The influence of maternal depression, caregiving,and socioeconomic status in the post-natal year onchildren’s language development

A. Stein,*† L.-E. Malmberg,‡ K. Sylva,‡ J. Barnes,§ P. Leach†§ and the FCCC team**

*Section of Child and Adolescent Psychiatry, University of Oxford†The Tavistock and Portman NHS Trust‡Department of Educational Studies, University of Oxford§Institute for the Study of Children, Families and Social Issues, Birkbeck, University of London, and**The Families, Children and Child Care project team, London, UK

Accepted for publication 7 December 2007

Keywordslanguage development,parenting, post-nataldepression,socioeconomic status

Correspondence:Alan Stein, Section ofChild and AdolescentPsychiatry, Universityof Oxford, WarnefordHospital, OxfordOX3 7JX, UKE-mail:alan.stein@psych.ox.ac.uk

AbstractBackground Post-natal depression is common and has been associated with adverse effects on

children’s later emotional and behavioural development. The evidence for effects on children’s

cognitive development is unclear but this could potentially be a major public health issue. The aim

was to examine whether maternal depression and maternal caregiving during the first year of life

are associated with children’s subsequent language development.

Methods One thousand two hundred and one women were recruited from antenatal and

post-natal baby clinics in two areas in England, and followed up until their babies were 3 years.

Mothers and children were assessed by questionnaire, interview and home observation; 999

children’s language was assessed at 36 months, although 55 were excluded principally because

they had been exposed to insufficient English.

Results In bivariate analyses maternal depressive symptomatology in the post-natal year but not

at 36 months was associated with poorer child language at 36 months; maternal caregiving, was

positively associated with language. Structural Equation Modelling revealed that depression was

associated with poorer caregiving but was not independently associated with language. Higher

quality caregiving at 10 months was associated with better language. When the sample was split by

socioeconomic factors the effects of depression on caregiving were stronger in the less advantaged

group. In both groups poorer quality early caregiving predicted lower language outcome.

Conclusions Post-natal depression had a negative effect on caregiving, which in turn affected

language; post-natal depression did not have an additional direct effect on language.

Socioeconomic factors moderated the effects of depression on caregiving. When targeting

interventions at mothers with post-natal depression, it may be strategic to focus on lower

socioeconomic groups at higher risk.

Introduction

There has been enormous interest in the relevance of children’s

experiences in the first year of life, especially adversity, for later

cognitive development. Language is a key aspect of cognitive

development and it is especially important because it underlies

much communication between parents and young children,

and predicts subsequent academic achievement. There is good

Original Ariticle doi:10.1111/j.1365-2214.2008.00837.x

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd 603

Child: care, health and development

evidence that the quality of care provided by mothers to their

children including their speech, responsivity and cognitive

stimulation influences children’s early language development

(Raviv et al. 2004; Sohr-Preston & Scaramella 2006). Of particu-

lar relevance to these findings is that maternal depression in the

post-natal year has been identified as a phenomenon that has

the potential to adversely affect the quality of care provided by

the mother (Cooper & Murray 1998).

Maternal post-natal depression is recognized as a major

public health issue because of its high prevalence, estimated to

be around 13% (O’Hara & Swain 1996). While there is now

fairly clear evidence that post-natal depression is associated

with adverse effects on children’s later emotional and behav-

ioural development (Cooper & Murray 1998), the evidence for

effects on children’s language and cognitive development is

inconsistent (Cogill et al. 1986; Sharp et al. 1995; Murray et al.

1996; Brennan et al. 2000; Hay et al. 2001; Kurstjens & Wolke

2001; Milgrom et al. 2004; Sohr-Preston & Scaramella 2006).

The possible influence of maternal depression on children’s

language development, either directly or indirectly through

caregiving, is important clinically because the prevention of

delayed language development represents a major challenge to

health services. It also has the potential to illuminate critical

scientific issues in relation to the influence of early experience

on later development (Hay et al. 2001).

The critical factor linking post-natal depression to child lan-

guage is likely to be the quality of maternal caregiving. Mater-

nal post-natal depression has the potential to negatively affect

caregiving because of symptoms such as sadness, withdrawal,

irritability, and pessimism about the future. When depressed,

one’s mind is dominated by recurrent negative thoughts which

in turn interfere with one’s capacity to respond to one’s inter-

personal environment. However, not all research has found

links between depression and parenting, and there is now con-

siderable evidence that the effects of depression on caregiving

are moderated by socioeconomic factors (Lovejoy et al. 2000).

One of the possible explanations for the different findings in

relation to post-natal depression and cognitive outcome is that

studies such as those by Murray and colleagues (Murray et al.

