4—- 1&3! 2%. gvfifiw-I.‘ “:2 1‘“ f '; *‘A‘ézh’i 1",“ ‘ . w‘ .. 7. {3‘55 3‘; . ‘1 :6 4‘ V . .. 3;. a“ “ fink-"1:5? ;‘ S.“ .. M"; m: ' J :4 ' ‘fih, M ‘_a .‘x 115’ I'VE“. 3,19% at am“ ‘ (“33’ Hz .4 W“; #fififihfi fiv’pfi “1-4; #4541“ \_ :L > Fg‘l'. -'2:A" AU fl: 3'4 ”.3454, N “If”? I.\~':.f..&’ ~;4 1|“ 1 ‘ :11" r ,_ ”if 4 ‘ ~71- MQLN 3:: —IH. an #3223?“ 4’4; 1-1 " a a. ...: 5‘3.” .u u -l::1,g£nM :‘q 1 ¢ '81 ‘0 ’A 2:» - .:.‘:.‘i-I‘~ as” .- -. HEMO ‘25 KHz/o».- . ,‘.:“D~‘ ‘1 -'I . u #fifi‘igV.‘ cur '5 at c.‘ . g . ‘ , I“)! ‘V .%4.&W ’{ ! 4. ‘n ‘ ' ' ‘. ‘ ‘ I I "1 M “w‘ ‘0 sac»- - 1' ThESlS H I". .1 This is to certify that the dissertation entitled EFFECTS OF MOTHERS' MOOD AND CHILD HEALTH PROBLEMS ON THE QUALITY OF MOTHER :CHILD INTERACTIONS AND SUBSEQUENT CHILD HEALTH presented by ANN ELIZABETH WAGNER has been accepted towards fulfillment of the requirements for Ph . D . degree in Psychology ML Ma' rofessor Date October IL 1990 MSU u an Affirmative Action/Equal Opportunity lulituuou 0- 12771 EFFECTS OF MOTHERS' MOOD AND CHILD HEALTH PROBLEMS ON THE QUALITY OF MOTHER-CHILD INTERACTIONS AND SUBSEQUENT CHILD HEALTH BY Ann Elizabeth Wagner A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1991 "rut. R19 heavie illnes a var: ABSTRACT EFFECTS OF MOTHERS' MOOD AND CHILD HEALTH PROBLEMS ON THE QUALITY OF MOTHER-CHILD INTERACTIONS AND SUBSEQUENT CHILD HEALTH BY Ann Elizabeth Wagner Surveys of pediatric clinics have shown that their heaviest use is not by children with a specific chronic illness, but rather by children who present repeatedly with a variety of health problems. The present study is concerned with those children who are frequent users of pediatric care facilities because of a high incidence of common childhood illnesses. The study investigates a set of related variables that are hypothesized to contribute to the' vulnerability of young children to recurrent illness: maternal depressed mood, mothers' experience of parenting stress, and the quality of the mother-child relationship. Fifty-six mother-child dyads were recruited from a pediatric clinic at a midwestern university. Children were 29 girls and 27 boys between the ages of 3 and 4 years (M a 42 months). Mothers were married, between the ages of 22 and 39 years (M = 31.5), and predominantly Caucasian and middle class. Mothers completed self-report measures of depressed mood and stress. Mother-child pairs were videotaped in structured play situations. Child illness was rated from medical records. A model is presented which links child health, mothers' depressed mood, maternal stress, and the quality of mother- child interactions at one point in time to child health during the following twelve months. Multiple regression analyses partially supported the model. Analyses revealed a compensatory process by which mothers experiencing higher levels of stress were more positive, supportive, and facilitative in interactions with their children. Only previous child illness predicted health problems during the follow-up year. Post hoc analyses explored the influence of mothers' employment status on variables in the proposed model. Iam‘ Lb: O‘Q ACKNOWLEDGEMENTS I am very grateful to Dr. Susan Frank for her guidance throughout this project. Her enthusiasm for research, and her demand for high quality, has made working with her both a challenge and an inspiration. Her contributions to my research and professional growth are immeasurable. I also wish to thank other members of my doctoral committee. Dr. Kris Freeark contributed to the conceptualization and design of the study. Her ideas were greatly appreciated, as was her encouragement. Dr. Frank Floyd and Dr. Hiram Fitzgerald provided very valuable assistance with methodological and statistical aspects of the project. I thank them for their interest and assistance. Many research team members assisted with data collection and coding. I am forever grateful to Carol Laub, Lisa Pirsch, Carla Monestere, Kathy DeVet, Mary Bowers, and Mary Churchill for their many hours of coding videotapes: and to Dr. Gerard Breitzer and Dr. John Peters for their coding of medical records. Finally, I am most grateful to my family and friends for their limitless support and encouragement. iv Intro: Chapt. Ma Th Chap: Chap: TABLE OF CONTENTS Introduction...........................................1 Chapter 1 Review of the Literature.....................5 Maternal mental health and child health problems....5 Effects of mothers' psychological distress on mother-child relationship........................8 The effect of child health problems on mothers' mood...................................16 Chapter 2 Summary and Hypotheses.....................20 Chapter 3 Method.....................................24 Participants.......................................24 Procedure..........................................25 Instruments........................................25 Chapter 4 Results....................................34 Operationalizing the quality of mother-child interactions....................................34 Correlational analyses.............................37 Tests of the predicted model.......................37 Additional analyses................................42 Influence of mothers' employment status............45 Chapter 5 Discussion.................................56 Predictors of parent role stress...................56 Pr In Me Predictors of the quality of mother-child interactions.....................................S9 Predictors of child health problems................66 Influence of mothers' work status..................68 Methodological considerations and implications for future research..............................70 Summary and conclusion.............................73 Appendix A Beck Depression Inventory.................78 Appendix 8 Parenting Stress Index....................81 Appendix C Mother-child Interaction Codes............91 List of references. ...... ............................121 vi Table Table Table LIST OF TABLES Table 1. Items coded for quality of mother-child interactions.....................................32 Table 2. Descriptives of items in quality of motheréchild interactions........................35 Table 3. Item-total correlations for quality of mother-child interactions........................36 Table 4. Intercorrelations among variables in the proposed model for total subjects................38 Table 5. Descriptives of variables in the proposed model............................................38 Table 6. Values of R? for predicted and "full" models...........................................43 Table 7. Values of R? for predicted and "full" models when Total Child Illness represents prior illness....................................47 Table 8. Oneway analyses of variance for Total Prior Illness, Mothers' Depressed Mood, Parent Stress, Child Stress, Quality of Interactions, and Follow-Up Illness by work status.................50 Table 9. Correlations between predictor variables and follow-up illness for non-employed mothers...51 Vii Table Table Table A. Table Table 10. Correlations between predictor variables and follow-up illness for mothers employed