Journal of Adolescent Health 54 (2014) 88e93

www.jahonline.org

Original article

The Long-Term Effects of Maternal Depression: Early Childhood Physical Healthas a Pathway to Offspring Depression

Elizabeth Raposa, M.A. a,*, Constance Hammen, Ph.D. a, Patricia Brennan, Ph.D. b, andJake Najman, Ph.D. caDepartment of Psychology, University of California, Los Angeles, CaliforniabDepartment of Psychology, Emory University, Atlanta, GeorgiacDepartment of Sociology, School of Population Health, University of Queensland, Brisbane, Australia

Article history: Received December 19, 2012; Accepted July 25, 2013Keywords: Depression; Child and adolescent health; Social adjustment; Community sample

A B S T R A C TIMPLICATIONS AND

Purpose: Cross-sectional and retrospective studies have highlighted the long-term negative effectsof maternal depression on offspring physical, social, and emotional development, but longitudinalresearch is needed to clarify the pathways by which maternal depression during pregnancy andearly childhood affects offspring outcomes. The current study tested one developmental pathwayby which maternal depression during pregnancy might negatively impact offspring mental healthin young adulthood, via poor physical health in early childhood.Methods: The sample consisted of 815 Australian youth and their mothers who were followed for20 years. Mothers reported on their own depressive symptoms during pregnancy and offspringearly childhood. Youth completed interviews about health-related stress and social functioning atage 20 years, and completed a questionnaire about their own depressive symptoms 2 to 5 yearslater.Results: Path analysis indicated that prenatal maternal depressive symptoms predicted worsephysical health during early childhood for offspring, and this effect was partially explained byongoing maternal depression in early childhood. Offspring poor physical health during childhoodpredicted increased health-related stress and poor social functioning at age 20. Finally, increasedhealth-related stress and poor social functioning predicted increased levels of depressive symp-toms later in young adulthood. Maternal depression had a significant total indirect effect on youthdepression via early childhood health and its psychosocial consequences.Conclusions: Poor physical health in early childhood and its effects on young adults’ socialfunctioning and levels of health related stress is one important pathway by which maternaldepression has long-term consequences for offspring mental health.

� 2014 Society for Adolescent Health and Medicine. All rights reserved.

* Address correspondence to: Elizabeth Raposa, M.A., Department ofPsychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563,Los Angeles, CA 90095.

E-mail address: raposa@ucla.edu (E. Raposa).

1054-139X/$ e see front matter � 2014 Society for Adolescent Health and Medicine. All rights reserved.http://dx.doi.org/10.1016/j.jadohealth.2013.07.038

CONTRIBUTION

This study is unique inhighlighting offspring phys-ical health and its psycho-social consequences inyoung adulthood as apathway of the long-term negative effects ofmaternal depression onoffspring mental health.Findings can help to informinterventions designed toprevent the negative con-sequences of maternaldepression on offspringphysical andmental health.

Maternal depression during and directly after pregnancy hasprofound effects on offspring physical health early in life, and hasbeen linked to problems such as low birth weight, growth

retardation, diarrheal episodes, and feeding problems [1e6].Additionally, maternal depression represents a significant publichealth cost, with children of depressed mothers showing lowerrates of receiving appropriate immunizations [7], higher rates ofhospitalization [8], and higher health expenditures [9]. Thus,current evidence points to a strong association betweenmaternal depression and offspring physical health throughoutinfancy and childhood.

E. Raposa et al. / Journal of Adolescent Health 54 (2014) 88e93 89

Maternal depression during pregnancy likely compromisesoffspring physical health through a number of different mecha-nisms. First, depression leads to negative health behaviors, such assubstance use and poor nutrition [3], which can affect the devel-oping fetus. Importantly, prenatal depression also predisposesmothers to higher rates of depression later in life, which couldcontinue to impact offspring development throughout earlychildhood [10e12]. Second, depression has been linked to dysre-gulation in the hypothalamic-pituitary-adrenal (HPA) axis [13]and elevated inflammation [14,15], which could affect devel-oping biological systems in the fetus. In support of this hypothesis,several studies have shown that mothers’ prenatal stress ordepression leads to alterations in the development of the HPA axisand immune system in offspring [16e19]. Such physiologicalalterations predispose offspring to health problems such as lowerbirth weight [18,20] and chronic illness [18,21].