1996) which found no direct relationship between depression

and children’s language were carried out with relatively

socioeconomically advantaged families, while the study carried

out by Hay and colleagues (Hay et al. 2001) with inner-

city disadvantaged families found direct effects of maternal

depression on cognitive development. This indicates that post-

natal depression may have different effects on caregiving

and child outcome depending on the socioeconomic context

(NICHD 1999). It is therefore important to study samples

large enough to examine the effects separately for socio-

economically disadvantaged and advantaged families rather

than simply to take account of socioeconomic factors in the

analyses.

Despite the potential inter-connectedness of socioeconomic

status, parenting, maternal depression, and children’s cognitive

and language outcomes, and the need to elucidate the processes

that link these factors, hardly any studies have focussed on all

these characteristics simultaneously and sample sizes have gen-

erally not been large enough to unravel the way in which they

are related.

A further issue is that most of the research in this area has not

included measures of the provision of opportunities for cogni-

tive stimulation and learning as part of maternal caregiving

which may be compromised by depression.

The purpose of this paper is to examine the relationship

between post-natal depression, maternal caregiving and socio-

economic factors in influencing children’s language devel-

opment at 3 years of age in a large longitudinal cohort.

Furthermore, it aims to examine whether any effects of mater-

nal depression on caregiving and ultimately on language devel-

opment differ in disadvantaged compared with advantaged

socioeconomic groups.

Methods

Participants

The participants for this study were drawn from a longitudinal

study of the influence of child care on children’s development.

Recruitment centred on antenatal clinics held in two large

hospitals in England, in North London and in Oxfordshire,

each catering for a demographically diverse population. In

addition a number of community post-natal baby clinics were

included to reach more disadvantaged families. Eligibility crite-

ria for mothers included: aged 16 or over at the child’s birth,

adequately fluent for interview in English. Eligibility criteria for

children were: singleton, birth weight 2500 g or more, gestation

of 37 weeks or more, no significant congenital abnormalities,

no more than 48 h in a Special Care Baby Unit.

Researchers approached 1862 mothers at recruitment of

whom 217 (11.6%) were found, to be ineligible for the study.

Of the remaining 1645, 444 (27.0%) chose not to participate,

making the final sample 1201.

At follow-up 1077 families were seen at 10 months and at 36

months 1036 mothers were interviewed and 999 children par-

ticipated in the language assessment.

604 A. Stein et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

Procedure

For the present paper, data were drawn from the information

collected at 3, 10 and 36 months by face-to-face interviews with

mothers, questionnaires, observations at home and child assess-

ments. This included demographic information, information

on maternal depression (3, 10 and 36 months), measures of

maternal responsivity and stimulation (10 and 36 months), and

assessments of children’s language development (36 months).

Measures

Demographic and child characteristics

Through structured interviews information was collected on:

child gender, birth order and bilingualism; partnership/marital

status; parental education; family income prior to maternity

leave and post-natally; and mothers and their partner’s occu-

pational status using the Socioeconomic Class Index (Rose &

O’Reilly 1998).

Maternal depression

At 3 and 10 months mothers completed the Edinburgh Postna-

tal Depression Scale [EPDS (Cox et al. 1987)]. The EPDS is a

10-item widely used and validated measure for screening for

post-natal depression with a sensitivity and specificity of >80%

(Murray & Carothers 1990). At 36 months mothers completed

the 12-item General Health Questionnaire [GHQ-12 (Goldberg

1982)], as the EPDS was developed specifically for a post-natal

sample. The GHQ is a very widely used and validated measure

of psychological symptomatology. Both these measures were

treated as continuous variables in the analyses.

Maternal care and stimulation

At 10 and 36 months, maternal caregiving was assessed during

2 h home observations, during which the home environments

as well as unstructured mother–infant interactions were rated.

At 36 months, the mothers also reported on their activities with

their child.

Subscales on two observation instruments were coded at 10

months. The Home Observation for Measurement of the Envi-

ronment [HOME (Bradley & Caldwell 1988)] was used to assess

the quality and quantity of support for emotional, social and

cognitive development available to the child in the home

environment (Bradley & Caldwell 1988). One subscale was

used for assessing maternal responsivity: Emotional and Verbal

Responsiveness of Mother and three subscales were used for

assessing the instructional/teaching qualities of the maternal

care: Organisation of the Physical and Temporal Environment,

Provision of Appropriate Play Materials, and Opportunities for

Variety in Daily Stimulation. Inter-rater agreement between a

gold standard rater and four raters of 20 child observations was

k = 0.70–0.74. To supplement the emotional and verbal respon-

siveness subscale, two subscales of the Caregiver Interaction

Scale were used (Arnett 1989): Positive Relationship, which

measures the warmth, level of enthusiasm and developmental

appropriateness of the caregiver’s interaction with children, and

the Detachment subscale, which rates the extent to which the

caregiver is uninvolved with and uninterested in the children.

Weighted mean Kappa coefficients of inter-rater agreement

were k = 0.68–0.74.

