abuse during pregnancy, although we considered review of that literature outside the scope of this report.

Infants and Young Children

The social-environmental risk factors for child hospitalization in the first two years were examined in a Canadian cohort while controlling for biological risk factors. Elevated maternal depressive symptoms, single parenthood, and income inadequacy each increased the risk of hospitalization 1.5 to 1.8 times, independent of the infant’s poor health and prematurity (Guttman, Dick, and To, 2004). In an ambulatory setting, even after controlling for socioeconomic factors, infants or young children of mothers with depressive symptoms were two times more likely to have more acute care visits and three times more likely to have an emergency room visit (Mandl et al., 1999). Among a prospective cohort of infants followed for the first year of life, infants of mothers with the diagnosis of depression were three times more likely to have acute care visits (Chee et al., 2008).

The emergency department is another frequently used acute care venue. In a prospective study, after controlling for disease morbidity and other factors, it was found that 6 months later inner-city mothers with high levels of depressive symptoms were 30 percent more likely to take their school-age children to an inner-city emergency department for asthma care than mothers with low levels of depressive symptoms (Bartlett et al., 2001). In another study, a diverse population of mothers who screened positive for depression were more than three times more likely to have had multiple emergency department visits and to have missed other outpatient visits, relative to mothers without depressive symptoms (Flynn et al., 2004). These increased rates of acute care visits and hospitalization were also found in two studies of socially disadvantaged populations and one community cohort with children up to age 3 years (Casey et al., 2004; Chung et al., 2004; Minkovitz et al., 2005). Maternal depressive symptoms have not been found to influence overall hospitalization rates for older children. However, in a prospective study of urban, economically disadvantaged, 4- to 9-year-olds with asthma, clinically significant maternal mental health symptoms were the strongest psychosocial predictor of hospitalization 9 months later (Weil et al., 1999). Further discussion of the influence of maternal depression on illness management for children with asthma in the inner-city setting is discussed later in this section.

Studies that examined preventive health care utilization found it to be associated with depressive symptoms in mothers (Mandl et al., 1999; Minkowitz et al., 2005). Minkowitz’s study determined that higher levels of maternal depressive symptoms at 2 to 4 months postpartum predicted fewer well-child visits up to age 24 months in a prospective primary care



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