Poor physical health during childhood, in turn, can have socialand emotional consequences for the offspring of depressedwomen. A variety of early physical health problems, such as lowbirth weight or chronic illness, predict increased rates of psychi-atric disorders during adolescence and adulthood [22e25], withdepression an especially common diagnosis [23,26]. Thus,maternal depression puts some children at risk for health prob-lems during early childhood, and these difficulties with physicalhealth might in turn lead to increased rates of depression inoffspring. Yet, research on long-term mental health outcomes inoffspring is typically cross-sectional, with retrospective reports ofthe variables of interest, rather than longitudinal designs.Furthermore, few studies have acknowledged the interplaybetween offspring physical health andmental health outcomes byexamining childhood physical health as one potential pathwayfrom maternal depression to offspring depression.

It is also crucial for research on the interplay between physicaland mental health to examine mechanisms by which poorphysical health in childhood might predict increased depressionlater in life. Two potential pathways linking poor childhoodhealth and increased depression involve ongoing stress anddisability related to poor health [27] and poor social functioning[28]. A range of early health problems, including preterm birth,low birth weight, and chronic illness predict difficulties such asacademic underachievement, school absence, and reducedproductivity at school [27,29]. This ongoing health-related stressand impairment is one pathway by which early childhoodphysical illness might lead to later depression. In addition, bothfrequent, minor illnesses and severe chronic illness have beenlinked to problems with social adjustment, including fewerinteractions with friends and distress in social relationships[28,30]. Thus, social difficulties are another pathway by whichearly childhood physical health problems might lead to laterdepression. Nevertheless, these specific mechanisms of theeffects of poor childhood health on later mental health outcomeshave not been examined in longitudinal studies.

The current project addresses these issues by examining thelongitudinal relationships among maternal depression, offspringphysical health, and offspring depression, and by exploring twopotential mechanisms of the effects of offspring physical healthon later depression: ongoing health-related stress and problemswith social functioning. We hypothesize that maternal depres-sive symptoms during pregnancy will predict risk for increasedhealth problems for offspring in early childhood, possiblythrough ongoing maternal depression in early childhood. Inaddition, we hypothesize that childhood health problems will

predict higher youth depressive symptoms in young adulthood.Finally, we also predict that health-related stress and poor socialfunctioning will serve as two pathways by which early childhoodhealth affects later youth depression. We will use a largecommunity sample to examine whether this model is true forboth children with and without chronic illness. This is animportant question, given the potentially different effects offrequent, minor health problems and more serious chronicillness on psychosocial outcomes.

Method

Participants

Participants were 815 youth drawn from a larger sample of7,775 children born between 1981 and 1984 studied as a birthcohort for the Mater Misericordiae Mothers’ Hospital-Universityof Queensland Study of Pregnancy [31]. At youth age 15 years,815 mother-child pairs were selected for a follow-up study ofyouth risk for depression based onmothers’ patterns of elevationof scores on the Delusions Symptoms States Inventory (DSSI),a 7-item self-report measure of depression and anxiety. Familieswith youth at age 15 years were selected to represent a range ofsymptom presence, chronicity, and severity of maternaldepression, and were over-selected for maternal depressionrelative to the general population. From the original sample, 991families were targeted for inclusion in the follow-up, and 815consented and were included. Children in the high-risksubsample (n ¼ 815) were not significantly different from theoriginal birth cohort in terms of gender, c2(1, N ¼ 7,775) ¼ .53,p ¼ .48; income, t(7147) ¼ .81, p ¼ .42; or mother’s education,t(7612) ¼ 1.70, p ¼ .09.

The adolescent sample at age 15 years was 50.6% male and49.4% female. The families were largely lower middle class andpredominantly Caucasian (91.4% Caucasian; 3.6% Asian; 5% otheror not reported). The majority of mothers worked outside thehome (66%), and were married to the father of the target youth(66%; 21% married to someone else; 13% no partner).