At 36 months, quality of maternal responsivity was measured

again by direct observation using two instruments: first, the

toddler version of the HOME instrument was administered and

this contains: the HOME Pride, Affection and Warmth subscale.

Inter-rater agreement was k = 0.85. Second, the Observation

Rating Scale of the Environment (ORCE) (NICHD 1996) was

used and consists of a number of global constructs, of which

the following were rated here: sensitivity/responsiveness to dis-

tress, sensitivity/responsiveness to non-distress, intrusiveness/

overcontrol, detachment/disengagement, stimulation of

cognitive development, positive regard for the child, negative

regard for the child and flatness of affect. Inter-rater agreement

was weighted k = 0.86.

To obtain age appropriate information on the mothers’ pro-

vision of opportunities for learning at home, mothers were

asked a series of questions on their child’s engagement in a

number of stimulating activities. These questions were derived

from the EPPE home interview (Melhuish et al. 2008). Items

covered activities which provide clear learning opportunities

and were combined into one composite measure, called the

Home Learning Environment.

For the purpose of this study, two aggregate scales were

created at 10 and 36 months: Maternal Responsivity and Oppor-

tunities for Learning. At 10 months, maternal responsivity con-

sisted of the two CIS subscales (positive relationship and lack of

detachment) and the HOME emotional and verbal responsive-

ness subscale. Opportunities for learning consisted of the three

relevant HOME subscales. At 36 months, maternal responsivity

consisted of the HOME: pride, warmth and affection subscale,

and the ORCE and opportunities for learning consisted of the

HLE (Melhuish et al. 2008). This operationalization of the

caregiving constructs maximized conceptual overlap between

the 10 and 36 month assessments, utilizing age-appropriate

Post-natal depression and children’s language development 605

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

measures at each time point. These two constructs were then

combined to form latent constructs representing the quality of

maternal caregiving at both time points, which were then used

in the structural equation models (see below).

Child language

Language development was assessed at 36 months using the

Reynell Developmental Language Scale [RDLS (Reynell 1990)],

a widely used and standardized instrument consisting of 124

items on two subscales, comprehension and expressive lan-

guage. The Comprehension Scale measures receptive skills and

the Expressive Scale assesses structure, vocabulary and content.

Initially 999 children were administered the RDLS. However,

after screening for bilingualism, 41 bilingual children with

English as second language, and less than 1 year of exposure to

English, and 14 children for whom the score was deemed unre-

liable for other reasons (n = 14; no evident language expression

or comprehension, diagnosis of developmental disorder or ill

health), were excluded from the analysis. Bilingual children with

English as first language, or children with two mother tongues

were included, leaving a sample of n = 944. All models included

bilingualism as a control variable.

Analytic strategy

The present study sought to examine the inter-connectedness of

socioeconomic status, parenting, maternal depression and chil-

dren’s language outcomes, including the testing for indirect

pathways and moderation. First, bivariate correlation analyses

were conducted to examine the associations between the differ-

ent independent variables and the dependent variable (see

Table 1). Second, with the aim of integrating variables on socio-

economic status, parenting, maternal depressive symptomatol-

ogy and children’s language outcomes in one conceptual model,

Structural Equation Modelling (SEM) was carried out in amos

6.0 (Arbuckle & Wothke 1995–1999). This permitted the exami-

nation of the complex pathways that might potentially shape

children’s language development. In the baseline model (Fig. 1)

family socioeconomic background was represented by three

indicators (average parental educational level, average parental

occupational status and family income), depressive symptoma-

tology at each time point as a continuous measure, the language

outcome by its two subscales, and three covariates (bilingual,

birth order and child’s gender), and maternal caregiving at 10

and 36 months by two indicators (maternal responsivity and

opportunities for learning). Missing data (3.8%) were estimated

using the Full Information Maximum Likelihood method

(Little & Rubin 2002) (see Table 1 for bivariate description).

Non-significant paths were set to zero in all models. The fol-

lowing cut-offs for goodness of fit were used for good model fit:

a non-significant c2, a Root Mean Square Error of Approxima-

tion (RMSEA) below 0.05, and a Comparative Fit Index (CFI)

and Non-Normative Fit Index (NNFI) above 0.95 (Browne &

Cudeck 1993; Marsh et al. 1996).

A particular focus was to investigate parenting as a possible

mechanism that links post-natal depression to children’s lan-

guage outcomes as well as to identify any possible direct effects

of maternal depression on language development. Path analyses

allowed the examination of the overall fit of a model that simul-

taneously included direct and indirect variables included in the

study (see Fig. 1). Thus, direct pathways from parenting at 10

months were included in this model, as well as indirect path-

ways through later parenting at 36 months. Regression paths

between depressions at each time point were included to esti-

mate the stability of depression. Finally, the socio-demographic

background was modelled to predict depression, language and

caregiving. Not shown in Fig. 1 are the paths from the covariates

(gender, bilingualism, birth order) to depression, caregiving and

language.

