Child Physical Well-Being in the Context of Maternal Depression

Child Physical Well-Being in the Context of Maternal Depression Abstract Maternal depression is associated with negative outcomes in children, with less known about physical health outcomes. Poor child physical health is a robust predictor of negative outcomes across the life course. Thus, authors examined the association between maternal depression and child physical well-being, accounting for multiple risk and protective factors. Data from the Fragile Families and Child Wellbeing Study (N = 2,965) were used to examine the association between three indicators of child physical well-being (overall health status, overweight, and asthma) and maternal depression at the nine-year follow-up, controlling for child-, maternal-, and family-level risk and protective factors. Unadjusted regression analyses revealed that maternal depression was associated with increased rates of poor overall health, overweight, and asthma. When adjusting for parenting stress and competence, maternal depression was no longer a significant risk factor for overall poor health; when controlling for sociodemographic characteristics, it was no longer a risk factor for asthma. After adjusting for multiple factors, maternal depression remained a significant risk factor for childhood overweight. Findings highlight the importance of reducing perceived parenting stress and increasing competence for depressed mothers and suggest that more research is needed to examine pathways through which maternal depression may lead to childhood overweight. Ensuring that all children have a healthy start in life is an important social work priority (Hawkins et al., 2015), as poor physical health in childhood is one of the most robust predictors of adverse outcomes in adolescence and adulthood (Hardie & Landale, 2013; Shonkoff, Boyce, & McEwen, 2009). Poor physical health at any point throughout childhood may lead to impairments in daily functioning and increase the risk of morbidity and early mortality, resulting in substantial individual, economic, and social consequences (Ogden, Carroll, Kit, & Flegal, 2014; U.S. Burden of Disease Collaborators, 2013). Nevertheless, poor physical health in childhood remains a significant problem in the United States. Although the majority of parents report that their child is in excellent or very good health, 16% of children are reported as not having optimal overall health (U.S. Department of Health and Human Services [HHS], 2014). In addition, nearly one in three children in the United States is overweight or obese (Ogden et al., 2014), and 14% of children have a lifetime diagnosis of asthma, a chronic health condition associated with a decreased quality of life (Bloom & Freeman, 2015). It is noteworthy that from early to middle childhood there are significant increases in the rates of poor overall health, overweight, and asthma (Bloom & Freeman, 2015; Ogden et al., 2014; HHS, 2015). Poor overall health, overweight, and asthma in childhood are associated with negative consequences that may continue into adulthood (Shonkoff et al., 2009). Understanding factors in childhood associated with poor physical health is essential for improving overall health and functioning throughout the life course. For young children, the family, particularly the mother, has the most influence on overall child well-being, including physical health, as mothers are often the primary caregiver (Maternal and Child Health Bureau, 2010; Parker, Baldwin, Israel, & Salinas, 2004). Thus, maternal health factors, including maternal depression, may be associated with differences in child physical health outcomes (Hardie & Landale, 2013; Turney, 2011). In a given year, approximately 10% to 20% of mothers will have an episode of depression (American Psychiatric Association [APA], 2013), with over 7.6 million children living with a mother with depression (Ertel, Rich-Edwards, & Koenen, 2011; Pratt & Brody, 2014). Depression is a psychiatric disorder characterized by persistent dysphoria or anhedonia, along with other somatic, psychological, and behavioral symptoms (APA, 2013). There is also a specifier for women if symptom onset occurs during the peripartum period, commonly called postpartum depression (APA, 2013). The timing of symptom onset is important; however, fewer studies have examined the impact of maternal depression on child well-being occurring later in childhood, despite the fact that depression may be present at any time throughout childhood (Turney, 2012). By definition, maternal depression is a debilitating and persistent condition, leading to impairments in daily functioning for the mother related to her physical health, family relationships, and social interactions (Farr & Bish, 2013; Pratt & Brody, 2014). Maternal depression is associated with lower levels of self-efficacy and decreased feelings of mastery (Farmer & Lee, 2011). As such, mothers may perceive parenting as more stressful and may view themselves as less able to parent effectively (Farmer & Lee, 2011). Maternal depression has also been consistently identified as a risk factor to child emotional and psychological well-being, with disruptions in the maternal–child relationship as the primary mechanism (Gladstone, Beardslee, & Diehl, 2015; Goodman et al., 2011; Reuben & Shaw, 2015). Among the few studies that have examined the impact of maternal depression on child physical well-being, depression was associated with increased rates of poor child health, overweight, and asthma (Lampard, Franckle, & Davison, 2014; Repetti, Taylor, & Seeman, 2002; Turney, 2011). However, many of these studies did not include a comprehensive set of confounding factors or consider the impact of factors related to the maternal–child relationship, such as parenting stress and competence. A comprehensive set of factors is needed, as there are common contextual risks, like income and material hardship, associated with increased rates of both maternal depression and poor child physical health (Ertel et al., 2011; Pratt & Brody, 2014; HHS, 2015). These factors must be accounted and controlled for to determine the unique association between maternal depression and child physical health outcomes. Thus, the aims of this article were, first, to determine the association between maternal depression on three indicators of child physical well-being (overall health status, overweight, and asthma) and, second, to identify risk and protective factors related to child physical well-being, including the role of maternal perception of parenting stress and competence. Method The Fragile Families and Child Wellbeing Study is an ongoing, longitudinal, cohort study following 4,898 children born in a large U.S. city between 1998 and 2000 to mostly unmarried parents (Bendheim-Thoman Center for Research on Child Wellbeing [CRCW], 2008). Biological mothers (N = 4,898) were interviewed at or around the time of the focal baby’s birth (baseline), with follow-up interviews conducted when the child was one, three, five, and nine years old. Interviews consisted of core telephone interviews and in-home face-to-face interviews. Of the 4,898 mothers initially interviewed, 3,309 (67.6%) completed the nine-year in-home primary caregiver interview (CRCW, 2011). Present analyses included 2,965 mothers interviewed at year 9. Observations were excluded if data were missing on any of the sociodemographic variables (n = 312) or maternal depression indicator (n = 12), if the child had a serious physical disability (for example, cerebral palsy, n = 75), and if the child lived less than half-time with the mother (n = 4). Some mothers satisfied more than one exclusion criterion. There were also 239 missing observations for child body mass index (BMI), with 162 children having not been measured and 77 flagged due to measurement errors. Observations with missing BMI data were excluded from that analysis only. The analytic sample was more advantaged when compared with the nine-year follow-up sample, with lower rates of low birthweight, longer breast-feeding duration, higher levels of maternal education, and higher income, and mothers were more likely to be married (p < .01). In addition, mothers in the analytic sample were less likely to be depressed (16.3%) as compared with those in the nine-year follow-up sample (24.0%), χ2(1) = 18.7, p < .001. However, there were no differences in baby’s sex, mother’s age, and levels of parenting stress and competence between the analytic and the nine-year follow-up sample. Measures Child Physical Well-Being Outcome measures were three commonly used indicators of child physical well-being at age nine: (1) overall health status; (2) overweight, including obesity; and (3) diagnosis of asthma (Moore, Murphey, Bandy, & Lawner, 2014). Overall health status was reported by the mother, who was asked about the general health of her child. There were three coded response categories (0 = excellent, 1 = very good, 2 = good/fair/poor). Overweight, including obesity, was based on the Centers for Disease Control and Prevention BMI growth chart guidelines for age and sex using the interviewer measured