part-time........................................52 Table 11. Correlations between predictor variables and follow-up illness for mothers employed full-time........................................53 Table 12. Partial correlations between prior illness and mother domain stress, controlling for mothers' depressed mood..........................55 Table 13. Partial correlations between mothers' depressed mood and follow-up child illness, controlling for prior illness....................55 viii Figure of Figure p: LIST OF FIGURES Figure 1. Proposed model predicting quality of mother-child interactions and subsequent child illness ..... ...............................21 Figure 2. Beta weights for proposed model predicting quality of mother-child interactions and subsequent child illness.....................40 Figure 3. Trimmed model predicting the quality of mother-child interactions and subsequent child illness ....... ..... ..... .........................44 Figure 4. Beta weights for the proposed model with total previous illness substituted for illness during the past year.............................46 Figure 5. Trimmed model with total previous illness substituted for illness during the past year.....48 ix heavie illnes a Var; has b care illne INTRODUCTION Surveys of pediatric clinics have shown that their heaviest use is not by children with a specific chronic illness, but rather by children who present repeatedly with a variety of health problems (Starfield et. al., 1985). It has been suggested that since high utilization of pediatric care facilities is not related to specific chronic illnesses, other biological, psychological or social factors might be involved in predisposing certain children to repeated health problems (Starfield et. al., 1985). Alternatively, frequent visits to health professionals might reflect a tendency to overreact to illness on the part of the child or parent, resulting in frequent visits for minor symptoms that other families might ignore (Starfield et. al., 1985). The present study is interested in those children who are frequent users of pediatric care facilities because of a high incidence of common childhood illnesses. The study investigates a set of related variables that are hypothesized to contribute to the vulnerability of young children to recurrent illness: maternal depressed mood, mothers' experience of parenting stress, and the quality of the mother-child relationship. The idea that psychological distress of mothers can 1 have ne the lit that cl more he stress Moos, Psycho freque 1966; I the pc illn95 2 have negative effects on children's health is supported by the literature on maternal depression. It has been shown that children of clinically depressed mothers experience more health problems and higher levels of psychosocial stress than children of non-depressed mothers (Billings & Moos, 1985: Weissman et. al., 1986). Moreover, children's psychosocial stress increases the likelihood of even greater frequency and severity of health problems (Meyer et. al., 1966; Boyce et. al., 1977; Chandler, 1985). The literature on maternal mental health also suggests the possibility of a "vicious cycle" in which repeated illnesses in the child causes increased distress in the mother, which in turn exacerbates the child's vulnerability to further illness. While few investigations of mothers' reactions to children's general health problems have been undertaken, it has been demonstrated that the experience of a high number of stressful events, especially those associated with family life, increases risk for depression in women (Billings & Moos, 1985; Lloyd, 1980: Stewart & Salt, 1981). Child illness could certainly be considered a family-related stressor, and might therefore contribute to mothers' experience of stress and depressed mood (Casey, 1983). Further support for this inference comes from the chronic illness literature that has demonstrated increased levels of stress, anxiety and depression in mothers of 3 children with severe chronic illnesses (Browne et. al., 1960: Lawler et. al., 1966; Gayton et. al., 1977; Binger et. al., 1979; Meijer, 1980-81: Bywater, 1981: Klein & Nimorwicz, 1982; Kupst et. al., 1984). Similar but less dramatic effects might be associated with repeated illnesses of a more routine nature. The present study hypothesizes that the presumed link between maternal depression and child health problems which has been reported is actually an indirect one. The proposed model suggests that both mothers' depressed mood and child health problems contribute to the mother's experience of her role as a parent as stressful, and that it is a high degree of maternal stress that subsequently contributes to an even greater incidence of child health problems. While recognizing that maternal stress may impact on the child in many ways, the present study is primarily concerned with disruptions in the quality of the mother- child relationship that may result from the child's illness and the mothers' experience of stress and depressed mood. Studies on depression in women support the idea that mothers' distress impacts negatively on their feelings about their children and on mother-child interactions (Weissman et. al., 1972: Susman et. al., 1984; French, 1983). While most investigations of the effects of mothers' mood on mother-child relationships have been with clinical populations, an important study by Belle (1982) and her colleag mood in It adjusts needs 2 events betweez child I envirol recipr. intera: VUlner, SUScep. T1 health gnalit: child 1 4 colleagues found similar effects of stress and depressed mood in a non-clinical population of low-income mothers. It has been demonstrated that parents who are well- adjusted and are warm and responsive to their children's needs are best able to buffer the effects of stressful life events (Chandler, 1985). A secure, reciprocal relationship between mother and child is the primary means by which a child learns a sense of security and mastery over his or her environment (Belsky, 1984; Bretherton, 1985). The lack of reciprocity, warmth and consistency inherent in the interaction styles described above may leave the child vulnerable to routine or unusual stressful events, and hence susceptible to more frequent or severe illnesses. The present study tests a model which links child health, mothers' depressed mood, maternal stress, and the quality of mother-child interactions at one point in time to child health during the following twelve months. Chapter 1 The idea that psychological distress of mothers can have negative effects on children's health is supported by the literature on maternal depression. Depression is the most commonly reported psychological problem in women, and it is estimated that 20% to 30% of all women experience depressive episodes at some point in their lives (Carmen et.al., 1981). Married women with preschool-aged children constitute the group with the highest risk for depression (Bernard, 1976; Radloff & Rae, 1981: Myers et.al., 1984: Weissman et.al., 1986). In most cases, women's experience of depression does not become debilitating enough to require hospitalization, and may not even reach the