In a next step we examined whether socioeconomic status

moderated these complex relationships (Fig. 2). A two-group

comparison was carried out, whereby the sample was split

on the socio-demographic variable into the top two-thirds

(n = 633) (i.e. the top third and the middle third) and the lower

third (n = 311). This split was made on the combined variable

(socioeconomic class, education and income). It was decided to

split off the lower third because approximately this proportion

fell within the lower social classes in our sample (Sylva et al.

2007). Approximately 40% of mothers and 30% of fathers fell

into this category.

Results

Bivariate correlations (see Table 1)

The presence of more maternal depressive symptoms at both 3

(r = -0.10, P < 0.01) and 10 months (r = -0.10, P < 0.01) but

not at 36 months were associated with lower child language

scores at 36 months (data) (see Table 1). Higher quality mater-

nal caregiving at 10 and 36 months were related to higher lan-

guage scores: rs were 0.28 and 0.35 (P < 0.001) for maternal

responsivity, and 0.24 and 0.26 (P < 0.001) for mother’s provi-

sion of opportunities for stimulation at 10 and 36 months

respectively. Depressive symptoms at both time points related to

606 A. Stein et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

Tab

le1

.U

niv

aria

teco

rrel

atio

ns

betw

een

alli

nde

pen

den

tva

riab

les

and

lan

guag

esc

ores

1.

2.

3.

4.

5.

6.

7.

8.

9.

10

.1

1.

12

.1

3.

14

.1

5.

16

.1

7.

18

.

1.M

oth

er’s

edu

cati

on

alle

vel3

mo

nth

s(1

–6)

2.Fa

ther

’sed

uca

tio

nal

leve

l3m

on

ths

(1–6

)0.

52a

3.M

oth

er’s

Soci

oEc

on

om

icC

lass

3an

d36

mo

nth

s(1

–3)

0.47

a0.

30a

4.Fa

ther

’sSo

cio

Eco

no

mic

Cla

ss3

and

36m

on

ths

(1–3

)0.

45a

0.52

a0.

42a

5.Fa

mily

inco

me

3–36

mo

nth

s0.

44a

0.38

a0.

49a

0.52

a

6.C

hild

’sg

end

er(0

=b

oy,1

=g

irl)

0.03

0.04

-0.0

10.

00-0

.02

7.C

hild

bili

ng

ual

(0=

mo

no

ling

ual

,1

=b

ilin

gu

al)

0.12

a0.

07c

-0.0

30.

02-0

.03

0.04

8.B

irth

ord

er(1

–4+)

-0.1

7a-0

.14a

-0.2

8a-0

.18a

-0.1

4a0.

01-0

.04

9.3

mEP

DS

(0–3

0)-0

.08b

-0.0

6-0

.11b

-0.0

9b-0

.18a

0.01

0.02

0.03

10.

10m

EPD

S(0

–30)

-0.0

6-0

.01

-0.0

8c-0

.10b

-0.1

6a0.

030.

060.

030.

59a

11.

36m

GH

Q12

(0–3

6)-0

.01

0.06

0.04

0.06

-0.0

20.

02-0

.01

-0.0

20.

33a

0.34

a

12.

Mre

spo

nsi

vity

10m

on

ths

(z)

0.26

a0.

19a

0.25

a0.

28a

0.28

a0.

02-0

.05

-0.1

4a-0

.10b

-0.0

9b0.

0313

.H

om

eo

pp

ort

un

itie

sfo

rle

arn

ing

10m

on

ths

(z)

0.12

a0.

08c

0.04

0.11

b0.

14a

-0.0

1-0

.07c

-0.1

0b-0

.06

-0.1

1b-0

.04

0.29

a

14.

Mre

spo

nsi

vity

36m

on

ths(

z)0.

31a

0.21

a0.

29a

0.34

a0.

30a

-0.0

20.

03-0

.12a

-0.1

0b-0

.15a

-0.0

8c0.

30a

0.17

a

15.

Ho

me

Lear

nin

gO

pp

ort

un

itie

s36

mo

nth

s(z

)0.

21a

0.22

a0.

21a

0.24

a0.

19a

0.07

c-0

.02

-0.2

2a-0

.06

-0.0

8c-0

.11b

0.25

a0.

19a

0.35

a

16.

Reyn

ellc

om

pre

hen

sio

n0.

28a

0.26

a0.

27a

0.38

a0.

38a

0.17

a-0

.09b

-0.1

4a-0

.11a

-0.1

0b0.

000.

28c

0.23

c0.

34c

0.25

c

17.

Reyn

elle

xpre

ssio

n0.

29a

0.27

a0.

27a

0.30

a0.

32a

0.13

a-0

.08b

-0.1

2a-0

.07

-0.0

8c-0

.01

0.25

a0.

21a

0.31

a0.

24a

0.72

a

18.

Reyn

ellt

ota

l0.