height (m) and weight (kg), with 1 indicating a BMI (kg/m2) at or above the 85th percentile (Waldfogel, Craigie, & Brooks-Gunn, 2010). For asthma, the mother reported whether her child had ever been diagnosed with asthma by a health care professional, with 1 indicating asthma diagnosis. Maternal Depression Maternal depression was measured at year 9 using the Composite International Diagnostic Interview–Short Form (CIDI–SF) (Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998). If mothers reported experiencing either dysphoria or anhedonia on most days for at least two weeks during the past 12 months, they were asked about seven additional symptoms. Those reporting either dysphoria or anhedonia and three additional symptoms were considered depressed. Mothers who reported taking medication for depression were not asked about symptoms, but were coded as having depression (CRCW, 2011). Maternal depression was coded as present (1) or absent (0). Child Health and Health Behaviors To determine the independent impact of current maternal depression and other risk and protective factors, a dichotomous indicator of poor child health at age three or five was included, with 1 indicating the mother reported the child not in optimal health during at least one of the previous two time points. Five mother-reported child physical health behaviors at year 9 were included: (1) physical activity, (2) television viewing, (3) fast-food consumption, (4) fruit and vegetable consumption, and (5) sleeping patterns (Gladstone et al., 2015; Lang, 2012). Physical activity was measured as the amount of time spent playing outside, with a higher value representing more physical activity (0 to 16 hours per day). Television viewing was a dichotomous variable, with 1 indicating more than the recommended two hours of television watched daily (Strasburger et al., 2013). Fast-food consumption per week included three categories: (1) never ate fast-food, (2) ate fast-food once per week, and (3) ate fast-food two or more times per week. Fruit and vegetable consumption per day included three categories: (1) zero to one serving per day, (2) two to three servings per day, and (3) four or more servings per day. Sleeping pattern was a dichotomous variable, with 1 indicating the child on average got the minimum recommended hours (for example, at least nine hours) of sleep per night (Hirshkowitz et al., 2015). Maternal Health Factors Four indicators of maternal physical health at year 9 were included: (1) presence of a serious physical disability, (2) weight status, (3) diagnosis of asthma, and (4) smoking status. Mothers self-reported whether they had a serious physical disability that interfered with the ability to work, as a dichotomous variable. Maternal BMI was calculated by dividing weight (kg), which was measured by a trained interviewer at year 9, by height squared (m2), which was measured by a trained interviewer at year 3 or 5. However, 9.8% of mothers self-reported their weight. BMI was categorized into three groups: normal (<25 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). A category indicating missing data was included to retain sample size for the multivariate analyses (10.9%). Mothers also self-reported whether they had a diagnosis of asthma and how many packs of cigarettes they smoked per day, coded as no smoking, less than a pack, or a pack or more. Maternal–Child Relationship We included two mother-reported measures related to the maternal–child relationship at year 9: (1) perceived parenting stress and (2) perceived parenting competence. Parenting stress was measured by summing responses (ranging from 0 = strongly disagree to 3 = strongly agree) to the four-item Parenting Stress Index (Abidin, 1995) related to (1) parenting being harder than expected, (2) feeling trapped by parenting responsibilities, (3) finding parenting to be more work than pleasure, and (4) often feeling exhausted from parenting. A higher score indicated higher levels of perceived parenting stress. Cronbach’s alpha was .66. Parenting competence was measured by summing the responses to three items selected by Fragile Families (CRCW, 2011) from the Family Functioning section of the National Survey of Child Health (Blumberg et al., 2005) on a four-point scale, including feeling of closeness with child (ranging from 0 = not very close to 3 = extremely close), ability to communication with child (ranging from 0 = not very well to 3 = very well), and rating of self as a parent (ranging from 0 = not very good parent to 3 = excellent parent). A higher score indicated greater parenting competence. Items were combined based on face validity and Cronbach’s alpha was .59. Sociodemographic Characteristics We included 11 sociodemographic variables at the child, maternal, and family levels commonly linked to child physical well-being and maternal depression (Gladstone et al., 2015; Hardie & Landale, 2013; Lang, 2012; Turney, 2011, 2012). Child-level characteristics collected at baseline included maternal report of the child’s sex and if the child had low birthweight (<2,500 grams). Mothers were also asked if they breast-fed, and, reporting they had, were asked for how long. Breast-feeding duration included three categories: never breast-fed, breast-fed for four months or less, and breast-fed for more than four months. Baseline maternal-level controls measured included the mother’s race (white, black, other), nativity status (U.S. or foreign born), education level (less than high school, high school/GED, more than high school), marital status (married to father, not married), age (continuous in years), and report of being in poor or fair general health at baseline. Maternal poor health status at baseline was included as a proxy for postpartum depression, as data related to depression at or around the time of the child’s birth were not available (Le Strat, Dubertret, & Le Foll, 2011). Family-level controls measured at baseline include family income-to-poverty ratio based on annual poverty thresholds established by the U.S. Census Bureau (CRCW, 2008) and mother report of material hardship. Material hardship was based on seven dichotomous indicators: (1) going hungry because unable to afford food, (2) evicted due to nonpayment, (3) utilities shut off due to nonpayment, (4) housing instability due to financial problems, (5) homelessness, (6) unable to pay for needed medical services, and (7) telephone services disconnected due to nonpayment, with 1 indicating at least one past-year material hardship. Statistical Analyses All analyses were conducted using Stata (Version 12/SE) (StataCorp, 2011). Univariate analyses were conducted to examine each indicator of child physical well-being overall and by maternal depression status. Unadjusted regression analyses were conducted to examine the relationships between overall child physical health (ordered logistic) and, separately, childhood overweight and asthma (logistic) with maternal depression, sociodemographic characteristics, child health and health behaviors, maternal health factors, and maternal–child relationship factors. Significant factors (p ≤ .05) were included in adjusted models using a stepped approach. Stepped multivariate analyses estimated the relationships between the three indicators of child physical well-being and maternal depression, adjusting for sociodemographic characteristics, child health and health behaviors, maternal health factors, and maternal–child relationship factors. Survey weights were not used as there are no appropriate sample weights for data drawn from the in-home interviews (CRCW, 2008). However, variables used to generate survey weights (for example, race, marital status, and so on) were included in the analyses, and robust standard errors were estimated. Results As illustrated in Table 1, mother’s average baseline age was 25.1 years (SD = 6.0). The majority of mothers were black (48.8%), with 14.3% born outside the United States. Most mothers were unmarried (74.4%) and had a high school education or higher (69.2%), with 60% at or below 199% of the federal poverty level. Overall, 16.3% of mothers met past-year diagnostic criteria for depression. Table 1: Descriptive Statistics for Main Predictors and Covariates, by Maternal Depression (N = 2,965) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Notes: Missing: poor health at age three or five (n = 77), average hours played outside daily (n = 21), daily television viewing (n = 4), weekly fruits and vegetable consumption (n = 4), weekly fast-food consumption (n = 1), hours of sleep per night (n = 4), maternal serious disability (n = 3), maternal weight status (n = 319), maternal diagnosis of asthma (n = 54), maternal smoking status (n = 3). Superscripted numbers indicate which wave data were from. 0Baseline. 1Year 1. 3Year 3. 5Year 5. 9Year 9. Table 1: Descriptive Statistics for Main Predictors and Covariates, by Maternal Depression (N = 2,965) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Notes: Missing: poor health at age three or five (n = 77), average hours played outside daily (n = 21), daily television viewing (n = 4), weekly fruits and vegetable consumption (n = 4), weekly fast-food consumption (n = 1), hours of sleep per night (n = 4), maternal serious disability (n = 3), maternal weight status (n = 319), maternal diagnosis of asthma (n = 54), maternal smoking status (n = 3). Superscripted numbers indicate which wave data were from. 0Baseline. 