attention of professionals (Levitt et.al., 1981), but constitutes what one author has called the "garden variety" of depression (Carmen et. al., 1981). Anthony (1983) conceptualizes a "depressive spectrum" that ranges from transient feelings of sadness, weepiness, and emotional lability to schizodepressive reactions. He points out that with the exception of delusions, it is generally the intensity and frequency of symptoms that distinguish neurotically from psychotically depressed individuals. The kinds of symptoms most commonly associated with depression (sad faces, stooped posture, slow speech, depres: feelin; wishes, fatigak of app: with va T? childre depress M005, 1 The ful materna Suicida 5 Morri al., 19 1987); (Billin the mos been 1i ‘ MODS ' 6 depressed mood, feelings of hopelessness, conscious guilt, feelings of inadequacy, somatic preoccupations, suicidal wishes, indecisiveness, loss of motivation and interest, fatigability and sleep disturbance, constipation, and loss of appetite) can be experienced in various combinations and with varying degrees of intensity. The deleterious effects of maternal depression on children is well-documented when the mother is clinically depressed (Morrison, 1983: Billings & Moos, 1983: Billings & Moos, 1985; Weissman et. al., 1986: Kaplan et. al., 1987). The full range of child behavior problems has been linked to maternal depression: fighting, depressed mood, sad feelings, suicidal thoughts, unexplained headaches, and apathy (Reid & Morrison, 1983): peer problems and withdrawal (Cohler et. al., 1983): depression and conduct problems (Hammen et. al., 1987): academic difficulties and attention deficits (Billings & Moos, 1983: Weissman et. al., 1986) are among the most frequently reported. Maternal depression has also been linked to children's physical health problems (Billings & Moos, 1985: Weissman et. al., 1986). Billings & Moos (1983) conducted a longitudinal study with families in which one parent had entered treatment in a psychiatric facility, and had a diagnosis of minor or major depression. At the start of treatment, patients and family members were assessed on a variety of dimensions, including both parents' reports of their children's psychological, behavi When c nondep were r health coughs their more p Child: the pa Parent were f 7 behavioral and health problems over the previous month. When compared with a control group of children of nondepressed parents, the children in the clinical group were reported to have had a greater number of physical health problems (e.g., allergies, asthma, frequent colds or coughs, headaches, indigestion) during the month preceding their parents' seeking help. Their parents also reported more psychological and behavioral problems in their children. In order to rule out a negative reporting bias on the part of the depressed parent, comparisons of both parents' reports were made, but no significant differences were found. Among the group of families in which the parent's depression had remitted at follow-up, the children's health, psychological, and behavior problems had improved. However, these families and children continued to have significantly more problems than control families in which neither parent had ever been depressed. What may be occurring is a two-way interaction between family problems and maternal depression, where each exacerbates the other. Causal modelling and longitudinal designs would be useful for investigating such an interaction. Weissman and her colleagues (1986) investigated the health, social, and psychiatric difficulties of 220 children from families with a depressed parent and matched non-depressed control families. In addition to being more Physical Primarij their c! using n PSYChol a need child h {Elatic Attribu Parent, 8 likely to be diagnosed with a psychiatric disorder, children with depressed parents were reported to have had more traumatic perinatal events, more developmental delays, and more convulsions, head injuries, and operations. There is, then, support for the hypothesis that there is an association between maternal mental health and child physical health. However, investigations thus far have been primarily with a clinical sample of depressed parents and their children. There is a need for similar investigations using nonclinical samples of women, and using indicators of psychological distress other than depression. There is also a need for more objective and comprehensive measures of child health problems. Finally, the nature of the relationship between maternal mental health and child physical health should be explored. One of the implications of the above literature is that depressed mothers somehow relate differently to their children, and that some dysfunction in parenting is contributing to difficulties in their children. Attributional and cognitive models of depression suggest ways in which depressed mood might influence mothers' perceptions of their children and their abilities as a parent, which in turn may influence their parenting behavior. A: helplesi propose negativ factors Problem Charact unable 9 Abramson's reformulation of the learned helplessness theory of depression (Abramson et. al., 1978) proposes that depression is the result of attributing negative outcomes or events to internal, global, stable factors. Accordingly, a depressed mother would attribute problems with her child or within the family to characteristics within herself, and would feel that she is unable to change either herself or the difficult situation. Similarly, Beck's cognitive model of depression (Beck et. al., 1979) suggests that the depressed person has a negative self-concept and a sense of helplessness and hopelessness about current experiences and future events. The depressed person sees life as lacking pleasure, has few hopeful expectations, and little motivation to act. The depressed parent, then, would feel helpless in the face of difficult situations, would feel inadequate as a parent, and would be less likely to take an active role in handling day to day routines and activities. Furthermore, this model proposes that the depressed individual is likely to distort actual events to fit the hopeless thought patterns described above, thereby maintaining the depressive cognitive style. The depressed mother might therefore be likely to interpret her children's behavior in a more negative light, which would impact both her perceptions of her child and her feelings about the parent role. When considering the impact of maternal depression on Tut: «I! childre I childre other cg her lesJ more li) light. reported the nond Psycholo However, Spouses! bY each ¢ behavior be from g "911° A: behavior the laboi Sch; and tEac) behaViOr their Chi Howerr' signifiCa fathers: To a and child 10 children, one possibility that has to be considered is that children of depressed mothers are not more problematic than other children, but that the mothers' affective state makes her less tolerant of children's behavior, or that she is more likely to view her child's behavior in a negative light. As previously mentioned, Billings 8 Moos (1983) reported good agreement between the depressed parent's and the nondepressed parent's reports of their children's psychological, behavioral, and physical health problems. However, a family systems perspective would predict that spouses' perceptions of their children would be influenced by each others' perceptions as well as by the child's actual behavior. A more objective report of child behavior might be from someone outside of the home who knows the child well. An alternative might be direct observations of child behavior in natural settings or in analogue situations in the laboratory. Schaughency & Lahey (1985) compared mothers', fathers' and teachers' reports of child behavior using a standardized behavior rating scale. Mothers' and fathers' ratings of their children's behavior were significantly correlated. However, mothers' ratings of the children's behavior were significantly correlated with teachers' ratings while fathers' ratings were not. To assess the relative influence of maternal depression and child behavior on mothers' ratings of their children's orb.