31a

0.28

a0.

29a

0.37

a0.

38a

0.16

a-0

.10a

-0.1

4a-0

.10b

-0.1

0b-0

.01

0.28

a0.

24a

0.35

a0.

26a

0.93

a0.

93a

a P<

0.00

1;bP

<0.

01;c P

<0.

05.

Post-natal depression and children’s language development 607

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

concurrent measures of caregiving; rs at 10 months were -0.09

and -0.11 (P < 0.01) for responsivity and opportunities for

stimulation; rs at 36 months were -0.08 (P < 0.05) for respon-

sivity and -0.11 (P < 0.001) for stimulation. A number of socio-

demographic variables were associated with higher language

scores, including maternal and paternal education (r = 0.31 and

0.28; P < 0.001), social class (rs = 0.29 and 0.37; P < 0.001 for

mother and partner) and family income (r = 0.28; P < 0.001).

The child’s gender (girl higher) (r = 0.16; P < 0.05) and birth

order also related to children’s language scores, with later born

children scoring lower (r = 0.14; P < 0.001).

Examining direct and indirect pathways from depressionto child language (see Fig. 1)

The baseline model fitted data well (c2[193] = 317.43; P < 0.001;

c2/d.f. = 1.645; RMSEA = 0.026; CFI = 0.984; NNFI = 0.979).

Higher socio-demographic background predicted lower

maternal depressive symptomatology at 3 months (b = -0.19;

P < 0.001), higher quality caregiving at 10 months (b = 0.64;

P < 0.001) and higher language scores (b = 0.32; P < 0.001).

Caregiving was stable between 10 and 36 months (b = 0.87;

P < 0.001), and depression between 3 and 10 months

Socio-Dem

Depr 3

Caregiving10

Language

Depr 10 Depr 36

Caregiving36

0.28a*

0.32a

–0.14a

0.25a

0.87a

–0.09c

0.64a

0.63a

–0.19a

0.20a

r2 = 0.03 r2 r0.40 = 2 = 0.16

r2 = 0.41

r2 = .42 r2 = .80

0.09a*

Figure 1. Socio-demographic background, maternal depression, caregiving, and language development (n = 944).aP < 0.001; bP < 0.01; cP < 0.05, Non-significant paths fixed to zero. *Paths fixed to equality.

Language

Depr 36

Caregiving36

Caregiving10

Depr 10

0.61 a / 0.78 a

0.34 a / 0.20 a

–0.21 b / –0.13 c

–0.27 a / 0.00

0.29 b / 0.22 b

0.28 b / 0.23 b

Figure 2. Depression and caregiving as predictors of language development at 36 months, among disadvantaged (33% bottom n = 311) and advantaged(top 67%; n = 633) mothersAll non-significant paths were set to zero (0.00 n.e.); non-significant paths are indicated by broken arrows. Coefficients for the two groups are presentedalongside each other with the disadvantaged groups being presented before the dash, and the coefficients for the advantaged group after the dash.Where coefficients differ significantly between the two groups, they are printed in bold (standardized b-coefficients). Depression at 3 months andcovariates not depicted for sake of clarity. aP < 0.001; bP < 0.01; cP < 0.05. All estimates are from amos 6.0.

608 A. Stein et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

(b = 0.63; P < 0.001) and between 10 and 36 months

(b = 0.25; P < 0.001). Language was not predicted by either

depressive symptoms at 10 nor 36 months. However, depres-

sion at 10 months predicted lower quality concurrent care-

giving (b = -0.09; P < 0.05) and depression at 36 months

predicted lower quality concurrent caregiving (b = -0.14;

P < 0.001).

Before examining the effects of caregiving on language in the

full model, the effect of caregiving at 10 months and caregiving

at 36 months on language was estimated separately, i.e. they

were tested one at a time in the model. Thus, the effect of

caregiving at 10 months on language was estimated to be,

b = 0.26 (P < 0.001), while the effect of caregiving at 36 months

on language was estimated to be, b = 0.34 (P < 0.001). As care-

giving at 10 and 36 months were highly interrelated (b = 0.88,

P < 0.001), this leads to problematically large standard errors

for the paths from caregiving to language outcomes. To resolve

this collinearity issue we used the method recommended by

Marsh and colleagues (Marsh et al. 2004) in which the paths

from 10-month caregiving to language, and 36-month caregiv-

ing to language were equated. This substantially reduced the

standard errors and provided a better model fit, suggesting that

caregiving at both 10 and 36 months contributes to language

outcomes. Thus, both paths were found to be significant:

bunstand = 4.08; se = 0.57; standardized bs were 0.09 (P < 0.001)

and 0.29 (P < 0.001) for the respective paths from caregiving to

language at 10 and 36 months. This final model is presented in

Fig. 1.