1Year 1. 3Year 3. 5Year 5. 9Year 9. Approximately 15% of nine-year-old children were reported in poor/fair/good health, 41.8% were overweight (including obesity), and 29.9% had a lifetime diagnosis of asthma (see Table 2). Compared with children whose mothers were not depressed, those with depressed mothers had a lower percentage of excellent health (48.6% versus 58.0%) and a higher percentage of poor health (20.7% versus 14.1%), overweight (47.2% versus 40.7%), and asthma (33.9% versus 29.1%). Table 2: Descriptive Statistics for Child Physical Well-Being Outcomes, by Maternal Depression (N = 2,965) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Note: Missing cases for overweight (n = 239). Table 2: Descriptive Statistics for Child Physical Well-Being Outcomes, by Maternal Depression (N = 2,965) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Note: Missing cases for overweight (n = 239). Based on unadjusted regression analyses, maternal depression was a risk factor for poor overall health, with the odds of reporting poor versus very good/excellent child health being 50% higher when the mother had depression (see Table 3). In unadjusted regression analyses, maternal depression was also associated with a 35% increased risk of overweight and a 25% increased risk of asthma. Table 3: Multivariate Regression Analyses Estimating Overall Child Health Status, Childhood Overweight, and Diagnosis of Asthma as a Function of Maternal Depression Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Notes: OR = odds ratio, CI = confidence interval with robust standard errors. Ordered logistic regression: overall health status (2 = poor/fair/good, 1 = very good, 0 = excellent). Logistic regression: overweight (1 = overweight, including obesity); diagnosis of asthma (1 = lifetime diagnosis of asthma). Reference group: no maternal depression. aAdjusted for sociodemographic characteristics (child’s sex, low birthweight, breast-feeding duration, mother race, nativity status, mother education, mother age, mother marital status, mother poor health at birth, household income-to-poverty ratio, past-year material hardship). bAdjusted for child health and health behaviors (poor child health at age three or five, average hours of outside play daily, daily television viewing, daily fruit and vegetable consumption, weekly fast-food consumption, hours of sleep per night). cAdjusted for maternal health factors (mother has serious disability, mother weight status, mother diagnosis of asthma, smoking status). dAdjusted for maternal–child relationship (perceived parenting stress scaled score, perceived parenting competence scaled score). *p < .05. **p < .01. ***p < .001. Table 3: Multivariate Regression Analyses Estimating Overall Child Health Status, Childhood Overweight, and Diagnosis of Asthma as a Function of Maternal Depression Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Notes: OR = odds ratio, CI = confidence interval with robust standard errors. Ordered logistic regression: overall health status (2 = poor/fair/good, 1 = very good, 0 = excellent). Logistic regression: overweight (1 = overweight, including obesity); diagnosis of asthma (1 = lifetime diagnosis of asthma). Reference group: no maternal depression. aAdjusted for sociodemographic characteristics (child’s sex, low birthweight, breast-feeding duration, mother race, nativity status, mother education, mother age, mother marital status, mother poor health at birth, household income-to-poverty ratio, past-year material hardship). bAdjusted for child health and health behaviors (poor child health at age three or five, average hours of outside play daily, daily television viewing, daily fruit and vegetable consumption, weekly fast-food consumption, hours of sleep per night). cAdjusted for maternal health factors (mother has serious disability, mother weight status, mother diagnosis of asthma, smoking status). dAdjusted for maternal–child relationship (perceived parenting stress scaled score, perceived parenting competence scaled score). *p < .05. **p < .01. ***p < .001. In an adjusted ordered logistic regression, including sociodemographic characteristics attenuated the risk of poor health associated with maternal depression to 1.37 (95% confidence interval [CI] 1.13, 1.67), a 26% reduction (see Table 3). Adjusting for child health and health behaviors and maternal health factors further attenuated the odds of poor health associated with maternal depression to 1.27 (95% CI [1.03, 1.58]). After adjustment for the maternal parenting stress and competence sum scores, the association between maternal depression and overall health status was no longer significant. In addition, results from a Karlson-Holm-Breen (KHB) mediational model (Breen, Karlson, & Holm, 2013) indicated that maternal parenting stress and competence completely mediated the association between maternal depression and overall child health status after controlling for all other risk and protective factors from the final model (total effect odds ratio [OR] = 1.28, p = .025; direct effect OR = 1.16, p = .188; indirect effect OR = 1.11, p < .001). However, maternal depression remained a significant risk factor for overweight after controlling for sociodemographic characteristics, child health and health behaviors, maternal health factors, and the maternal–child relationship, resulting in a 35% increased odds for children with a depressed mother. Maternal depression was no longer associated with a lifetime diagnosis of childhood asthma after adjusting for sociodemographic characteristics. In the final models, there were also a number of individual predictors related to each child physical health outcome. For child overall health, risk factors included poor child health at age three or five (adjusted OR [AOR] = 4.31, 95% CI [3.38, 5.51]) more than two hours of television daily (AOR = 1.30, 95% CI [1.11, 1.53]), fast-food consumption two or more times per week (AOR = 1.27, 95% CI [1.03, 1.57]), and higher parenting stress (AOR = 1.04, 95% CI [1.01, 1.07]). Protective factors associated with a decreased risk of poor health included more hours spent playing outside (AOR = 0.96, 95% CI [0.93, 0.99]), four or more servings of fruits and vegetables (AOR = 0.69, 95% CI [0.54, 0.88]), and higher parenting competence (AOR = 0.81, 95% CI [0.77, 0.86]). For child overweight, additional risk factors included fast-consumption more than two times per week (AOR = 1.26, 95% CI [1.01, 1.58]) and having an overweight (AOR = 1.89, 95% CI [1.50, 2.38]) or obese (AOR = 3.20, 95% CI [2.58, 3.98]) mother. Factors associated with an increased risk of a diagnosis of asthma included poor child health at three or five years of age (AOR = 2.57, 95% CI [1.96, 3.38]), fast-food consumption one to two times per week (AOR = 1.26, 95% CI [1.01, 1.57]), maternal diagnosis of asthma (AOR = 2.57, 95% CI [2.06, 3.21]), and higher parenting competence (AOR = 1.07, 95% CI [1.01, 1.15]. No protective factors were associated with either child overweight or asthma. Discussion This study used a large community sample of mothers and children with information on a comprehensive list of sociodemographic, child-, maternal-, and family-level factors, including two maternal–child relationship factors. We found that whereas most nine-year-olds were reported to be in very good or excellent health, nearly half of children were overweight and about a third had a lifetime diagnosis of asthma. Approximately one in six mothers had experienced past-12-month depression, and children of these mothers were more likely reported to be in poor health and to have an increased risk of overweight and asthma. However, the association between maternal depression and these three indicators of child physical health outcomes differed after taking into account additional risk and protective factors. Maternal depression was associated with an increased risk of poor overall child health after controlling for sociodemographic characteristics, child health and health behaviors, and maternal health, but was no longer significant after including two factors related to the maternal–child relationship. This suggests that lower parenting stress and greater parenting competence may attenuate the risk of poor overall child health as a function of maternal depression. A KHB mediational model supported that these two maternal–child relationship factors completely mediated the association between maternal depression and child overall health at age nine. Although the importance of the maternal–child relationship for child psychological and emotional well-being in the context of maternal depression has been well established (Gladstone et al., 2015; Goodman et al., 2011; Reuben & Shaw, 2015), this factor has rarely been examined for child physical health outcomes. For children, physical and psychological well-being are interconnected