At youth age 20 years, 705 youth from the original 815participants completed follow-up questionnaires and interviews.Finally, when youth were ages 22e25 years, participants werecontacted for a final follow-up to provide biological specimensand complete additional questionnaires. Of the 705 youth whoparticipated in the age 20 assessment, 475 (57% female) partic-ipated in the age 22e25 questionnaires. Youth who participatedin the final assessment had a similar income range (M ¼ 3.05,SD ¼ 2.1) and ethnic distribution (c2 ¼ 2.62, p ¼ .62) to theoriginal sample. In addition, youth who participated in the age22e25 follow-up did not differ from those who did not partici-pate in the follow-up in terms of prenatal maternal depression(t(814) ¼ �.73, p ¼ .46), maternal depression during earlychildhood (t(814)¼ 1.10, p¼ .27), early childhood physical health(t(506) ¼ .45, p ¼ .66), health-related stress at age 20 years(t(703) ¼ �1.25, p ¼ .21), social functioning at age 20 years(t(703) ¼ .70, p ¼ .49), or youth depressive symptoms at age20 years (t(631) ¼ 1.30, p ¼ .19). However, males had a higherdropout rate than females (c2 ¼ 26.34, p < .001).

Procedure

Mothers completed questionnaires during pregnancy, 3e4days after the child’s birth, 6months after birth, and at youth ages

E. Raposa et al. / Journal of Adolescent Health 54 (2014) 88e9390

5, 15, and 20. Children completed interviews and questionnairesat ages 15 and 20 years, and questionnaires once between ages 22and 25 years. Interviews and questionnaires asked about motherand child psychopathology, youth stress, youth physical health,and demographic information. Interviews were conducted bytrained postgraduate students in the participants’ homes or otherconvenient locations. Participants all gave informed consent(assent), and the institutional review/ethics panels of theUniversity of Queensland, Emory University, and the University ofCalifornia, Los Angeles approved the research protocols.

Measures

Maternal depressive symptoms. Maternal depressive symptomsduring pregnancy were measured using the depression subscaleof the DSSI, a 7-item self-report measure of depression andanxiety. This scale has been validated against the clinical judg-ments of experienced clinicians and psychiatrists, and showsgood predictive and concurrent validity [32,33]. Maternaldepressive symptoms during early childhood were measuredusing an average of mothers’ DSSI scores at three additional timepoints after offspring birth: 3e4 days, 6 months, and 5 years afterbirth (all three time points were significantly correlated: 3e4days with 6months (r¼ .39, p< .001); 3e4 days with 5 years (r¼.15, p < .001); 6 months with 5 years (r ¼ .13, p < .001)). Coef-ficient alphas for DSSI scores at the four time points ranged from.79 to .84.

Childhood physical health

A composite of offspring physical health during infancy andearly childhood was created from six different indicators ofhealth collected from mothers 3e4 days after offspring birth,6 months after birth, and 5 years after birth.

Postnatal health problems. Mothers indicated whether offspringhad suffered from any medical problems during or immediatelyafter birth. Youth were coded as having postnatal medical diffi-culties if mothers indicated that children had experienced“moderate” or “major” medical problems.

Health problems in infancy. Six months after birth, mothers re-ported whether offspring had experienced any of a number ofdifficulties with their physical health (e.g., colic, diarrhea, feedingproblems, colds). Youth were coded as having physical healthdifficulties in infancy if they were in the highest third of thesample in terms of the number of physical difficulties endorsedby mothers at least several times per month.

Healthcare utilization in infancy. Youth were coded as highhealthcare utilizers if they were in the highest third of thesample in terms of the number of times their mothers reportedseeking medical attention for their children in the first 6 monthsafter birth.

Hospitalization by age 5 years. At age 5 years, mothers reportedwhether offspring had experienced multiple hospitalizationsbefore the age of 5 or not.

Physical limitations at age 5 years. At age 5 years, mothers re-ported on whether offspring had physical health problems thatlimited their daily activities or not.

Chronic illness by age 5 years. Finally, mothers reported whetheroffspring suffered from at least one chronic illness (e.g., asthma,diabetes) before the age of 5 or not.