In addition, not shown in Fig. 1, girls had higher language

scores than boys (b = 0.18; P < 0.001) and bilingual children had

lower scores than monolingual children (b = -0.11; P < 0.001),

but no effect of birth order was found. No significant effects of

the covariates on depression or caregiving were found.

Examining socio-demographic background as amoderator of the relationship between depression,caregiving and language development (see Fig. 2)

In order to test the hypothesis that depressive symptomatology

has a stronger effect in lower socioeconomic families, the

sample was split into two groups on the socio-demographic

variable (top two-thirds, lower third). The two-group model

fitted data well (c2[304] = 383.89; P = 0.002; c2/d.f. = 1.26;

RMSEA = 0.017; CFI = 0.987; NNFI = 0.983). Factor loadings

and indicator intercepts were equated across the two groups,

while allowing the latent means to vary across the groups as a

test of strong measurement invariance. A nested model was

then conducted using a non-significant difference Dc2 between

a model in which the theoretically relevant beta-paths were

freely estimated and a model in which these were constrained.

Constraining all regression paths to equality across the two

groups suggested a moderation effect (Dc2[19] = 38.10;

P < 0.01). A model in which four theoretically relevant regres-

sion paths were freely estimated fitted data as well as the

model in which all paths were constrained (Dc2[24] = 30.98;

P = 0.154). As shown in Fig. 2, the effect of depression at 10

months on concurrent caregiving was stronger in the disad-

vantaged (b = -0.21; P < 0.01), than in the advantaged group

(b = -0.13; P < 0.05). The effect of depression at 36 months on

concurrent caregiving at 36 months was also stronger in the

disadvantaged (b = -0.27; P < 0.001), than in the advantaged

group (which was not significant). Early caregiving was posi-

tively related to children’s language in both the disadvantaged

and advantaged groups (b = 0.29 and 0.22; P < 0.01 respec-

tively), and the same was true for the effect of concurrent car-

egiving on children’s language (b = 0.28 and 0.23; P < 0.01 for

the disadvantaged and advantaged group). Thus the effect of

caregiving on language was very similar in both advantaged

and disadvantaged groups.

Discussion

In summary, in bivariate analyses, maternal depressive symp-

tomatology in the post-natal period but not 36 months was

associated with poorer language development; maternal caregiv-

ing both post-natally and concurrently was positively associated

with child language at 36 months while socioeconomic disad-

vantage was strongly associated with poorer language develop-

ment. SEM revealed that depression at 10 months was associated

with poorer caregiving which in turn had a negative effect on

language at 36 months. Furthermore, poorer caregiving at 10

months was associated with caregiving at 36 months which in

turn was associated with poorer language development. There

was no evidence of an additional direct effect of post-natal

depression on language. This indicates that maternal depression

influences child language indirectly and that the pathway is

through its negative effects on the quality of caregiving.

As socio-demographic variables are strongly associated with

child language, the sample was then split by socioeconomic

factors into more advantaged and less advantaged groups, and

separate SEMs were run for each group. The adverse effect of

depression on caregiving was considerably stronger for less

socioeconomically advantaged families at both time points (in

fact the effect of 36 month depression on caregiving in the

higher SES group was not significant). The negative indepen-

dent effect of poorer early maternal caregiving on language

Post-natal depression and children’s language development 609

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

development was evident in both groups indicating that there

was a direct relationship between the quality of caregiving and

language. Thus, there was evidence for a moderation effect of

socioeconomic factors on the relationship between depression

and caregiving but this moderation was not evident for the

relationship between caregiving and language.

The strengths of the study were that maternal psychological

state was measured twice in the post-natal year, at 3 and 10

months, and then again at 36 months concurrent with the

language assessment. The quality of maternal caregiving was

measured and observed in detail by direct observation and

included maternal responsivity as well as the provision of

opportunities for learning. Opportunities for learning have

rarely been measured in these kinds of studies and this is an

important component of caregiving especially in relation to

language development. The sample of 944 infants was large

compared with other similar studies. This relatively large

sample allowed us to test whether the effects differed between

more and less advantaged groups. The limitations of the study

included the lack of a face-to-face interview in order to diag-

nose depression, instead the EPDS, a well as validated and

widely used self-report measure, was used. The use of this self-

report measure may have had the effect of over-estimating the

levels of depressive symptomatology which may have weak-

ened the statistical effect of depression on the outcome. While

the same measure of maternal psychological state was used at

3 and 10 months (the EPDS) a different one, the GHQ, was

used at 36 months because the EPDS had not been validated

outside the post-natal period. A measure of maternal IQ was

not obtained. However, maternal education was assessed and

used as a proxy. The detailed observations of the caregiving

provided by the mothers were not carried out with fathers on

the entire sample hence the quality of the paternal caregiving

could not be taken into account.