and should garner more equal attention from research and practice. It is important to acknowledge that the report of overall child health is based on maternal report and that those who report high levels of parenting stress and low levels of parenting competence may be more likely to report poor child health, regardless of the actual health of the child. Also, mothers with depression may have a distorted perception of their parenting ability and the well-being of their children (Gartstein, Bridgett, Dishion, & Kaufman, 2009), suggesting that mothers with depression should be supported in their appraisal of parenting stress and competence as well as their child’s health status. Regardless, the mother’s perception that her child is in poor health may have consequences for the well-being of the child. Findings also revealed that maternal depression remained a significant risk factor for childhood overweight, even after controlling for multiple risk and protective factors. Our findings, while consistent with a meta-analysis of current literature (Lampard et al., 2014), contribute to this body of research by including a more comprehensive set of risk and protective factors. Our results highlight additional factors influencing overweight, including fast-food consumption and maternal weight status. Given the nature of depression, mothers may be more likely to rely on fast food as opposed to preparing meals for their children, contributing to their own unhealthy weight and that of the children. More research is needed to better understand the pathways through which maternal depression affects childhood overweight. Maternal depression was no longer a risk factor for a lifetime diagnosis of asthma after adjustment for sociodemographic characteristics, suggesting that these factors attenuated the risk associated with maternal depression. It is noteworthy that parenting competence was significantly associated with an increased risk of an asthma diagnosis, which may be related to the fact that the indicator of asthma requires a diagnosis from a health care professional. As such, greater parenting competence may mean that the mother is more likely to take the child to a doctor. Findings also highlighted modifiable risk and protective factors associated with overall health, overweight, and diagnosis of asthma, which are consistent with existing literature (Gladstone et al., 2015; Hirshkowitz et al., 2015; Lang, 2012). For overall health, more television viewing and fast-food consumption were related to poor child health, whereas more time spent playing outside and more fruits and vegetables consumed were related to better overall health. For overweight, more fast-food consumption and maternal overweight and obesity were associated with increased risk of childhood overweight, similar to previous findings (Lang, 2012). For asthma, increased fast-food consumption was also a risk factor. These findings suggest that modifiable child health behaviors had a major impact on child health outcomes and should be the focus of intervention and prevention programs before school age. In addition, research should focus on how maternal depression may affect child health behaviors, leading to poor health outcomes. There are some limitations to address. First, our factors were not exhaustive, but did represent a range of well-established risk and protective factors influencing children’s physical well-being (Gladstone et al., 2015; Turney, 2011, 2012). Additional variables that would be important to consider are those related to maternal health behaviors, including levels of physical activity, dietary habits, and sleep patterns, which have been shown to influence a mother’s health and the health behaviors of her children (Lampard et al., 2014). Also, the indicator of maternal depression is a dichotomous measure of past-12-month depression and does not take into account onset, severity, or chronicity, as attrition resulted in missing data for maternal depression across waves. Depression was not measured at baseline, so poor maternal general health was included as a proxy for postpartum depression (Le Strat et al., 2011). Regardless, the CIDI is a highly validated measure of depression (Kessler et al., 1998). Although our findings do not suggest a causal relationship, they highlight a significant association between maternal depression and child physical health outcomes. Finally, the analytic sample was more advantaged than the follow-up sample, suggesting that our results may be an underrepresentation of the association between maternal depression and child physical well-being. Despite limitations, our findings contribute to the literature regarding the impact of maternal depression on child physical well-being, particularly by providing a more in-depth understanding of the role of two factors related to the mother–child relationship. Based on our findings, programs aimed at helping mothers with depression reduce parenting stress and increase competence may mitigate the risk to child physical well-being. Screening for maternal depression during routine child well-visits may lead to early identification and treatment, which may also have an upstream effect on child health outcomes. Our findings also suggest that screening for maternal depression should continue throughout childhood. Finally, additional research should focus on exploring the pathways through which maternal depression is associated with child physical well-being, including the temporal order between maternal depression symptom and child physical health outcomes. Sarah Dow-Fleisner, PhD, is assistant professor, Faculty of Health and Social Development, School of Social Work, University of British Columbia-Okanagan, 1147 Research Road, Kelowna, BC, Canada V1V 1V7; e-mail: sarah.dow-fleisner@ubc.ca. Summer Sherburne Hawkins, PhD, MS, is associate professor, School of Social Work, Boston College, Chestnut Hill, MA. The Fragile Families and Child Wellbeing Study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (NIH) under award numbers R01HD36916, R01HD39135, and R01HD40421 and by a consortium of private foundations. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. References Abidin , R. R. ( 1995 ). Parenting Stress Index . Odessa, FL : Psychological Assessment Resources . American Psychiatric Association . ( 2013 ). Diagnostic and statistical manual of mental disorders ( 5th ed. ). 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Rockville, MD : Author . Waldfogel , J. , Craigie , T. , & Brooks-Gunn , J. ( 2010 ). Fragile Families and Child Wellbeing . Future of Children, 20 ( 2 ), 87 – 112 . doi:10.1353/foc.2010.0002 Google Scholar CrossRef Search ADS © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social Work Research Oxford University Press

Child Physical Well-Being in the Context of Maternal Depression

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Oxford University Press
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© 2018 National Association of Social Workers
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1070-5309
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1545-6838
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10.1093/swr/svy006
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Abstract

Abstract Maternal depression is associated with negative outcomes in children, with less known about physical health outcomes. Poor child physical health is a robust predictor of negative outcomes across the life course. Thus, authors examined the association between maternal depression and child physical well-being, accounting for multiple risk and protective factors. Data from the Fragile Families and Child Wellbeing Study (N = 2,965) were used to examine the association between three indicators of child physical well-being (overall health status, overweight, and asthma) and maternal depression at the nine-year follow-up, controlling for child-, maternal-, and family-level risk and protective factors. Unadjusted regression analyses revealed that maternal depression was associated with increased rates of poor overall health, overweight, and asthma. When adjusting for parenting stress and competence, maternal depression was no longer a significant risk factor for overall poor health; when controlling for sociodemographic characteristics, it was no longer a risk factor for asthma. After adjusting for multiple factors, maternal depression remained a significant risk factor for childhood overweight. Findings highlight the importance of reducing perceived parenting stress and increasing competence for depressed mothers and suggest that more research is needed to examine pathways through which maternal depression may lead to childhood overweight. Ensuring that all children have a healthy start in life is an important social work priority (Hawkins et al., 2015), as poor physical health in childhood is one of the most robust predictors of adverse outcomes in adolescence and adulthood (Hardie & Landale, 2013; Shonkoff, Boyce, & McEwen, 2009). Poor physical health at any point throughout childhood may lead to impairments in daily functioning and increase the risk of