“ 11 behaviors, multiple regression analyses were conducted, using teacher ratings of child behavior and mothers' scores on the Beck Depression Inventory as predictor variables. While both variables were strongly correlated with mothers' child behavior ratings, teacher ratings predicted the greatest amount of variance. These results seem to suggest that although mothers' depression does affect their perceptions of their child's behavior, they remain relatively consistent with those of an independent observer. Alternatively, the authors point out that the causal relationship may be in the other direction, with child deviance contributing to the experience of depression in these mothers. Similarly, Brody and Forehand (1986) found that an interaction between high maternal depression and high levels of child noncompliance predicted mothers' perceptions of more child maladjustment. Sixty clinic-referred mother-child dyads were observed over four 40-minute interaction periods. Observer ratings of child noncompliance were derived from these interactions. Mothers' level of depression was measured by self-report using the Beck Depression Inventory. Mothers' perceptions of child maladjustment were derived from their scores on a standardized Behavior Rating Scale. A 2 X 2 analysis of variance revealed that the group characterized by high maternal depression and high levels of child noncompliant behavic naladju materna depress depress K? distres a sizpj t0 inve their . mother with 1 D attire childi conduc et- a: Self‘: and n. and C: disci: m°the; 12 behavior was associated with more perceived child maladjustment than were the other three groups (high maternal depression/low child noncompliance, low maternal depression/low child noncompliance, and low maternal depression/high child noncompliance). While the relationship between mothers' psychological distress and their perceptions of their children may not be a simple one, it is clear that any research which attempts to investigate the effects of mothers' mental health on their children must take into account possible biases in the mothers' reports of their child's functioning associated with level of depression. Depressed mothers also report differences in their attitudes about parenting and their behaviors toward their children. An investigation of child-rearing environments conducted by the National Institute of Mental Health (Susman et. al., 1985) compared the parental attitudes, self-reported behaviors, and goals of depressed, abusive, and normal control mothers. Differences between depressed and control mothers were primarily in the areas of discipline/control and expression of affect. Depressed mothers reported more inconsistency in discipline and control, and were more overprotective of their children than were non-depressed control mothers. They were also less emotionally expressive themselves, and were less likely to encourage their children to express their feelings. The: «in 13 Only a few reports of direct observations of depressed mothers and their children have been published. Kochanska and others (1987) reported that in control situations, depressed mothers were less likely to compromise with their children and were more likely to avoid confrontations when compared with well mothers. They speculated that low compromise reflected the mothers' inability to encourage autonomy and independence, and that the avoidance of confrontations was due to their inability to cope with emotionally intense situations. Hops and his colleagues (1987) demonstrated that depressed mothers' behavior has an effect on the behavior of family members, and that this effect is reciprocal. They observed the interactions between depressed women and their families in their homes. They observed that the mother's expression of dysphoria was followed by a suppression of aggressive affect in family members. Conversely, aggressive affect seemed to suppress dysphoric affect on the part of the mother. The authors hypothesize a negative interaction cycle by which family members try to manipulate each other with aversive behaviors which actually serve to reinforce the very behaviors they are trying to suppress. While most investigations of mothers' mental health and the effects on mother-child relationships have been with clinically depressed mothers, Belle (1982) and her colleagues conducted an important investigation of a cal. 14 non-clinical population of low income mothers' experience of stress and depression. They demonstrated that the women's experience of parenting-related stress and depression affects their feelings about being a parent and their interactions with their children. Women who reported high levels of stress and depressed mood reported that they made more demands for assistance with household chores on their children, were less likely to assist in these tasks, and were more likely to punish attention-getting behavior, when compared with mothers who reported less distress. They also reported higher expectations of immediate compliance, but said that they were less consistent about following through with consequences for noncompliance (Zelkowitz, 1982). In home observations, the mothers with higher stress and depression scores were observed to be less responsive to children's dependency needs and less likely to initiate nurturant interactions with their children. Depressed mood was additionally associated with more hostile and dominating interaction styles, and with fewer demonstrations of warmth, affection and positive affect (Longfellow et. al., 1982). The literature suggests that mothers who experience high levels of depressed mood and stress do interact differently with their children. The differences seem to be primarily related to the regulation and expression of affect, and to difficulties in balancing appropriate control n... s19 15 over their children's behavior while encouraging the development of autonomy and independence. It is suggested that disturbances in the parent-child relationship may cause emotional, behavioral, and physical health problems in these children. There is need for longitudinal research that uses