate by encouraging and modeling parenting skills (Bronfrenbrenner, 1979) or by serving as a resource for alternate child care, thereby minimizing the negative impact of stress on parenting (Cohen and McKay, 1984). Similarly, stress has been identified as a major determinant of qualities of parenting (Belsky and Jaffee, 2006). In studies of general populations samples of parents (not depressed parents), the effect of stress on parenting has been found to be contingent on social support (Crockenberg, 1981; Cutrona, 1984; Goldstein, Diener, and Mangelsdorf, 1996). Specifically, both stress and social support were found to signifi- cantly predict maternal attitudes and interactive behavior. Mothers with high stress were found to be less positive, while mothers with high social support were found to be more positive. Furthermore, social support has been found to moderate the effects of stress on maternal behavior (Crnic et al., 1983). For example, in a study of low-income African American mothers, although depression levels were not specified, mothers with larger support networks tended to be more respon- sive during interactions with their child (Burchinal, Follmer, and Bryant, 1996). The study also investigated the influence of structure on the effect of social support, finding that the source (father or grandmother) of social support through co-residence was associated with maternal responsiveness. Among the few studies that considered the role of stress and social support in associations between depression and parenting, the large-scale study by Radke-Yarrow (1998) found that, over time, the effects of mothers’ affec- tively symptomatic behaviors on the quality of the mother-child relationship were moderated by levels of family stress. Not only are qualities of parenting stressful for children of depressed parents, but also such children are exposed to a greater level of contextual

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