Parents with Depression and Child Outcomes: How Parents’ Depression Affects Children by Rachel Freed When one member of a family is stricken with depression, the effects are profound. Depression permeates family life, striking deep into family bonds and escalating tension and stress. Children growing up in the context of this challenging family environment are at risk for a number of negative outcomes. This article provides information on the effects of parental depression. It covers the research in this area and provides up-to-date information and resources on what families and providers can do to help children of parents with depression.

“An eminent child psychologist once observed that all children need at least one adult who is irrationally enthusiastic about them. I lacked such a parent because my mother suffered from a chronic depression that prevented her from feeling enthusiastic about anything, including me. Neither she nor I is alone in the brand of lasting grief her depression caused us both . . . Although depression is not contagious in the sense that measles and tuberculosis are, its presence virtually ensures that those closest to the depressed person will in their turn suffer from the depression's fallout.” “Emerging from my own darkness, I caught my first glimpse of my mother as depressed rather than mean-spirited, as unable to love rather than unloving, as the victim of her illness rather than a free agent who chose to be hurtful . . . Had she been depression-free, both her life and mine, and our respective views of ourselves and each other, might have been quite different. That insight, so many years in coming, has lightened some of the burdens I have needlessly dragged throughout my life, burdens that also weigh on the many others with a similar background. Many mothers suffer from depression and most feel and behave in a manner akin to that of my mother, not because they are bad, aberrant people but because their illness distorts thinking and feeling.” —Anne Sheffield Sorrow's Web, Overcoming the Legacy of Maternal Depression

Like most parents, individuals with mental illness describe their relationships with their children and fulfilling the parenting role as extremely important to them (Nicholson et al., 2001). Yet when parents become depressed, they bear a double burden: They must both cope with their own symptoms of hopelessness and sadness and struggle to maintain their function as guardians, role models, and protectors in their children's lives. Further, as Anne Sheffield described in the quotation above, depression itself can distort individuals' thinking and feeling. It is often difficult for parents struggling with depression to offer the quality of support, protection, and guidance that they would like to provide or that these children require.

Every year, about 7% of adults in the U.S. suffer from depression and one in every six adults in the U.S. has experienced major depression at some point in their lives (Kessler et al., 2003). Because 65% of women are mothers and 52% of men are fathers (Nicholson et al., 2001), countless children and adolescents around the country grow up with experiences similar to what Anne Sheffield refers to above as “depression's fallout.”

WHAT DOES THE RESEARCH SAY ABOUT CHILDREN OF PARENTS WITH DEPRESSION?

Children of parents with depression are at increased risk for a number of negative outcomes, ranging from severe mental illness to poor behavioral and social functioning. While some of these negative outcomes result from genetic influences, others develop from, or are heightened by, environmental risk factors. According to Goodman and Gotlib (1999), the risk for an affective disorder (e.g., depression, anxiety, or bipolar disorder) in the adult first-degree relatives of a person with depression is 20–25%, compared with a general population risk of 7%. Similarly, other researchers have reported that parental major depression is associated with higher rates of phobias, panic disorder, disruptive behavior disorders, poorer social functioning, and worse academic performance (Anderson & Hammen, 1993; Beiderman et al., 2001; Weissman et al., 1997). According to Anderson and Hammen (1993), these findings hold true when children of parents with depression are compared to not only the children of parents without psychiatric disorders, but also to the children of parents with bipolar disorder and medical illness. In addition, researchers have discovered that children of parents with depression are at increased risk for alcohol dependence and are more likely to report suicidal thoughts or behaviors (Weissman et al., 1997, Klimes-Dougan et al., 1999).

These negative outcomes appear to continue though adolescence. Weissman and colleagues (1997) reported that the peak time for the incidence of major depressive disorder is between ages 15–20. Adolescent children of mothers with depression are more likely to report fewer friends and social activities and are less secure and have more fearful cognitions about relationships (Hammen & Brennan, 2001).

The children of parents with early-onset depression (before the age of 19) were found to have even more withdrawn, anxious, and depressed feelings and have worse social functioning (Petersen et al., 2003). These children also exhibited higher rates of social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior (Petersen et al., 2003). Further, early-onset depression in mothers is associated with a 14-fold increase in the risk of onset of major depression before age 13 in their children (Weissman et al., 1987).

WHAT IS IT ABOUT HAVING A PARENT WITH DEPRESSION THAT PLACES A CHILD AT RISK?