direct observations of mother-child interactions to confirm the direction of effects, and to clarify the exact nature of these relationships. The present study investigates the relationship between mothers' experience of depressed mood and parenting stress, and the quality of their interactions with their children. Depressed mood is expected to have both direct and indirect effects on the mother-child interactions. Because depressed people appear to have difficulty with interpersonal relationships in general, it is anticipated that higher levels of depressed mood in mothers will be associated with less responsive and facilitative interactions with their children. Additionally, it is predicted that the global "depressive" attributes and cognitions will be associated with higher levels of parenting stress, as mothers with high levels of depressed mood will feel less confident and rewarded by their role as parent. This is likely to translate into less consistency, warmth, and facilitation in the mother-child interactions. ,- - ~- . , . ,-. , . .. -u; ., u. ,- e U... As has been pointed out by Shaughency and Lahey (1985), correlational studies which find associations between mothers' mental health and child difficulties leave unanswered the question of direction of effects. Such findings often are interpreted as evidence that disturbances in mothers' mood contribute to child dysfunction. But an alternative hypothesis might be that child dysfunction contributes to the experience of depressed mood and stress in the mothers. The present study is concerned with the contribution of recurrent child health problems to mothers' mood and the quality of mother-child interactions. Virtually all of the research on mothers' adjustment to child illness has looked at reactions to severe, life-threatening diseases or major developmental disorders such as congenital heart disease, childhood cancer, cystic fibrosis, asthma, diabetes, and mental retardation (e.g., Solnit 8 Stark, 1961: Olshansky, 1962: Sterky, 1962: Chodoff et.al., 1964: McCollum & Gibson, 1970: Falkman, 1977: Boll et. al., 1978: Paquay-Weinstock et.al., 1979: Parker & Lipscombe, 1979: Schulman & Kupst, 1980: Venters, 1981). While there is little evidence of increased incidence of major depressive episodes in these mothers, higher than normal occurrences of depressed mood, sadness, guilt, low confidence in parenting skills, low self-esteem, helplessness, unmet dependency needs, sleep -'i ,rnlo l7 disturbances, and anxiety have been reported (Browne et. al., 1969: Lawler et.al., 1966: Meijer, 1976: Gayton et.al., 1977: Binger et.al., 1979: Bywater, 1981: Klein & Nimorwicz, 1982: Kupst et.al., 1984). Although comparable research has not been done with mothers of children with less severe chronic illnesses, one might expect similar though less dramatic results. Many studies have found a correlation between life stressors and depression (Lloyd, 1980: Billings 8 Moos, 1982: Billings & Moos, 1983: Billings & Moos, 1985: Hammen et.al., 1987), and family-related stressors seem to be particularly relevant to depression in mothers (Stewart & Salt, 1981: Billings & Moos, 1983). Chronic childhood illness would certainly be considered a family-related stressor. According to the cognitive and attributional models of depression, the imminent or threatened death of the child, the financial strain and daily hassles associated with management of the illness, behavioral or developmental disturbances associated with the illness, and changes in family members' lifestyles could cause depressive symptomatology in parents who are predisposed to negative cognitive or attributional sets. Because this sample is relatively healthy (i.e. they do not have severe chronic illnesses) and because maternal depressed mood is also influenced by other family stressors (e.g., marital relationship, financial status) (Shaughency & 18 Lahey, 1985) and cognitive set (Abramson et. al., 1978: Beck et. al., 1979) not investigated in this study, the health status of children in this study is not expected to contribute directly to mothers' depressed mood. However, it has been demonstrated that young children with common illnesses and fevers are more clingy, whiny and dependent while ill and while recuperating from the illness (Mattson & Weisberg, 1970). Mothers of children with recurrent otitis media, one of the most common childhood illnesses, have described their children as more moody and inattentive (Feagans et. al., 1987: Casey, 1983) than children without ROM. It could be expected, then, that child illness may indirectly contribute to mothers' depressed mood via increased levels of stress. While this bidirectional relationship between child illness, parenting stress, and maternal depression seems plausible, the recursive nature of the proposed path model does not allow for testing this idea. A stronger relationship is hypothesized to exist between child health problems and mothers' experience of their parenting role as stressful. Casey (1983) found that mothers of children with severe or recurrent serous otitis media (SOM) reported higher levels of parenting stress, as measured by the Parenting Stress Index (Abidin, 1986), than did mothers of children with little or no experience with SOM. Specifically, these mothers experienced their children "(Luz c 1 Q 19 as more demanding and less adaptable. These mothers reported lower levels of acceptance and less attachment to their children. The above study needs replication, but it nevertheless gives supportive evidence to the hypothesis that common but recurrent childhood illnesses can contribute to mothers' experience of parenting stress. The proposed model predicts that child health problems will directly influence mothers' experience of parenting stress, both in terms of their feelings about themselves as mothers (parent domain) and their experience of their child as stressful (child domain). These predictions are based on the assumption that repeated illnesses, even minor or "routine" ones can undermine parents' confidence in their ability to protect their children, and the increased need for caretaking a frequently ill child can increase mothers' feelings of restriction and isolation in the role of parent. Additionally, the difficult child behavior associated with illnesses is expected to cause mothers to experience their sick children as causing them stress. Child domain stress, therefore, is predicted both by mothers' experience of parent domain stress (and indirectly by maternal depressed mood) and by child illness. Chapter 2 W The Family Factors in Children's Health Study is an ongoing research project relating family characteristics to children's health problems. ‘The purpose of the present study is to investigate the effects of mothers' depressed mood and stress on preschool children's health problems in 56 mother-child dyads who are participating in the larger study. The proposed model (see Figure 1) predicts a reiterative process, in which recurrent health problems in the child, and depressed mood and stress in the mother, negatively effect the quality of the parent-child interactions. In turn, poor interactions and parenting stress are expected to be related to further health problems in the child. To test this model, the following hypotheses will be addressed: New Mothers' experience of their parent role as stressful will be predicted by a) their level of depressed mood, and b) the extent of their child's health problems prior to their participation in the study. It is expected that level of depressed mood and child health problems will both be positively associated with mothers' reports of parent-domain stress. 