morbidity and early mortality, resulting in substantial individual, economic, and social consequences (Ogden, Carroll, Kit, & Flegal, 2014; U.S. Burden of Disease Collaborators, 2013). Nevertheless, poor physical health in childhood remains a significant problem in the United States. Although the majority of parents report that their child is in excellent or very good health, 16% of children are reported as not having optimal overall health (U.S. Department of Health and Human Services [HHS], 2014). In addition, nearly one in three children in the United States is overweight or obese (Ogden et al., 2014), and 14% of children have a lifetime diagnosis of asthma, a chronic health condition associated with a decreased quality of life (Bloom & Freeman, 2015). It is noteworthy that from early to middle childhood there are significant increases in the rates of poor overall health, overweight, and asthma (Bloom & Freeman, 2015; Ogden et al., 2014; HHS, 2015). Poor overall health, overweight, and asthma in childhood are associated with negative consequences that may continue into adulthood (Shonkoff et al., 2009). Understanding factors in childhood associated with poor physical health is essential for improving overall health and functioning throughout the life course. For young children, the family, particularly the mother, has the most influence on overall child well-being, including physical health, as mothers are often the primary caregiver (Maternal and Child Health Bureau, 2010; Parker, Baldwin, Israel, & Salinas, 2004). Thus, maternal health factors, including maternal depression, may be associated with differences in child physical health outcomes (Hardie & Landale, 2013; Turney, 2011). In a given year, approximately 10% to 20% of mothers will have an episode of depression (American Psychiatric Association [APA], 2013), with over 7.6 million children living with a mother with depression (Ertel, Rich-Edwards, & Koenen, 2011; Pratt & Brody, 2014). Depression is a psychiatric disorder characterized by persistent dysphoria or anhedonia, along with other somatic, psychological, and behavioral symptoms (APA, 2013). There is also a specifier for women if symptom onset occurs during the peripartum period, commonly called postpartum depression (APA, 2013). The timing of symptom onset is important; however, fewer studies have examined the impact of maternal depression on child well-being occurring later in childhood, despite the fact that depression may be present at any time throughout childhood (Turney, 2012). By definition, maternal depression is a debilitating and persistent condition, leading to impairments in daily functioning for the mother related to her physical health, family relationships, and social interactions (Farr & Bish, 2013; Pratt & Brody, 2014). Maternal depression is associated with lower levels of self-efficacy and decreased feelings of mastery (Farmer & Lee, 2011). As such, mothers may perceive parenting as more stressful and may view themselves as less able to parent effectively (Farmer & Lee, 2011). Maternal depression has also been consistently identified as a risk factor to child emotional and psychological well-being, with disruptions in the maternal–child relationship as the primary mechanism (Gladstone, Beardslee, & Diehl, 2015; Goodman et al., 2011; Reuben & Shaw, 2015). Among the few studies that have examined the impact of maternal depression on child physical well-being, depression was associated with increased rates of poor child health, overweight, and asthma (Lampard, Franckle, & Davison, 2014; Repetti, Taylor, & Seeman, 2002; Turney, 2011). However, many of these studies did not include a comprehensive set of confounding factors or consider the impact of factors related to the maternal–child relationship, such as parenting stress and competence. A comprehensive set of factors is needed, as there are common contextual risks, like income and material hardship, associated with increased rates of both maternal depression and poor child physical health (Ertel et al., 2011; Pratt & Brody, 2014; HHS, 2015). These factors must be accounted and controlled for to determine the unique association between maternal depression and child physical health outcomes. Thus, the aims of this article were, first, to determine the association between maternal depression on three indicators of child physical well-being (overall health status, overweight, and asthma) and, second, to identify risk and protective factors related to child physical well-being, including the role of maternal perception of parenting stress and competence. Method The Fragile Families and Child Wellbeing Study is an ongoing, longitudinal, cohort study following 4,898 children born in a large U.S. city between 1998 and 2000 to mostly unmarried parents (Bendheim-Thoman Center for Research on Child Wellbeing [CRCW], 2008). Biological mothers (N = 4,898) were interviewed at or around the time of the focal baby’s birth (baseline), with follow-up interviews conducted when the child was one, three, five, and nine years old. Interviews consisted of core telephone interviews and in-home face-to-face interviews. Of the 4,898 mothers initially interviewed, 3,309 (67.6%) completed the nine-year in-home primary caregiver interview (CRCW, 2011). Present analyses included 2,965 mothers interviewed at year 9. Observations were excluded if data were missing on any of the sociodemographic variables (n = 312) or maternal depression indicator (n = 12), if the child had a serious physical disability (for example, cerebral palsy, n = 75), and if the child lived less than half-time with the mother (n = 4). Some mothers satisfied more than one exclusion criterion. There were also 239 missing observations for child body mass index (BMI), with 162 children having not been measured and 77 flagged due to measurement errors. Observations with missing BMI data were excluded from that analysis only. The analytic sample was more advantaged when compared with the nine-year follow-up sample, with lower rates of low birthweight, longer breast-feeding duration, higher levels of maternal education, and higher income, and mothers were more likely to be married (p < .01). In addition, mothers in the analytic sample were less likely to be depressed (16.3%) as compared with those in the nine-year follow-up sample (24.0%), χ2(1) = 18.7, p < .001. However, there were no differences in baby’s sex, mother’s age, and levels of parenting stress and competence between the analytic and the nine-year follow-up sample. Measures Child Physical Well-Being Outcome measures were three commonly used indicators of child physical well-being at age nine: (1) overall health status; (2) overweight, including obesity; and (3) diagnosis of asthma (Moore, Murphey, Bandy, & Lawner, 2014). Overall health status was reported by the mother, who was asked about the general health of her child. There were three coded response categories (0 = excellent, 1 = very good, 2 = good/fair/poor). Overweight, including obesity, was based on the Centers for Disease Control and Prevention BMI growth chart guidelines for age and sex using the interviewer measured height (m) and weight (kg), with 1 indicating a BMI (kg/m2) at or above the 85th percentile (Waldfogel, Craigie, & Brooks-Gunn, 2010). For asthma, the mother reported whether her child had ever been diagnosed with asthma by a health care professional, with 1 indicating asthma diagnosis. Maternal Depression Maternal depression was measured at year 9 using the Composite International Diagnostic Interview–Short Form (CIDI–SF) (Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998). If mothers reported experiencing either dysphoria or anhedonia on most days for at least two weeks during the past 12 months, they were asked about seven additional symptoms. Those reporting either dysphoria or anhedonia and three additional symptoms were considered depressed. Mothers who reported taking medication for depression were not asked about symptoms, but were coded as having depression (CRCW, 2011). Maternal depression was coded as present (1) or absent (0). Child Health and Health Behaviors To determine the independent impact of current maternal depression and other risk and protective factors, a dichotomous indicator of poor child health at age three or five was included, with 1 indicating the mother reported the child not in optimal health during at least one of the previous two time points. Five mother-reported child physical health behaviors at year 9 were included: (1) physical activity, (2) television viewing, (3) fast-food consumption, (4) fruit and vegetable consumption, and (5) sleeping patterns (Gladstone et al., 2015; Lang, 2012). Physical activity was measured as the amount of time spent playing outside, with a higher value representing more physical activity (0 to 16 hours per day). Television viewing was a dichotomous variable, with 1 indicating more than the recommended two hours of television watched daily (Strasburger et al., 2013). Fast-food consumption per week included three categories: (1) never ate fast-food, (2) ate fast-food once per week, and (3) ate fast-food two or