One of the critical scientific issues is whether experiences in

the first year of life have longer-term effects on children’s devel-

opment. Brain development continues after birth and there is

evidence that adverse social experiences can influence its devel-

opment (Glaser 2000). According to the sensitive period

hypothesis certain environmental experiences exert a particu-

larly strong effect on brain development during specific time

periods in early life which affects longer-term outcome. It has

been argued that the post-partum period represents such a

period for cognitive development (Hay 1997). While the design

of this study does not provide a strict test of the sensitive period

hypothesis, it does illuminate some relevant issues. It does

suggest that for more socioeconomically disadvantaged chil-

dren, the quality of caregiving does influence later language

development. This confirms the importance of ensuring that

positive policies should be in place to support parents in the

post-natal period to enhance the quality of their caregiving

especially when they are depressed. This study, along with

others before it (NICHD 1999; Sohr-Preston & Scaramella

2006), confirms that maternal caregiving is especially vulner-

able to depression in the context of lower socioeconomic status.

In lower risk families, secure income or good social support

might buffer the adverse effect of depression on parenting

(Sohr-Preston & Scaramella 2006).

These findings suggest that in targeting interventions in rela-

tion to post-natally depressed mothers and their infants, prior-

ity should be given to mothers living in situations of relative

socioeconomic disadvantage. Furthermore, while most research

has been concerned with increasing responsivity of depressed

mothers, interventions need to include a component in which

the mother and other caregivers are supported to provide

opportunities for cognitive stimulation and learning for their

infants. A recent review of treatments targeted at the mother–

infant relationship in the context of maternal depression con-

cluded that it is possible to mitigate the impact of maternal

post-natal depression on the mother–infant relationship and

child development. However, most were relatively small studies

with considerable variability in outcome and much work

remains to be done particularly in identifying the key compo-

nents of the interventions (Nylen et al. 2006).

Large screening programmes have been introduced in some

countries with the aim of identifying women suffering from

post-natal depression. The ultimate aim is to support and treat

these women, and to mitigate possible adverse effects on the

child. Our findings suggest that because the pathway from post-

natal depression to language is indirectly through caregiving,

interventions should be focussed on enhancing mothers’

responsivity to their infants and the opportunities for learning

that they provide. It is argued that such interventions could be

conducted by primary healthcare workers. Further research

could usefully be focussed on testing the hypothesis that a tar-

geted intervention to help mothers with post-natal depression

and their infants in the context of socioeconomic disadvantage,

in their own homes, would enhance the cognitive development

of their children.

Acknowledgements

We are grateful to the Tedworth Charitable Trust and the

Glass-House Trust for generously funding this study; to the

families who participated in the study, the study staff for their

contribution and to the obstetricians, midwives and health

610 A. Stein et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

visitors who facilitated recruitment. We would also like to

acknowledge the help of Lynne Murray, Peter Cooper and Paul

Ramchandani.

References

Arbuckle, J. L. & Wothke, W. (1995–1999) Amos 4.0 User’s Guide.

Smallwaters, Chicago, IL, USA.

Arnett, J. (1989) Caregivers in day-care centers: does training matter?

Journal of Applied Developmental Psychology, 10, 541–552.

Bradley, R. H. & Caldwell, B. M. (1988) Using the HOME

inventory to assess the family environment. Pediatric Nursing, 14,

97–102.

Brennan, P., Hammen, C., Andersen, M., Bor, W., Jnajman, J. &

Williams, G. (2000) Chronicity, severity, and timing of maternal

depressive symptoms: relationships with child outcomes at age 5.

Developmental Psychology, 36, 759–766.

Browne, M. W. & Cudeck, R. (1993) Alternative ways of assessing

model fit. In: Testing Structural Equation Models (eds K. A. Bollen

& J. S. Long), pp. 136–162. Sage, Beverley Hills, CA, USA.

Cogill, S., Caplan, H., Alexandra, H., Robson, K. & Kumar, R. (1986)

Impact of postnatal depression on cognitive development of young

children. British Medical Journal, 292, 1165–1167.

Cooper, P. & Murray, L. (1998) Postnatal depression. British Medical

Journal, 316, 1884–1886.

Cox, J. L., Holden, J. M. & Sagovsky, R. (1987) Detection of

postnatal depression: development of the 10-item Edinburgh

Postnatal Depression Scale. British Journal of Psychiatry, 150,

782–786.

Glaser, D. (2000) Child abuse and neglect and the brain: a review.

Journal of Child Psychology and Psychiatry, 41, 97–116.

Goldberg, D. (1982) General Health Questionnaire Manual. National

Foundation for Educational Research, Windsor, UK.

Hay, D. F. (1997) Postpartum depression and cognitive development.

In: Postpartum Depression and Child Development (eds L. Murray

& P. Cooper), pp. 85–110. Guildford Press, New York, NY, USA.

Hay, D. F., Pawlby, S., Sharp, D., Asten, P., Mills, A. & Kumar, R.