20 u ”—5." 21 88:... 230 52.8.35 new 82599:. grosses. .0 35:0 9.585 .282 6382.. amour azuiozou :_mmoc:_ EEO .0 Ergow o .F 929“. wmotw EmEoo EEO V mmoc:_ EEO tote so >:._o>ow N 9.020335 220-5502 B 3:26 m 0 wmwzm EmEoo 29mm m boos. commocaoo 9.282 F 'fL:f:C‘I0 22 W Mothers' experience of their children as stressful will be predicted by a) their experience of their parent role as stressful, and b) the extent of their child's health problems prior to the study. It is expected that both parent-domain stress and prior health problems will be positively associated with child-domain stress. W The quality of mother-child interactions will be predicted by a) level of mothers' depressed mood, b) mothers' experience of stress in their role of parent, and c) mothers' experience of their children as stressful. It is expected that depressed mood, parent-domain stress, and child-domain stress will each be negatively associated with the quality of mother-child interactions. HmtbesiLm Greater extent of child health problems in the year after completion of the study will be predicted by a) more health problems prior to the study, b) mothers' reported feelings of stress related to the parent role, c) mothers' reported feelings of stress related to their child, and d) the quality of interactions between the mother and child in the taped dyadic interactions. It is expected that prior health problems, role-related stress, and child-related stress will be positively associated with health problems during follow-up, whereas the quality of parent-child 23 interactions will be negatively associated with future health problems. Chapter 3 mm Wt: Subjects are 56 mother-child dyads who participated in the Family Factors and Children's Health Study, which is an ongoing research project investigating characteristics of families associated with children's health problems. The present study included mother-child dyads in which the children had a range of common childhood illnesses. Children were excluded if they had a history of life-threatening or serious chronic illness. The children (29 girls, 27 boys) were 3 and 4 years of age (M = 42 months). To avoid confounding effects of child health with other major family stressors, families were included only if both parents were living in the home, both parents had at least a high school education, and there were not more than four children in the family. Sixty-eight percent of the eligible families agreed to participate. Mothers ranged in age from 22 to 39 years, with a mean age of 31.5 years. They had been married an average of 7.25 years, with years of marriage ranging from 3 to 10 years. The sample was predominantly Caucasian (48 White, 6 Black, 2 Hispanic). Education level of the mothers ranged from high school to graduate level education. Eighteen percent of the subjects had never attended college: fifteen percent had 24 TLIKCIQ M.A. or Ph.D. degrees. Seventy percent of the mothers in this sample were working outside of the home at the time of their participation in the study. Forty-two percent of the working mothers were working full time. Average yearly income for the participating families was between $35,000 and $40, 000. EIQ£§QBI§ Names of families with three-year-old children were identified from the medical records at the Pediatric Clinic at the Michigan State University Clinical Center. Families who agreed to participate were interviewed in their homes on two occasions, filled out questionnaires between home visits, and participated in videotaped parent-child interactions at the MSU Psychological Clinic. Medical records were obtained from all physicians and medical care facilities who treated the child from birth through the one-year follow-up period. The study utilized data from questionnaires filled out by parents and videotaped interactions at the beginning of the study, and health and medical data collected both initially and one year following the family contacts. Instruments Child_flea1§h‘ The children's health histories were gathered from medical records from the MSU Clinical Center and other health care agencies identified by the mothers as having treated the child. Severity of Illness scores were 25 .." qrolo 26 computed by summing illness severity scores coded for each illness diagnosed at each physician contact. Scores for each visit were based on Horwitz (1983: Horwitz et. al., 1988) and range from 0 (assigned to health maintenance visits or "follow up" visits for a prior, resolved illness) to 3 (usually assigned to illnesses requiring hospitalization). A pediatrician coded the medical records. A second pediatrician who was not involved with the study, and was unaware of the hypothesized relationships, coded 10 of the 56 medical records. Interrater reliability for the double-coded records was .93. The model tested includes two variables derived from the Illness Severity scores. Sgye:1§y_9£_111n§§§_1n_§h§ £regigug_iear_1£3£;1LLl was derived by summing illness severity codes over the 12 months prior to the family's participation in the study. Seygrity_gf_111nes§_nnzing_th§ £91193:flp_!ear_1£fl;1LLl was derived by summing illness severity scores over the 12 months following the collection of questionnaire data and the family's participation in the videotaped interactions. Loglinear transformations of the variables were used to reduce skewness in these scores. EgQk_Depre§§ign_1nyentgzy‘ The BDI is a 21-item self-report questionnaire designed to assess current cognitive, affective, and somatic symptoms of depression. (See Appendix A) Each item consists of four alternative statements describing symptoms of depression ranging in 27 severity from 0 to 3. A total depression score is computed by adding the severity ratings of each alternative chosen. A score of 0 to 9 indicates no or minimal depression: 10 - 18 indicates mild to moderate depression: 19 - 29 indicates moderate to severe depression: and 30 - 63 indicates severe depression (Beck, et. al., 1988). Beck et. al. (1988) conducted meta-analyses based on reliability and validity studies of the BDI from 1961 through June, 1986. Internal consistency estimates yield a mean coefficient alpha of .86 for psychiatric populations and .81 for nonpsychiatric populations. Concurrent validity has been assessed by comparing BDI scores to those of other tests of depression and to clinicians' ratings of depression. Mean correlations with clinicians' ratings with psychiatric and nonpsychiatric subjects were .72 and .60, respectively. Mean correlations of the BDI with other tests of depression were .73 for psychiatric populations and .74 for nonpsychiatric subjects. The BDI is also reported to discriminate