Heritability of Depression

Although it is difficult to determine the precise cause of depression and other negative outcomes in the children of parents with depression, it is clear that having a depressed parent confers a genetic predisposition to the illness. According to researchers, parental depression is more important as a predictor of major depression than are environmental risk factors (Fendrich, Warner, & Weissman, 1990; Nomura et al., 2002). It is also true that children of parents with depression inherit vulnerabilities to personality and cognitive traits, such as shyness, negative mood, low self-esteem, and low sociability, which increase the risk for developing depression.

Exposure to Parent's Negative Thinking, Behavior, and Mood

The development of mental health problems in children of parents with depression can also be influenced by parents' own maladaptive moods, thoughts, and behaviors. In fact, parents with depression are more likely to endorse negative views of themselves as parents, be less positive and more punitive with their children, and engage in more angry, hostile, and discordant behavior toward their children (Goodman & Gotlib, 1999). This can lead to detrimental consequences for children at every stage of development.

Infants: For infants, two important aspects of effective parenting are nurturing an attachment relationship and promoting the development of emotional self-regulation. The lack of parental attention toward infants can result in insecure attachment, problems with emotional regulation, and poorer cognitive development (Goodman & Gotlib, 1999).

Researchers report that when interacting with their infants, parents with depression provide less and lower quality stimulation, are less responsive, and use less affectionate contact (Goodman & Gotlib, 1999). Infant children of mothers with depression are also fussier, less active, and have more difficult temperaments (Cummings & Davies, 1994). Additionally, these infants are harder to comfort, appear listless, and may be difficult to feed or put to sleep (O'Connor, 2001).

Toddlers/Preschool-age Children: Parents must provide the support and guidance necessary for their toddlers to develop an accurate understanding of social and emotional situations. Cicchetti and Shneider-Rosen (1986) predicted that toddlers and preschool age children whose parents failed to provide for these needs would have difficulty functioning self-sufficiently and managing in stressful and other emotionally arousing situations.

Research has shown that mothers with depression spend less time mutually engaged with their children in a shared activity and fail to encourage sustained attention to an object or activity (Goodman & Gotlib, 1999). As a result, toddlers of mothers with depression exhibit high levels of anxiety during mildly stressful situations (Goodman & Gotlib, 1999). Such children are also often hard to handle, defiant, negative, and refuse to accept parental authority (O'Connor, 2001).

School-age Children: For school-age children and adolescents, the parental role involves helping children cope with stressors, sustain their focus on school, develop social skills, and maintain friendships (Goodman & Gotlib, 1999). Parents with depression, who often suffer restricted social relationships themselves, may have particular trouble offering support for their children's emerging social lives. Indeed, research has shown that school-age children of parents with depression often have difficulty relating to their peers. Teachers have rated such children as less popular with their classmates (Goodman, et al., 1993).

It is equally important for parents with school-age children to monitor their children's behavior and provide consistent discipline (Goodman & Gotlib, 1999). However, mothers with depression were found to be more critical of, and have lower tolerance for, their school-age children's challenging behaviors (Goodman et al., 1994). Other studies have reported that parents with depression are either ineffective in resolving conflicts or alternate between harsh, punitive discipline and lax undercontrol (Goodman & Gotlib, 1999). As mentioned previously, parental major depression is associated with higher rates of disruptive behavior disorders in children. O'Connor (2001) suggests that a child's problematic behavior might in some cases be a cry for attention—to get a rise out of their parents, to get parents to put their foot down, enforce rules, and show some interest.

Exposure to Stress

Parents with depression and their children are likely to experience higher rates of stress than well families (Fendrich, Warner, & Weissman, 1990). Children in these families are exposed not only to their parents' depression but also to a variety of stressors associated with the illness: more job stress, higher marital conflict, financial stress, conflict in parent-child relationship, etc. The stressful context of these children's lives can be another source for the development of psychopathology. Fendrich, Warner, and Weissman (1990) have found that the presence of environmental risk factors such as parents' marital discord, parent-child discord, low family cohesion, affectionless control, and parental divorce is associated with higher rates of major depression, conduct disorder, and any psychiatric diagnosis in children.

It appears that adolescents of parents with depression may be especially vulnerable to increased stressors in the home. The transition from childhood to adulthood is a period where stress can be relatively high in any adolescent's life. Yet, the multiple challenges associated with adolescence, combined with the continued reliance on parents, may make a young adolescent particularly vulnerable to a depressed parent (Klimes-Dougan & Bolger, 1998).

SOME CHILDREN EXPOSED TO PARENTAL DEPRESSION FUNCTION WELL

It is important to realize that parents' depression does not guarantee poor outcomes in children. Some children are resilient, meaning that even when exposed to stressful life experiences, they do just fine. Research on resilience has focused on both individual and family factors that are associated with children's positive outcomes (Klimes-Dougan & Kendziora, 2000). The “classic” study of resilience was conducted by Emmy Werner and her colleagues on the Hawaiian island of Kauai, enrolling almost 700 children born in 1955 and following up with them at ages 1, 2, 10, 18, and 32. Thirty percent of the children were at high risk due to various socioeconomic, biological, or family factors; of this group, one-third was resilient (Werner, 1991; Werner & Smith, 2001).