more times per week. Fruit and vegetable consumption per day included three categories: (1) zero to one serving per day, (2) two to three servings per day, and (3) four or more servings per day. Sleeping pattern was a dichotomous variable, with 1 indicating the child on average got the minimum recommended hours (for example, at least nine hours) of sleep per night (Hirshkowitz et al., 2015). Maternal Health Factors Four indicators of maternal physical health at year 9 were included: (1) presence of a serious physical disability, (2) weight status, (3) diagnosis of asthma, and (4) smoking status. Mothers self-reported whether they had a serious physical disability that interfered with the ability to work, as a dichotomous variable. Maternal BMI was calculated by dividing weight (kg), which was measured by a trained interviewer at year 9, by height squared (m2), which was measured by a trained interviewer at year 3 or 5. However, 9.8% of mothers self-reported their weight. BMI was categorized into three groups: normal (<25 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). A category indicating missing data was included to retain sample size for the multivariate analyses (10.9%). Mothers also self-reported whether they had a diagnosis of asthma and how many packs of cigarettes they smoked per day, coded as no smoking, less than a pack, or a pack or more. Maternal–Child Relationship We included two mother-reported measures related to the maternal–child relationship at year 9: (1) perceived parenting stress and (2) perceived parenting competence. Parenting stress was measured by summing responses (ranging from 0 = strongly disagree to 3 = strongly agree) to the four-item Parenting Stress Index (Abidin, 1995) related to (1) parenting being harder than expected, (2) feeling trapped by parenting responsibilities, (3) finding parenting to be more work than pleasure, and (4) often feeling exhausted from parenting. A higher score indicated higher levels of perceived parenting stress. Cronbach’s alpha was .66. Parenting competence was measured by summing the responses to three items selected by Fragile Families (CRCW, 2011) from the Family Functioning section of the National Survey of Child Health (Blumberg et al., 2005) on a four-point scale, including feeling of closeness with child (ranging from 0 = not very close to 3 = extremely close), ability to communication with child (ranging from 0 = not very well to 3 = very well), and rating of self as a parent (ranging from 0 = not very good parent to 3 = excellent parent). A higher score indicated greater parenting competence. Items were combined based on face validity and Cronbach’s alpha was .59. Sociodemographic Characteristics We included 11 sociodemographic variables at the child, maternal, and family levels commonly linked to child physical well-being and maternal depression (Gladstone et al., 2015; Hardie & Landale, 2013; Lang, 2012; Turney, 2011, 2012). Child-level characteristics collected at baseline included maternal report of the child’s sex and if the child had low birthweight (<2,500 grams). Mothers were also asked if they breast-fed, and, reporting they had, were asked for how long. Breast-feeding duration included three categories: never breast-fed, breast-fed for four months or less, and breast-fed for more than four months. Baseline maternal-level controls measured included the mother’s race (white, black, other), nativity status (U.S. or foreign born), education level (less than high school, high school/GED, more than high school), marital status (married to father, not married), age (continuous in years), and report of being in poor or fair general health at baseline. Maternal poor health status at baseline was included as a proxy for postpartum depression, as data related to depression at or around the time of the child’s birth were not available (Le Strat, Dubertret, & Le Foll, 2011). Family-level controls measured at baseline include family income-to-poverty ratio based on annual poverty thresholds established by the U.S. Census Bureau (CRCW, 2008) and mother report of material hardship. Material hardship was based on seven dichotomous indicators: (1) going hungry because unable to afford food, (2) evicted due to nonpayment, (3) utilities shut off due to nonpayment, (4) housing instability due to financial problems, (5) homelessness, (6) unable to pay for needed medical services, and (7) telephone services disconnected due to nonpayment, with 1 indicating at least one past-year material hardship. Statistical Analyses All analyses were conducted using Stata (Version 12/SE) (StataCorp, 2011). Univariate analyses were conducted to examine each indicator of child physical well-being overall and by maternal depression status. Unadjusted regression analyses were conducted to examine the relationships between overall child physical health (ordered logistic) and, separately, childhood overweight and asthma (logistic) with maternal depression, sociodemographic characteristics, child health and health behaviors, maternal health factors, and maternal–child relationship factors. Significant factors (p ≤ .05) were included in adjusted models using a stepped approach. Stepped multivariate analyses estimated the relationships between the three indicators of child physical well-being and maternal depression, adjusting for sociodemographic characteristics, child health and health behaviors, maternal health factors, and maternal–child relationship factors. Survey weights were not used as there are no appropriate sample weights for data drawn from the in-home interviews (CRCW, 2008). However, variables used to generate survey weights (for example, race, marital status, and so on) were included in the analyses, and robust standard errors were estimated. Results As illustrated in Table 1, mother’s average baseline age was 25.1 years (SD = 6.0). The majority of mothers were black (48.8%), with 14.3% born outside the United States. Most mothers were unmarried (74.4%) and had a high school education or higher (69.2%), with 60% at or below 199% of the federal poverty level. Overall, 16.3% of mothers met past-year diagnostic criteria for depression. Table 1: Descriptive Statistics for Main Predictors and Covariates, by Maternal Depression (N = 2,965) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Notes: Missing: poor health at age three or five (n = 77), average hours played outside daily (n = 21), daily television viewing (n = 4), weekly fruits and vegetable consumption (n = 4), weekly fast-food consumption (n = 1), hours of sleep per night (n = 4), maternal serious disability (n = 3), maternal weight status (n = 319), maternal diagnosis of asthma (n = 54), maternal smoking status (n = 3). Superscripted numbers indicate which wave data were from. 0Baseline. 1Year 1. 3Year 3. 5Year 5. 9Year 9. Table 1: Descriptive Statistics for Main Predictors and Covariates, by Maternal Depression (N = 2,965) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Variable Total No Depression Depression n (%) M (SD) n (%) M (SD) n (%) M (SD) Maternal depression9  No depression 2,481 (83.7)  Depression 484 (16.3) Sociodemographic characteristics  Child’s sex0   Female 1, 417 (47.8) 1,199 (48.3) 218 (45.1)   Male 1,548 (52.2) 1,282 (51.7) 266 (54.9)  Low birthweight0   No 2,703 (91.2) 2,265 (91.3) 438 (90.5)   Yes 262 (8.8) 216 (8.7) 46 (9.5)  Breast-feeding duration1   Did not breast-feed 1,225 (41.3) 1,026 (43.4) 199 (41.1)   Breast-fed ≤ 4 months 890 (30.0) 730 (29.4) 106 (33.1)   Breast-fed > 4 months 850 (28.7) 725 (29.2) 125 (25.8)  Mother race0   White 669 (22.6) 552 (22.2) 117 (24.2)   Black 1,446 (48.8) 1,197 (48.3) 249 (51.5)   Other 850 (28.7) 732 (29.5) 118 (24.4)  Nativity status0   Foreign born 425 (14.3) 381 (15.4) 44 (9.1)   U.S. born 2,540 (85.7) 2,100 (84.6) 440 (90.9)  Mother education0   Less than high school 913 (30.8) 730 (29.4) 183 (37.8)   High school 934 (31.5) 783 (31.6) 151 (31.2)   More than high school 1,118 (37.7) 968 (39.0) 150 (31.0)  Mother’s age (years) 25.12 (6.0) 25.27 (6.1) 24.32 (5.7)  Mother married0   No 2,206 (74.4) 1,802 (72.6) 404 (83.5)   Yes 759 (25.6) 679 (27.4) 80 (16.5)  Mother poor health status0   No 2,007 (67.7) 1,715 (69.1) 292 (60.3)   Yes 958 (32.3) 766 (30.9) 192 (39.7)  Household income-to-poverty ratio (%)0   0–49 513 (17.3) 407 (16.4) 106 (21.9)   50–99 485 (16.4) 395 (15.9) 90 (18.6)   100–199 778 (26.2) 649 (26.2) 129 (26.7)   200–299 465 (15.7) 391 (15.8) 74 (15.3)   300–399 401 (13.5) 348 (14.0) 53 (10.9)   400+ 323 (10.9) 291 (11.7) 32 (6.6)  Experienced material hardship in past year9   No 1,968 (66.4) 1,772 (71.4) 196 (40.5)   Yes 997 (33.6) 709 (28.6) 288 (59.5) Child health and health behaviors  Poor health at age three or five3,5   No 2,576 (89.2) 2,156 (89.2) 420 (89.0)   Yes 312 (10.8) 260 (10.7) 52 (11.0)  Average hours played outside daily9 3.88 (2.26) 3.85 (2.25) 4.05 (2.32)  Daily television viewing9   Two hours or less 1,163 (39.3) 1,009 (40.7) 154 (31.9)   More than two hours 1,798 (60.7) 1,469 (59.3) 329 (68.1)  Weekly fruit/vegetable consumption9   One or fewer servings 899 (30.4) 748 (30.2) 151 (31.2)   Two to three servings 1,590 (53.7) 1,336 (53.9) 254 (52.5)   Four or more servings 472 (15.9) 393 (15.9) 79 (16.3)  Weekly fast-food consumption9   0 times 770 (26.0) 645 (26.0) 125 (25.8)   1 time 1,259 (42.5) 1,059 (42.7) 200 (41.3)   2 or more times 935 (31.5) 776 (31.3) 159 (32.9)  Hours of sleep per night9   Fewer than nine hours 1,023 (34.6) 837 (33.8) 186 (38.6)   Nine hours or more 1,938 (65.4) 1,642 (66.2) 296 (61.4) Maternal health factors   Has serious disability9   No 2,631 (88.7) 2,293 (92.5) 338 (70.1)   Yes 331 (11.3) 187 (7.5) 144 (29.9)  Weight status9   Normal 776 (29.3) 661 (29.7) 115 (27.3)   Overweight 740 (28.0) 636 (29.6) 104 (24.7)   Obese 1,130 (42.7) 928 (41.7) 202 (48.0)  Has diagnosis of asthma9   No 2,466 (84.71) 2,098 (85.8) 368 (79.0)   Yes 445 (15.29) 347 (14.2) 98 (21.0)  Smoking status9   Does not smoke 2,151 (72.62) 1,884 (76.0) 267 (55.3)   Less than one pack per day 574 (19.38) 444 (17.9) 130 (26.9)   One pack or more per day 237 (8.00) 151 (6.1) 86 (17.8) Maternal–child relationship  Parenting stress score  (continuous, 0–12)9 4.09 (2.72) 3.86 (2.62) 5.27 (2.90)  Parenting competence score  (continuous, 0–9)9 7.20 (1.45) 7.25 (1.44) 6.97 (1.52) Notes: Missing: poor health at age three or five (n = 77), average hours played outside daily (n = 21), daily television viewing (n = 4), weekly fruits and vegetable consumption (n = 4), weekly fast-food consumption (n = 1), hours of sleep per night (n = 4), maternal serious disability (n = 3), maternal weight status (n = 319), maternal diagnosis of asthma (n = 54), maternal smoking status (n = 3). Superscripted numbers indicate which wave data were from. 0Baseline. 1Year 1. 3Year 3. 5Year 5. 9Year 9. Approximately 15% of nine-year-old children were reported in poor/fair/good health, 41.8% were overweight (including obesity), and 29.9% had a lifetime diagnosis of asthma (see Table 2). Compared with children whose mothers were not depressed, those with depressed mothers had a lower percentage of excellent health (48.6% versus 58.0%) and a higher percentage of poor health (20.7% versus 14.1%), overweight (47.2% versus 40.7%), and asthma (33.9% versus 29.1%). Table 2: Descriptive Statistics for Child Physical Well-Being Outcomes, by Maternal Depression (N = 2,965) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Note: Missing cases for overweight (n = 239). Table 2: Descriptive Statistics for Child Physical Well-Being Outcomes, by Maternal Depression (N = 2,965) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Total No Depression Depression Indicator n (%) n (%) n (%) Overall health status  Poor, fair, good 450 (15.2) 350 (14.1) 100 (20.7)  Very good 841 (28.4) 692 (27.9) 149 (30.8)  Excellent 1,674 (56.5) 1,439 (58.0) 235 (48.6) Overweight (including obesity)  No 1,587 (58.2) 1,351 (59.3) 236 (52.8)  Yes 1,139 (41.8) 928 (40.7) 211 (47.2) Diagnosis of asthma  No 2,078 (70.1) 1,758 (70.9) 320 (66.1)  Yes 887 (29.9) 723 (29.1) 164 (33.9) Note: Missing cases for overweight (n = 239). Based on unadjusted regression analyses, maternal depression was a risk factor for poor overall health, with the odds of reporting poor versus very good/excellent child health being 50% higher when the mother had depression (see Table 3). In unadjusted regression analyses, maternal depression was also associated with a 35% increased risk of overweight and a 25% increased risk of asthma. Table 3: Multivariate Regression Analyses Estimating Overall Child Health Status, Childhood Overweight, and Diagnosis of Asthma as a Function of Maternal Depression Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Notes: OR = odds ratio, CI = confidence interval with robust standard errors. Ordered logistic regression: overall health status (2 = poor/fair/good, 1 = very good, 0 = excellent). Logistic regression: overweight (1 = overweight, including obesity); diagnosis of asthma (1 = lifetime diagnosis of asthma). Reference group: no maternal depression. aAdjusted for sociodemographic characteristics (child’s sex, low birthweight, breast-feeding duration, mother race, nativity status, mother education, mother age, mother marital status, mother poor health at birth, household income-to-poverty ratio, past-year material hardship). bAdjusted for child health and health behaviors (poor child health at age three or five, average hours of outside play daily, daily television viewing, daily fruit and vegetable consumption, weekly fast-food consumption, hours of sleep per night). cAdjusted for maternal health factors (mother has serious disability, mother weight status, mother diagnosis of asthma, smoking status). dAdjusted for maternal–child relationship (perceived parenting stress scaled score, perceived parenting competence scaled score). *p < .05. **p < .01. ***p < .001. Table 3: Multivariate Regression Analyses Estimating Overall Child Health Status, Childhood Overweight, and Diagnosis of Asthma as a Function of Maternal Depression Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Model 1: Bivariate Model 2: M1 + Sociodemographic Characteristicsa Model 3: M2 + Child Health and Health Behaviorsa,b Model 4: M3 Maternal Health Factorsa,b,c Model 5: M4 + Maternal–Child Relationshipa,b,c,d Indicator Unadjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Adjusted OR [95% CI] Overall health  No maternal  depression — — — — —  Maternal  depression 1.50 [1.24, 1.80]*** 1.37 [1.13, 1.67]** 1.34 [1.10, 1.65]** 1.27 [1.03, 1.58]* 1.16 [0.93, 1.44] Overweight (including obesity)  No maternal  depression — — — — —  Maternal  depression 1.30 [1.06, 1.60]* 1.36 [1.10, 1.69]** 1.35 [1.08, 1.67]** 1.35 [1.06, 1.72]* 1.35 [1.06, 1.72]* Diagnosis of asthma  No maternal  depression — — — — —  Maternal  depression 1.25 [1.01, 1.53]* 1.12 [0.98, 1.40] 1.15 [0.92, 1.45] 1.07 [0.83, 1.38] 1.09 [0.85, 1.41] Notes: OR = odds ratio, CI = confidence interval with robust standard errors. Ordered logistic regression: overall health status (2 = poor/fair/good, 1 = very good, 0 = excellent). Logistic regression: overweight (1 = overweight, including obesity); diagnosis of asthma (1 = lifetime diagnosis of asthma). Reference group: no maternal depression. aAdjusted for sociodemographic characteristics (child’s sex, low birthweight, breast-feeding duration, mother race, nativity status, mother education, mother age, mother marital status, mother poor health at birth, household income-to-poverty ratio, past-year material hardship). bAdjusted for child health and health behaviors (poor child health at age three or five, average hours of outside play daily, daily television viewing, daily fruit and vegetable consumption, weekly fast-food consumption, hours of sleep per night). cAdjusted for maternal health factors (mother has serious disability, mother weight status, mother diagnosis of asthma, smoking status). dAdjusted for maternal–child relationship (perceived parenting stress scaled score, perceived parenting competence scaled score). *p < .05. **p < .01. ***p < .001. In an adjusted ordered logistic regression, including sociodemographic characteristics attenuated the risk of poor health associated with maternal depression to 1.37 (95% confidence interval [CI] 1.13, 1.67), a 26% reduction (see Table 3). Adjusting for child health and health behaviors and maternal health factors further attenuated the odds of poor health associated with maternal depression to 1.27 (95% CI [1.03, 1.58]). After adjustment for the maternal parenting stress and competence sum scores, the association between maternal depression and overall health status was no longer significant. In addition, results from a Karlson-Holm-Breen (KHB) mediational model (Breen, Karlson, & Holm, 2013) indicated that maternal parenting stress and competence completely mediated the association between maternal depression and overall child health status after controlling for all other risk and protective factors from the final model (total effect odds ratio [OR] = 1.28, p = .025; direct effect OR = 1.16, p = .188; indirect effect OR = 1.11, p < .001). However, maternal depression remained a significant risk factor for overweight after controlling for sociodemographic characteristics, child health and health behaviors, maternal health factors, and the maternal–child relationship, resulting in a 35% increased odds for children with a depressed mother. Maternal depression was no longer associated with a lifetime diagnosis of childhood asthma after adjusting for sociodemographic characteristics. In the final models, there were also a number of individual predictors related to each child physical health outcome. For child overall health, risk factors included poor child health at age three or five (adjusted OR [AOR] = 4.31, 95% CI [3.38, 5.51]) more than two hours of television daily (AOR = 1.30, 95% CI [1.11, 1.53]), fast-food consumption two or more times per week (AOR = 1.27, 95% CI [1.03, 1.57]), and higher parenting stress (AOR = 1.04, 95% CI [1.01, 1.07]). Protective factors associated with a decreased risk of poor health included more hours spent playing outside (AOR = 0.96, 95% CI [0.93, 0.99]), four or more servings of fruits and vegetables (AOR = 0.69, 95% CI [0.54, 0.88]), and higher parenting