A second composite was also created to explore whether theeffects of early childhood physical health problems would persistwhen chronic illness was not included. This composite wasidentical to the first, except that it eliminated the chronic illnessby age 5 variable (range 0e5).

Health-related stress. Ongoing stress and disability associatedwith physical health at youth age 20 years was measured usingthe UCLA Life Stress Interview [34]. This semistructured inter-view has been used and validated in a number of otheradolescent and young adult samples [35,36]. Interviewers pro-bed individuals’ experiences with chronic stress in variousdomains over the past 6 months and assigned objective severityratings for health-related stress on a 5-point scale (with 1indicating excellent health and 5 indicating extreme physicalhealth problems). This measure of health-related stress hasbeen validated against other indices of poor health [35], andratings of health-related stress showed high interrater reliabilityin the current study (.77).

Social functioning. The UCLA Life Stress Interview also probeschronic stress across three domains of social functioning withpeers: romantic relationship, relationship with a best friend, andsocial life. The interviewer assigned an objective severity ratingfor the level of chronic stress in each interpersonal domain ona 5-point scale (with 1 indicating excellent social functioning and5 indicating extremely poor social functioning). Objectiveseverity ratings for all three interpersonal domains were thensummed to create an overall measure of social functioning atyouth age 20. The interrater reliabilities for social domainsranged from .72 to .84. Validity data for these scales have beenreported in Hammen et al. (2008) [36].

Youth depressive symptoms. Depressive symptoms were assessedonce between ages 22 and 25 years using the Beck DepressionInventory (BDI; 37). The BDI is a 21-item self-report measurewith well-established psychometric properties, including highinternal reliability (coefficient alpha¼ .94 in the current sample),as well as convergent and discriminant validity [37].

Covariates. Youth gender was controlled for in all paths con-taining youth variables, given the strong association betweengender and depressive symptoms [38], and the higher rate ofdropout amongmales in the current sample. A secondmodel wasrun controlling for two potential confounding variables at youthage 15 years. Youth depressive symptoms at age 15, assessedwith the BDI, were included as a covariate, given the fact thatdepressive symptoms are associated with both social functioningat age 20 and youth depressive symptoms at ages 22e25 (seeTable 1). Family income at age 15 years, measured by maternalreport using a 7-point scale, was also included as a covariate,given that low family income could be related to both decreasedaccess to health care and increased depressive symptoms.

Analyses

Path models were tested within a structural equationmodeling framework, using robust maximum likelihood

Table 1Correlations, means, standard deviations, and ranges of maternal depression, child physical health, chronic health stress, social functioning, and youth depressivesymptoms

Study variable M SD Range 1 2 3 4 5 6 7

1. Maternal depressive symptoms (prenatal) 1.54 1.62 0e7 e

2. Maternal depressive symptoms (ages 0e5 years) 1.45 1.2 0e7 .40** e

3. Child physical health (age 5 years) 1.53 1.2 0e6 .20** .21** e

4. Chronic health stress (age 20 years) 2.29 .57 1e4.5 .03 .10** .12* e

5. Social difficulties (age 20 years) 7.43 2.13 3e14 .10** .13** .12** .27** e

6. Youth depressive symptoms (age 15 years) 5.91 6.41 0e44 0 .01 .09* .09* .16** e

7. Youth depressive symptoms (ages 22e25 years) 7.64 8.52 0e45 .09 .10* .23** .22** .28** .32** e

* p � .05.** p � .01.

E. Raposa et al. / Journal of Adolescent Health 54 (2014) 88e93 91

procedures to estimate standard errors. All analyses were carriedout in Mplus v5 [39] using full information maximum likelihoodmethods to accommodate missing data. The first two modelsexamined the main hypotheses controlling for the covariatesdescribed above. In addition, a third model was run to explorewhether observed effects were attributable mainly to childrenwith chronic illness. This model was identical to the first, but didnot include childhood chronic illness in the childhood physicalhealth composite. Moreover, the model was run in the subset ofchildren whose mothers reported no offspring chronic illness byage 5 years (n ¼ 623).