well between depression and anxiety (Beck & Beck, 1972: Beck et. al., 1988). The proposed model includes one variable, figygxity__gfi mgthgzsL_depressed_mggd_12£23£§§1 was derived from the total depression score of the BDI (Beck 5 Beck, 1972). In this study's sample, 67.9% (n - 38) of the mothers reported no or minimal depression: 25% (N a 14) reported mild to moderate depression: and 7.1% (H s 4) reported moderate to severe The: (:19 28 depression. No mothers reported depression in the severe range. Parenting_§trg§§L The Parenting Stress Index (Abidin, 1986: see Appendix B) is a 120-item questionnaire designed to assess the degree of stress in the parent-child system. A profile is derived which identifies the degree of stress associated with the Child Domain (adaptability, acceptability, demandingness, mood, distractibility/ hyperactivity, reinforces parent: 47 items), and the Parent Domain (depression, attachment, restriction of role, sense of competence, social isolation, relationship with spouse, parent health: 54 items). The PSI also includes an optional Life Stress scale (19 items). A Total Stress Score is derived by adding the Child Domain and Parent Domain scores. High scores on each subscale are indicative of greater stress. The PSI was normed on a sample of 534 mothers of children between the ages of 1 month and 19 months of age, with a mean age of 14 months. The sample group was predominantly white, with a wide range of family incomes represented, and a relatively high educational level. Normative data on 100 fathers, also predominantly white, are reported as well. Concurrent validity was demonstrated by correlating test scores with alternative measures of the same construct. The reported correlations were generally satisfactory, ranging from the .40's to the .80's. The Tut. Q19 29 instrument has also been shown to have good predictive and discriminant validity (Abidin, 1986). Alpha reliability coefficients for the subscales, domain scores and total score ranged from .52 to .95, indicating adequate internal consistency. Test-retest reliability coefficients ranged from .63 to .96 after three-month intervals, and from .55 to .70 after a one-year interval. Numerous studies have demonstrated the adequate reliability and discriminant validity of the PSI when used with parents of preschool and school-aged children as well (e.g., Breen & Barkley, 1988: Burke, 1978: Mouton & Tuma, 1988: Spielberger, Gorsuch, & Lushene, 1970). These results suggest that the PSI is a reliable and valid instrument for the assessment of stress in the parent-child system. The proposed model utilized two variables derived from the PSI. £3;en§_figmgin_g§ng§§ (MOSTRESS) is a composite of all subdomains included in the Parent Domain score with the exclusion of the depression subdomain score (alpha - .84). The depression subdomain was excluded to avoid confounding the parenting stress and depressed mood variables. Subdomains included in this variable (attachment, restriction of role, sense of competence, social isolation, relationship with spouse, parent health) reflect stresses associated with mother characteristics and perceptions of the parenting role. The 211W variable is the 30 complete Child Domain Score from the PSI. This variable reflects stresses associated with child characteristics (adaptability, acceptability, demandingness, mood, distractibility, reinforces parent). Eidggtapgd_in§eragtign§& Each mother and child dyad was videotaped during a number of interactions in the psychological clinic. The interactions took place in a small playroom in which the mother and child were seated on opposite sides of a small table containing age-appropriate toys. Three tasks were videotaped, during which the mother was directed via a bug-in-the-ear device. The first task was child-directed, during which time the mother was instructed to play with her child, allowing the child to direct the play. After 5 minutes the mother was instructed to tell the child that it was her turn to choose a game and to keep the child playing by her rules. After 5 minutes of mother-directed play, the mother was instructed to ask her child to clean up the toys. The clean-up task ended when the task was completed, or after 10 minutes if clean-up had not been accomplished. These tapes were coded using an adapted version of a system devised by Belsky (1987), which measures both parent and child variables. The coding system was developed to be consistent with research on parent-child relations which highlight the centrality of affect and control in parental behavior, and child behavior which reflects attention, THES‘S 31 affect, and social orientation. Mother behaviors are coded which reflect positive and negative affect, responsiveness to child's needs and affect, ability to facilitate or undermine child's functioning. Child variables reflect positive and negative affect, cognitive and behavioral competence, persistence in maintaining contact with the parent, dependency, compliance and disobedience. Table 1 briefly describes the codes, and Appendix C includes a complete description of each code. Tapes were coded by three graduate level students. Raters trained on pilot tapes until Pearson correlations between raters' codes (one code per variable per minute of tape) were above .70. Raters then coded subjects' tapes, double coding every fourth tape. Reliability was checked after each double-coded tape, and re-training was implemented when necessary. Pearson correlations across all doubly coded tapes for each item ranged from .53 to .95 (n = .82). Table 1 32 Items Coded for Quality of Mother-Child Interactions lte Desoliption !" em a or oz a Positive Affect Negative Affect Positive Feedback Negative Affective Feedback Facilities Self-Regulation lntrusive/Overcontrolling Unresponsive/Unavailable/ Undercontrolling Demands Self-Reliant Behavior . Undermines Child Functioning Focused Attention/ Involvement Cognitive Sophistication Sense of Mastery/Skill/ Competence . Organized Transitions Positive Affect/ Enthusiasm Negative Affect Degree of Distress Strange Behavior Transgressions Seeking Proximity to Parent Distancing from Parent Extent to which the parent displays warmth, nurturance, and positive affection toward child. Extent to which parent displays hostility, negative affect, and displeasure or annoyance . toward child. Extent to which parent provides contingent rewards and praise to child. Extent to which parent criticizes and/or demeans child's behavior. Extent to which parent facilitates child's ability to control and engage situation. Extent to which parental behavior is ill-timed, intrusive, or inappropriately controlling. Extent to which parent makes no attempt to control or facilitate child's behavior. Extent to which parent explicitly or indirectly requires child to be self-reliant. Extent to which parent subtly or overtly undermines child’s optimal functioning. Extent to which child involves self in play activities or exploration. Child’s SOphistication in play, and level of play organization. Mastery, skill or competence child displays during play. Child’s movement from one involved activity to another. Enthusiasm and comfortableness of the child. Extent to which child shows anger, dislike, or hostility. Degree of distress of child. Strange behaviors (e.g., rocking, blank staring, frozen posture). Extent to which child contacts objects and materials that have been placed off-limits. Extent to which child seeks proximity to parent. Extent to which child tries to increase physical distance between self and parent. 