Individual characteristics associated with resilience in the Kauai study have been identified beginning in infancy. Soon after birth, some infants appear to successfully elicit positive attention from their caregivers and are "easy" babies. They are active, alert, responsive, and sociable. In the preschool period, children who were skilled in communication, locomotion, and self-help skills were more likely to show resilience later on. From middle childhood onward, competence and self-efficacy are the hallmarks of successful adaptation under conditions of stress. Resilient children have good problem-solving and communication skills. Strong interests in hobbies and other leisure pursuits like sports, reading, or stamp collecting may also buffer children from the stressors they encounter. These interests may allow the child to remain somewhat detached from the stressors of their environment (Worland, Weeks, & Janes, 1987) or serve as an emotional refuge. Resilient youth are more responsible, achievement-oriented, and socially mature.

Although some longitudinal studies have noted the relationship between intelligence and resilience, there is little evidence that high intelligence alone promotes effective coping. As Luthar noted (Luthar & Zigler, 1991), high intelligence may be associated with an increased sensitivity to stressors and may heighten a child's susceptibility. Horowitz and Garber (2003) reported that for children of mothers with less chronic depression, higher IQ was associated with a lower likelihood of depression; in contrast, for children of mothers with a history of more chronic depression, higher IQ was associated with a greater likelihood of depression.

Family factors are enormously important to children's resilience to stress. In particular, a close bond between a child and caregiver is among the most important factors associated with resilience. This caregiver does not need to be a biological parent. Werner (1993) found that grandparents, older siblings, and other substitute caregivers supplied much of this important nurturing. Having a psychiatrically healthy caregiver can also promote resilience among children of parents with depression. A caring adult who is involved in the child's life might provide positive, supportive parenting for the child. Husbands whose wives had depression were found to be more positive in their interactions with their children than husbands with psychiatrically healthy wives (Warner, & Weissman, 1990).

HOW PARENTS WITH DEPRESSION CAN HELP THEIR CHILDREN

Parents with depression often worry that they have damaged their children for life. Yet parents with depression can still raise happy, well-adjusted children. Adult children of parents with depression reported positive outcomes of living with a depressed parent, including strength empathy and compassion, tolerance and understanding, healthy attitudes and priorities, and an appreciation of life (Nicholson et al., 2001). The following guidelines can help parents with depression overcome obstacles that accompany their illness and raise resilient children.

Set an example

Parents who ask for help and begin to follow treatment plans not only help themselves toward recovery, but they also set the stage for a healthy and happy environment for their children. Whatever parents can do to relieve their own depression will automatically help their children.

While in treatment, clinicians should not focus exclusively on the adult patients' illness while neglecting depression in the context of family and community. According to Nicholson and colleagues (2001), providers often neglect to even ask about an individual's family role and responsibilities. Clinicians working with adults with mental illness need to inquire about children and adolescents.

Because depression is a disorder that affects all family members, it is often useful for children and adolescents living with parents with depression to also be screened by a mental health professional. This can ensure that these youngsters receive any help they need and develop coping skills for healthy development despite troubles at home. Clinicians can help families work with the positive elements within a family and the natural strengths of the child to deal with his or her parent's illness and any related stressors. Beardslee and colleagues (1997) found that when clinicians met with the children of depressed patients, educating them about the disease relative to the children's concerns and experiences, results were significantly better than simply educating them in a lecture format. Specifically, the children who had the opportunity to meet with a clinician reported greater levels of understanding of their parents' disorder and had better adaptive functioning after intervention.

Help children understand what's happening in the family

When parents talk to their children about depression, they need to approach the illness as they would a physical disease or ailment. They should explain what is wrong and what doctors are doing to help. It is also important to emphasize that the mental illness is a biological disease and that the parent will get better. Additionally, parents should assure children that they are not to blame.

Parents should ask children open-ended questions and listen non-judgmentally. When they ask questions that can be answered with a "yes" or a "no," it is hard to keep the conversation going. To encourage sharing and gain insight into how children are thinking, parents should ask instead: "How did you feel about that?" "Why do you think that happened?" "What else could explain that?" (Go on and Live).