Results

Descriptive statistics and Pearson correlations among thevariables are presented in Table 1. First, a model that measuredthe indirect effects of maternal depression during pregnancy onoffspring mental health outcomes in young adulthood, via thepathway of childhood physical illness and the impact of physicalillness on ongoing disability and social adjustment at age20 years, was tested (Figure 1). Standardized beta values arereported.

Fit indices revealed that this model was a good fit to the data:c2 (df ¼ 8, N ¼ 815) ¼ 23.79, p ¼ .003; CFI ¼ .95; RMSEA ¼ .05(90% CI .03, .07); SRMR ¼ .04. Prenatal maternal depressivesymptoms had a significant indirect effect on offspring depres-sive symptoms in young adulthood (b ¼ .01, p < .01). In addition,parameter estimates for the hypothesized direct effects in thepath model were all significant, controlling for the effects ofyouth gender. Maternal depressive symptoms during pregnancywere directly related to increased health problems for offspringbefore the age of 5 years, but also had a significant indirect effecton offspring health problems via ongoing maternal depression

Figure 1. Results of structural equation model testing the indirect effects of maternayoung adulthood, via offspring physical health during childhood, and offspring healthpaths. All direct paths were significant and standardized coefficients are shown. * p

during early childhood (b ¼ .06, p < .01). Offspring healthproblems in turn predicted greater health stress and poorersocial adjustment for offspring at age 20 years. Greater health-related stress at age 20 also predicted concurrent difficultieswith social functioning. Finally, offspring health-related stressand poor social functioning predicted higher youth depressivesymptoms at ages 22e25 years. Importantly, when youthdepressive symptoms and family income at age 15 years werecontrolled for in paths predicting the psychosocial consequencesof childhood physical illness, the model fit and patterns of signif-icance remained largely unchanged (c2 (df¼ 10, N¼ 672)¼ 24.15,p ¼ .007; CFI ¼ .96; RMSEA ¼ .05 (90% CI .02, .07); SRMR ¼ .03).

Next, the same model was tested only in individuals who hadno reports of chronic illness by age 5 years, using a composite ofchildhood physical illness that excluded chronic illness. Fitindices revealed that this model also provided adequate fit to thedata: c2 (df ¼ 8, N ¼ 623) ¼ 20.25, p ¼ .009; CFI ¼ .95; RMSEA ¼.05 (90% CI .02, .08); SRMR ¼ .04. In addition, individual paths inthe model showed the same pattern and significance as in themodel that included chronic illness, except that childhoodphysical health by age 5 years was no longer a direct predictor ofdifficulties with social functioning at age 20 (b ¼ .03, p ¼ .45).Childhood physical health did continue to predict health-relatedstress and disability at age 20, which in turn predicted poorersocial functioning.

Discussion

The present study used a longitudinal, community-basedsample to show that poor childhood physical health is onepathway by which maternal depression affects youth depressionin young adulthood. Moreover, findings revealed that ongoingstress related to physical health and poor social functioning in

l depressive symptoms during pregnancy on offspring depressive symptoms in-related stress and social functioning at age 20. Gender was controlled for in all< .05; ** p < .01.

E. Raposa et al. / Journal of Adolescent Health 54 (2014) 88e9392

young adulthood are two mechanisms by which childhoodphysical health affects later youth depression.

Findings are consistent with previous evidence indicatingthat maternal depression is associated with a number ofoffspring health problems during early childhood [1,5]. Impor-tantly, the current study provided support for the effects ofmaternal depression on childhood health using a longitudinaldata set, allowing us to draw firmer directional conclusions. Inaddition, this relationship between maternal depression andchildhood physical health was observed even in childrenwith nohistory of early childhood chronic illness, indicating thatmaternal depression can lead to more general health problemsearly in life.