33 Table 1 (cont’d) _e_|t m Qasoflotioo U. Cooperation /Compliance Extent to which child complies with parent’s specific instructions or directions. V. Disobedience Extent to which child verbally refuses to comply with parent’s request. W. Dependency/Need for Help Extent to which child turns to parent for help. X. Verbal Interaction with Extent to which child maintains verbal contact Parent with parent. Chapter 4 0-5. 01- _ 1° 2‘ 'L- 0 u.- 9.‘ - 9 0. a ‘ a 0!: An aggregate score reflecting the ng11;y_gf W was derived by adding z-scores for the mother and child codes after multiplying those considered to reflect more negative interactions by -1. Codes were excluded if less than five subjects exhibited the behaviors in question. These included Mother's Negative Affect, Strange Behavior, and Degree of Distress Exhibited by Child. Items were also excluded if their item-total correlations were less than .20. Items excluded by this criterion were Child Seeks Proximity to Parent, Child's Organized Transitions, Verbal Interaction with Parent, and Child's Dependency/Need for Help. To reduce skewness due to outlying scores, z-scores greater than +3.00 and less than -3.00 were converted to +3.00 and -3.00, respectively. The raw score means, standard deviations, range of scores, and number of outliers for each code are listed in Table 2. The final quality scale (alpha = .87) included seventeen items. Item-total correlations are shown in Table 3. Three positive maternal behavior codes (Positive affect, Facilitates self-regulation, Positive feedback), and five negative maternal behaviors (Unresponsive/unavailable/ undercontrolling, Intrusive/overcontrolling, Negative 34 Tut; Q19 35 Table 2. D ritiv fltm in uli fMthr-hil Intr in Item _ea_M n $394291 midday #Mers MQEEB BEHAVIQRS Positive Affect 2.99 .47 1.93 - 3.79 Positive Feedback 1.45 .28 1.00 - 2.27 (1) 2‘ Negative Affect Feedback 1.12 .25 1.00 - 2.35 (28) Facilitates Self-Regulation 2.66 .35 1.86 - 3.46 Intrusive/Overcontrolling 1.20 .24 1.00 - 2.13 (15) 2‘ Unresponsive/Unavailable 1.04 .11 1.00 - 1.60 (45) 2‘ Demands Self-Reliant Behavior 1.02 .04 1.00 - 1.23 (44) 1‘ Undermines Child 1.03 .09 1.00 - 1.56 (40) 1‘ll CHILD BEHAVIQBS . Focused Attention 3.94 .49 2.24 - 4.64 1b Cognitive Sophistication 2.44 .36 1.52 - 3.31 Mastery/SkilI/Competence 3.46 .47 2.40 - 4.38 Organized Transitions 1.04 .06 1.00 - 1.18 (30) Positive Affect 3.16 .54 2.07 - 4.23 Negative Affect 1.32 .38 1.00 - 2.71 (10) 2‘l Transgress 1.20 .33 1.00 - 2.55 (20) 2‘ Seek Proximity 1.04 .18 1.00 - 2.24 (47) 1" Distancing 1.05 .14 1.00 - 1.90 (39) 1a Cooperation 2.04 .36 1.30 - 2.83 Disobedience 1.43 .44 1.00 - 3.00 (5) 1‘ Dependency 1.17 .18 1.00 - 1.67 (15) Verbal Interactive 3.06 .58 1.86 - 4.57 *(N) indicates number of subjects that did not exhibit behavior (value = 1.00). ‘ Z - score > +3.00 b 2 - score < -3.00 Table 3. Interactions... .,- 36 netbeLBehalier Positive affect Facilitates self- regulation Positive feedback Unresp./unavail./ undercont. Intrusive/overcon. Negative feedback Undermines child functioning Demands self-rel. .55 .37 .33 .57 .24 .50 .61 .23 Positive affect Mastery/self- confidence Cognitive soph. Focussed attent./ involvement Disobedience Transgressions Negative affect Distancing from parent .46 .53 .26 .66 .64 .69 .59 .55 37 feedback, Undermines child functioning, Demands self-reliance) were included. Child behavior codes included in the final scale consisted of five positive behaviors (Child positive affect, Mastery/self-confidence, Cognitive sophistication, Focussed attention/involvement, Cooperation/compliance) and four negative child behaviors (Disobedience, Transgressions, Child's negative affect, Distancing from parent). 0 'on To determine whether any of the proposed variables were linked to mother's age, education, or family income, Pearson correlations were used to test the association between these variables and the variables in the proposed model. Variables in the proposed model were shown to be unrelated to these demographic variables. Intercorrelations between the predictor variables (mothers' depressed mood, prior child health problems, parent domain stress, child domain stress, and quality of mother-child interaction) and child health problems during the follow-up year for the total sample are presented in Table 4. Means, standard deviations, and range of scores of all variables in the predicted model are presented in Table 5. WW Because of missing data, the path analyses are based on estimates from subsamples used to compute correlations in the total sample. N's for the pairwise correlations on THF SIS 38 Table 4 In r .-.orr|tin Ame-n V-J‘ril in th Proa- :0 MN I for To I 0: QEPRESS EBEJLL Mil-5185.35 QtlfiIElESS QUALELX FEE-ILL -.01 MQSIBESS .37** .13 W a .16 -.01 .59*** QM -.07 .05 .37** .16 F -ILL .18 .53*** .18 .13 -.05 Table 5 D ri tiv fV ri Ie in th Pr M I. v ri l a Mean $194192. Max. PRE-ILI. 55 1.21 .27 .60 - 1.89 DEPRESS 56 7.25 6.80 .00 - 29.0 MO-STRESS 56 103.05 16.56 67.0 - 143.0 CH-STRESS 56 102.27 16.73 67.0 - 133.0 QUALITY 54 .02 .05 -1.87 - .65 FU-lLL 53 .02 .36 .. o - 1.0 39 which the overall path analysis was based ranged from 53 to 56. Because all of the 3's are larger than 50, the relationships are assumed to be representative of the sample as a whole. Beta weights associated with the predicted pathways are presented in Figure 2. li:zpsztl1g,s,i§_;|;L Regression analyses only partially supported the hypothesis that parent domain stress would be predicted by mothers' depressed mood and prior child health problems. Although the predicted pathway accounted for a significant amount of variance (R21- .15, p,< .05), an examination of the beta coefficients for each of the predictor variables indicated that only mothers' depressed mood was positively associated with parent domain stress (6 = .37, p < .01). The expected association between severity of child illness in the previous year and parent domain stress was not found (6 = .13, p, n.s.). Hypothe§i§_11; Predicted influences on mothers' experience of child-domain stress were partially supported as well (R?a=.35, p < .001). The expected positive association between parent-domain stress and child-domain stress was found (3 c .60, p <.05). However, the prediction that severity of child illness during the prior year would contribute to parent domain stress was not supported (6 s -.08, p, n.s.). Hypoth§§1§_111‘ It was hypothesized that the quality of mother-child interactions would be predicted by mothers' .88.: 220 53888 new 898.2%. 2201252 .6 £30 3298:. .822 88%... .9 arms; 98 .w 9:6: FCC. V Q2: .wO. V Qse .mo. V as ”maoz i eccmm. n_.:|wma 00... n .Illlu N GO. wwwmhwnIO 0 .v 4 0w. 2.- . q .8. .373... t :. mmmmewoz :56. 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