Help children develop and maintain relationships outside of the family and be successful away from home

Beardslee and colleagues (1988) discovered that children of parents with depression who function well possess the following characteristics: self-understanding, a deep commitment to relationships, and the ability to think and act separately from their families. These findings suggest that children who manage to find the support they need, through activities and relationships with others, may be protected from the potentially harmful impact of parental depression. For this reason, parents should encourage their children to spend time away from home and become involved in activities that will promote resilience and self-confidence. To the same end, parents should help children work toward developing strong, supportive friendships outside of the home.

Additionally, as parents with depression begin to feel better, they should try to strengthen and renew their relationship with their child by showing interest in their child's daily life and maintaining open communication. Go on and Live suggests that parents participate in some of the family activities they used to enjoy and rediscover the joys of parenting by setting aside time to connect with their children (e.g., read to the child, ask the child questions about his or her day, join the child in activities, take walks together in the park).

Be alert to children's signs of depression

The behavior of children and teenagers with depression may differ from the behavior of adults with depression. It is also important to realize that signs and symptoms of depression can differ depending on the age, gender, and race/ethnicity of a person, and might look different than the descriptions that their parents have learned or their parents' own experiences. The National Institute of Mental Health (NIMH) suggests that if one or more of these signs of depression persist, parents should seek help (NIMH, 2000):

• Frequent vague, non-specific physical complaints such as headaches, muscle aches, stomach aches or tiredness
• Frequent absences from school or poor performance in school
• Talk of, or efforts to run away from home
• Outbursts of shouting, complaining, unexplained irritability, or crying
• Being bored
• Lack of interest in playing with friends
• Alcohol or substance abuse
• Social isolation, poor communication
• Fear of death
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Reckless behavior
• Difficulty with relationships

The following are specific examples of behaviors that a child with depression might exhibit (The Depressed Child, 1992):

• A child who used to play often with friends may now spend most of the time alone and without interests.
• Things that were once fun now bring little joy to the depressed child.
• Children and adolescents who are depressed may say they want to be dead or may talk about suicide.
• Depressed adolescents may abuse alcohol or other drugs as a way to feel better.
• Children and adolescents who cause trouble at home or at school may actually be depressed but not know it. Because the youngster may not always seem sad, parents and teachers may not realize that troublesome behavior is a sign of depression.

IS A PARENT'S DEPRESSION ADVERSELY AFFECTING A CHILD?

If a parent can answer “yes” to any of the following questions, it would be a good idea to bring up the issue with the child's pediatrician as well as with the adult's own physician or mental-health professional (Colino, 2002):

• Do you feel like you are constantly under stress?
• Do you have a drinking or drug problem?
• In the past year, have you felt depressed for two weeks or more?
• Do you and your spouse/partner fight frequently?
• Do you have food fears and fixations or a weight problem?
• Do you feel more angry or irritable?
• Are you more fatigued?

Here are some ways to bring up the subject with a pediatrician/physician or mental health professional (Source: May 2002 issue of Child Magazine). Once you start the conversation, the lines of communication will be open, and your physician will be able to give you advice or refer you to someone who can help.

• "Work has been pretty hectic lately, and I'm really stressed out by the time I get home and see my wife and kids."
• "I've been trying to cut down on my alcohol use. Do you have any suggestions?"
• "My child is healthy, but sometimes I feel as though I can barely function because I'm so depressed."
• "We're going through a tough time in our marriage. Do you think Bobby's frequent illnesses could be related to this?"
• "I worry about my weight a lot. What are the chances that this is affecting my child's eating habits?"

Even psychologically healthy children can grow up with the impression that they are unloved or that life is sad. Molineux (2002) reported that, in his practice, he has found that children sense several unspoken messages from a parent with depression. It is important that parents are not conveying these messages to their children—consciously or unconsciously—through words and/or actions:

1. Don't be happier than I am because then I'll feel worse. Children who believe they've received this message often struggle with depression in their adult lives because they feel guilty if they're happy. It's as if they unconsciously think to themselves, “It wouldn't be fair for me to be happier than my parent.”
2. Be happy or successful so I can feel better. By your accomplishments, make up for my deficiencies. Children who have received this impression may be depressed because they've accepted, or given themselves, an impossible task. Since no one can make another person happy, or compensate for his or her own unhappiness, these children may feel they've failed their parent.
3. Don't come to me with your problems, I'm too overwhelmed with my own. Children who believe this is what a parent with depression is covertly saying often grow up feeling lonely in their families. There may be no one in whom they can confide about their problems.
4. Stay with me and take care of me. I'll be so unhappy without you. This message may come from a parent with depression in his or her later years. It places the children of aging parents in another difficult position. Often, they feel torn between guilt for not responding to their parent or resentment for having to do so.

WHERE TO FIND MORE INFORMATION

Programs for parents with mental illness and their children

Useful web sites

Books for parents and children

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