Results also highlight the long-term effects of poor childhoodphysical health on psychosocial functioning. Previous work hasindicated that a range of childhood physical health problemspredict increased risk for later emotional distress [22,23], but hasrarely proposed and tested potential mechanisms of theseeffects. Current findings highlight ongoing health stress and poorsocial functioning as two pathways by which poor childhoodphysical health affects later offspring depression. Interestingly,secondary analyses exploring the long-term effects of generalphysical health in children with no history of chronic illnessshowed largely similar results. However, for children with nochronic illness, childhood health problems did not directlycompromise later social functioning, and only affected socialfunctioning indirectly through health-related stress. Thus, evenfrequent struggles with minor illness during childhood canconfer risk for later health-related stress and social functioning,but chronic illness might place children at particular risk for latersocial difficulties. It is possible that chronic illness leads to moreschool absences [27], thereby preventing children from formingstrong social bonds with peers and creating risk for increasedsocial isolation [28]. It might also be more difficult for childrenwith chronic illness to participate in extracurricular activities andsports teams that encourage friendships with peers.

Several limitations of the current study should be acknowl-edged. The physical health composite did not capture the fullrange of severity for certain physical health problems, given thatseveral continuous variables were dichotomized. In addition, thiscomposite was based largely on maternal reports of offspringhealth, whichmight be negatively biased bymaternal depression[40]. Future research should therefore utilize multiple infor-mants and/or biological markers of disease to more preciselymeasure offspring physical health.

The current sample was also over-selected for maternaldepression. Although this sample allows us to gain insight intoproblems that might be especially relevant to offspring ofdepressed mothers, results in the present sample might not berepresentative of a random community sample. In particular,motherswith depression likely have higher rates of physical healthproblems. Findings should be interpreted in light of this fact andreplicated in samples that are more representative of the generalpopulation. In addition, the rate of dropout in the current study bythe final assessment was relatively high, given the longitudinaldesign. Although the final sample did not differ from the originalsample on a number of key variables, there was a higher rate ofdropout among males. Although gender was controlled for in allanalyses, results should be interpreted in light of this fact.

Finally, the relationship between physical health anddepression among family members is doubtless bidirectional.Children’s physical health problems can also influence mothers’

emotional distress. Moreover, because offspring physical healthwas only measured in early childhood, the present study wasunable to determine whether physical health problems showcontinuity over the course of development. As a result, futureresearch should use repeated measures to examine fluctuationsin physical illness and depression as they unfold across devel-opment. Such research will help to clarify the role of earlychildhood illness, as well as other physical problems that emergeacross adolescence (e.g., acne, obesity), in predicting later socialand emotional distress.

Despite these limitations, these findings reveal an importantpathway by which maternal depression affects offspring depres-sion in young adulthood, via early childhood health. Poor offspringhealth is only one of many variables involved in the intergenera-tional transmission of depression. Nevertheless, findings haveimportant implications for clinical interventions in children ofdepressed mothers. Prevention efforts with depressed mothersduring pregnancy and early childhood might improve the devel-opmental trajectories of at-risk children. Moreover, interventionsinvolving stress management and social skills training for childrenwith poor physical health might have important implications fortheir psychosocial outcomes later in life.

Future studies in this area should explore dysregulation inbiological systems (e.g., HPA axis, immune system) that might beunderlying the negative effects of maternal depression onoffspring physical and mental health. Future research shouldalso test potential moderators of the effects of maternaldepression on early childhood health. For example, are theeffects of maternal depression on early childhood physical healthbuffered by the presence of a nondepressed partner? Clarifyingthese mediating and moderating factors might in turn lead tomore targeted interventions for the prevention of the adverseeffects of maternal depression on childhood physical and mentalhealth.

Acknowledgments

This research was supported by the National Health andMedical Research Council, the Mater Misericordiae Mother’sHospital in Queensland, Australia, the National Institute ofMental Health (NIMH) grant R01 MH52239, and an NIMHtraining grant MH15750 Biobehavioral Issues in Mental andPhysical Health (Dr. Stanton & Dr. Dunkel-Schetter). We thankMUSP colleagues William Bor, M.D., and Gail Williams, Ph.D.Special thanks to project coordinators Robyne LeBrocque, CheriDalton Comber, and Sascha Hardwicke. Preliminary results werepresented as a poster at the Association of Behavioral andCognitive Therapies Annual Convention in November, 2012.

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