(2001) Intellectual problems shown by 11-year-old children whose

mothers had postnatal depression. Journal of Child Psychology and

Psychiatry, 42, 871–889.

Kurstjens, S. & Wolke, D. (2001) Effects of maternal depression

on cognitive development of children over the first 7 years

of life. Journal of Child Psychology and Psychiatry, 42,

623–636.

Little, R. J. & Rubin, D. B. (2002) Statistical Analysis with Missing

Data, 2nd edn. Wiley, New York, NY, USA.

Lovejoy, M. C., Graczyk, P. A., O’Hare, E. & Neuman, G. (2000)

Maternal depression and parenting behavior: a meta-analytic

review. Clinical Psychology Review, 20, 561–592.

Marsh, H., Balla, J. & Hau, K.-T. (1996) An evaluation of incremental

fit indices: a clarification of mathematical properties. In: Advanced

Structural Equation Modeling. Issues and Techniques. Mahwah (eds

G. Marcoulides & R. Schumacker), pp. 315–353. Lawrence

Erlbaum, Mahwah, NJ, USA.

Marsh, H., Dowson, M., Pietsch, J. & Walker, R. (2004) Why

multicollinearity matters: a re-examination of relations between

self-efficacy, self-concept, and achievement. Journal of Educational

Psychology, 96, 518–522.

Melhuish, E. C., Sylva, K., Sammons, P., Siraj-Blatchford, I., Taggart,

B. & Phan, M. (2008) Effects of the home learning environment

and preschool center experience upon literacy and numeracy

development in early primary school. Journal of Social Issues, 64,

95–114.

Milgrom, J., Westley, D. T. & Gemmill, A.W. (2004) The mediating

role of maternal responsiveness in some longer term effects of

postnatal depression on infant development. Infant Behavior and

Development, 27, 443–454.

Murray, L. & Carothers, A.D. (1990) The validation of the Edinburgh

Postnatal Depression Scale on a community sample. British Journal

of Psychiatry, 157, 288–290.

Murray, L., Hipwell, A., Hooper, R., Stein, A. & Cooper, P. (1996)

The cognitive development of 5-year-old children of postnatally

depressed mothers. Journal of Child Psychology and Psychiatry, 37,

927–935.

NICHD, E. C. C. R. N. (1996) Characteristics of infant child care:

factors contributing to positive caregiving. Early Childhood

Research Quarterly, 11, 269–306.

NICHD, E. C. C. R. N. (1999) Chronicity of maternal depressive

symptoms, maternal sensitivity, and child functioning at 36

months. Developmental Psychology, 35, 1297–1310.

Nylen, K., Moran, T., Franklin, C. & O’hara, M. (2006) Maternal

depression: a review of relevant treatment approaches for mothers

and infants. Infant Mental Health Journal, 27, 327–343.

Key messages

• In this study the pathway from postnatal depression to

language occurred indirectly through its negative effects

on caregiving which in turn affected language

• There was no additional direct effect of postnatal depres-

sion on language.

• The pathway from postnatal depression to language

occurred indirectly through its negative effects on care-

giving which in turn affected language.

• The effects of postnatal depression on caregiving are

moderated by socioeconomic status with evidence for

considerably stronger effects on lower socioeconomic

status groups.

• Community interventions aimed at helping mothers

with postnatal depression and their infants are likely to

be best targeted at those who are socioeconomically

disadvantaged.

Post-natal depression and children’s language development 611

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612

O’Hara, M. & Swain, A. (1996) Rates and risk of postpartum

depression: a meta-analysis. International Review of Psychiatry, 8,

37–54.

Raviv, T., Kessenich, M. & Morrison, F. (2004) A mediational

model of the association between socioeconomic status and

three-year-old language abilities: the role of parenting factors.

Early Childhood Research Quarterly, 19, 528–547.

Reynell, J. (1990) Reynell Developmental Langauge Scales (U.S.

Edition). Western Psychological Services, Los Angeles, CA, USA.

Rose, D. & O’reilly, K. (1998) Final Report of the ESRC Review of

Government Social Classifications. Economic and Social Research

Council and Office for National Statistics, Swindon, UK.

Sharp, D., Hay, D. F., Pawlby, S., Schmucker, G., Allen, H. & Kumar,

R. (1995) The impact of postnatal depression on boys’ intellectual

development. Journal of Child Psychology and Psychiatry, 36,

1315–36.

Sohr-Preston, S. & Scaramella, L. (2006) Implications of timing of

maternal depressive symptoms for early cognitive and language

development. Clinical Child and Family Psychology Review, 9,

65–83.

Sylva, K., Stein, A., Leach, P., Barnes, J., Malmberg, L.-E. &

FCCC-TEAM (2007) Family and child factors related to the use of

non-maternal infant care: an English study. Early Childhood

Research Quarterly, 22, 118–136.

612 A. Stein et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd, Child: care, health and development, 34, 5, 603–612