competence (AOR = 0.81, 95% CI [0.77, 0.86]). For child overweight, additional risk factors included fast-consumption more than two times per week (AOR = 1.26, 95% CI [1.01, 1.58]) and having an overweight (AOR = 1.89, 95% CI [1.50, 2.38]) or obese (AOR = 3.20, 95% CI [2.58, 3.98]) mother. Factors associated with an increased risk of a diagnosis of asthma included poor child health at three or five years of age (AOR = 2.57, 95% CI [1.96, 3.38]), fast-food consumption one to two times per week (AOR = 1.26, 95% CI [1.01, 1.57]), maternal diagnosis of asthma (AOR = 2.57, 95% CI [2.06, 3.21]), and higher parenting competence (AOR = 1.07, 95% CI [1.01, 1.15]. No protective factors were associated with either child overweight or asthma. Discussion This study used a large community sample of mothers and children with information on a comprehensive list of sociodemographic, child-, maternal-, and family-level factors, including two maternal–child relationship factors. We found that whereas most nine-year-olds were reported to be in very good or excellent health, nearly half of children were overweight and about a third had a lifetime diagnosis of asthma. Approximately one in six mothers had experienced past-12-month depression, and children of these mothers were more likely reported to be in poor health and to have an increased risk of overweight and asthma. However, the association between maternal depression and these three indicators of child physical health outcomes differed after taking into account additional risk and protective factors. Maternal depression was associated with an increased risk of poor overall child health after controlling for sociodemographic characteristics, child health and health behaviors, and maternal health, but was no longer significant after including two factors related to the maternal–child relationship. This suggests that lower parenting stress and greater parenting competence may attenuate the risk of poor overall child health as a function of maternal depression. A KHB mediational model supported that these two maternal–child relationship factors completely mediated the association between maternal depression and child overall health at age nine. Although the importance of the maternal–child relationship for child psychological and emotional well-being in the context of maternal depression has been well established (Gladstone et al., 2015; Goodman et al., 2011; Reuben & Shaw, 2015), this factor has rarely been examined for child physical health outcomes. For children, physical and psychological well-being are interconnected and should garner more equal attention from research and practice. It is important to acknowledge that the report of overall child health is based on maternal report and that those who report high levels of parenting stress and low levels of parenting competence may be more likely to report poor child health, regardless of the actual health of the child. Also, mothers with depression may have a distorted perception of their parenting ability and the well-being of their children (Gartstein, Bridgett, Dishion, & Kaufman, 2009), suggesting that mothers with depression should be supported in their appraisal of parenting stress and competence as well as their child’s health status. Regardless, the mother’s perception that her child is in poor health may have consequences for the well-being of the child. Findings also revealed that maternal depression remained a significant risk factor for childhood overweight, even after controlling for multiple risk and protective factors. Our findings, while consistent with a meta-analysis of current literature (Lampard et al., 2014), contribute to this body of research by including a more comprehensive set of risk and protective factors. Our results highlight additional factors influencing overweight, including fast-food consumption and maternal weight status. Given the nature of depression, mothers may be more likely to rely on fast food as opposed to preparing meals for their children, contributing to their own unhealthy weight and that of the children. More research is needed to better understand the pathways through which maternal depression affects childhood overweight. Maternal depression was no longer a risk factor for a lifetime diagnosis of asthma after adjustment for sociodemographic characteristics, suggesting that these factors attenuated the risk associated with maternal depression. It is noteworthy that parenting competence was significantly associated with an increased risk of an asthma diagnosis, which may be related to the fact that the indicator of asthma requires a diagnosis from a health care professional. As such, greater parenting competence may mean that the mother is more likely to take the child to a doctor. Findings also highlighted modifiable risk and protective factors associated with overall health, overweight, and diagnosis of asthma, which are consistent with existing literature (Gladstone et al., 2015; Hirshkowitz et al., 2015; Lang, 2012). For overall health, more television viewing and fast-food consumption were related to poor child health, whereas more time spent playing outside and more fruits and vegetables consumed were related to better overall health. For overweight, more fast-food consumption and maternal overweight and obesity were associated with increased risk of childhood overweight, similar to previous findings (Lang, 2012). For asthma, increased fast-food consumption was also a risk factor. These findings suggest that modifiable child health behaviors had a major impact on child health outcomes and should be the focus of intervention and prevention programs before school age. In addition, research should focus on how maternal depression may affect child health behaviors, leading to poor health outcomes. There are some limitations to address. First, our factors were not exhaustive, but did represent a range of well-established risk and protective factors influencing children’s physical well-being (Gladstone et al., 2015; Turney, 2011, 2012). Additional variables that would be important to consider are those related to maternal health behaviors, including levels of physical activity, dietary habits, and sleep patterns, which have been shown to influence a mother’s health and the health behaviors of her children (Lampard et al., 2014). Also, the indicator of maternal depression is a dichotomous measure of past-12-month depression and does not take into account onset, severity, or chronicity, as attrition resulted in missing data for maternal depression across waves. Depression was not measured at baseline, so poor maternal general health was included as a proxy for postpartum depression (Le Strat et al., 2011). Regardless, the CIDI is a highly validated measure of depression (Kessler et al., 1998). Although our findings do not suggest a causal relationship, they highlight a significant association between maternal depression and child physical health outcomes. Finally, the analytic sample was more advantaged than the follow-up sample, suggesting that our results may be an underrepresentation of the association between maternal depression and child physical well-being. Despite limitations, our findings contribute to the literature regarding the impact of maternal depression on child physical well-being, particularly by providing a more in-depth understanding of the role of two factors related to the mother–child relationship. Based on our findings, programs aimed at helping mothers with depression reduce parenting stress and increase competence may mitigate the risk to child physical well-being. Screening for maternal depression during routine child well-visits may lead to early identification and treatment, which may also have an upstream effect on child health outcomes. Our findings also suggest that screening for maternal depression should continue throughout childhood. Finally, additional research should focus on exploring the pathways through which maternal depression is associated with child physical well-being, including the temporal order between maternal depression symptom and child physical health outcomes. Sarah Dow-Fleisner, PhD, is assistant professor, Faculty of Health and Social Development, School of Social Work, University of British Columbia-Okanagan, 1147 Research Road, Kelowna, BC, Canada V1V 1V7; e-mail: sarah.dow-fleisner@ubc.ca. Summer Sherburne Hawkins, PhD, MS, is associate professor, School of Social Work, Boston College, Chestnut Hill, MA. The Fragile Families and Child Wellbeing Study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (NIH) under award numbers R01HD36916, R01HD39135, and R01HD40421 and by a consortium of private foundations. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. References Abidin , R. R. ( 1995 ). Parenting Stress Index . Odessa, FL : Psychological Assessment Resources . American Psychiatric Association . ( 2013 ). Diagnostic and statistical manual of mental disorders ( 5th ed. ). 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Social Work ResearchOxford University Press

Published: Mar 28, 2018

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