maternal postpartum depression and risk of psychopathology
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Reported Maternal Postpartum Depression and Risk of ChildhoodPsychopathology
Meghan J. Walker Caroline Davis
Ban Al-Sahab Hala Tamim
Published online: 29 June 2012 Springer Science+Business Media, LLC 2012
Abstract Childhood emotional and behavioural disorders
are prevalent, can cause significant maladaptation andoften persist into adulthood. Previous literature investi-
gating the potential influence of postpartum depression
(PPD) is inconsistent. The present study examined the
association between PPD and childhood behavioural/emo-
tional outcomes, while considering a number of potentially
important factors. Data were analyzed prospectively from
the National Longitudinal Survey of Children and Youth at
two follow-up periods (ages 23, N = 1,452 and ages 45,
N = 1,357). PPD was measured using the diagnostic cri-
teria of the DSM-IV-TR. Four behavioural/emotional out-
comes were analyzed at each follow-up. For both age
groups, logistic regression models were used to estimatethe associations between PPD and each of the behavioural
and emotional outcomes adjusting for child, obstetric,
environmental and socio-demographic factors. PPD was
associated with the Emotional Disorder-Anxiety among
23 year olds [OR = 2.38, 95 % CI 1.15, 4.91]. Among23 year olds, hostile/ineffective parenting was associated
with Hyperactivity-Inattention [OR = 1.88, 95 % CI 1.14,
3.11] and Physical Aggression-Opposition [OR= 2.95,
95 % CI 1.77, 4.92]. Among 45 year olds, hostile/inef-
fective parenting was associated with Hyperactivity-Inat-
tention [OR= 2.34, 95 % CI 1.22, 4.47], Emotional
Disorder-Anxiety [OR = 2.16, 95 % CI 1.00, 4.67], Phys-
ical Aggression-Conduct Disorder [OR = 1.96, 95 % CI
1.09, 3.53] and Indirect Aggression [OR = 1.87, 95 % CI
1.09, 3.21]. The findings of the present study do not suggest
that PPD is independently associated with any enduring
sequelae in the realm of child behavioural/emotional psy-chology, though the symptoms of PPD may be giving way
to other important mediating factors such as parenting style.
Keywords Childhood behaviourBehavioural disorders
Emotional disorders Postpartum depression Parenting
Introduction
Behavioural and emotional disorders are prevalent among
children and can cause significant impairment and malad-
aptation in familial, social, academic and community set-
tings. North American epidemiologic studies have indicated
that the estimated prevalence of childrens mental disorders
ranges from approximately 1020 % [1]. Comorbidity is
common, with approximately half living with two or more
concurrent disorders [1]. However, these estimates only
consider children at clinical levels and the proportion who
are affected sub-clinically or remain undiagnosed is
approximately 20 % higher [2]. Behavioural problems
reported in preschool-aged years are highly predictive of
M. J. Walker (&)Division of Epidemiology, Faculty of Medicine, Dalla LanaSchool of Public Health, University of Toronto, Toronto, Canadae-mail: [email protected]
M. J. WalkerPrevention and Cancer Control, Cancer Care Ontario,
620 University Avenue, 11th Floor, Toronto, ON M5G 2L7,Canada
C. DavisDepartment of Psychiatry, Faculty of Medicine, UniversityHealth Network, Toronto, Canada
C. DavisCentre for Addiction and Mental Health, Toronto, Canada
C. Davis B. Al-Sahab H. TamimFaculty of Health Sciences, School of Kinesiology and HealthScience, York University, Toronto, Canada
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who reported longer than 14 days were grouped as having
PPD.
The outcome variables of interest were the presence of
behavioural/emotional problem(s) in children. Outcomes
were measured by the NLSCY Child Behavioural Scales,
which consist of items derived from previously-utilized,
population-based surveys with known psychometric prop-
erties to operationalize the diagnostic criteria for the cor-responding disorders within the DSM-IV-TR [4]. For
children aged 23, four outcomes were considered, as
identified by factor analysis: Hyperactivity-Inattention
[from the Ontario Child Health Study (OCHS) and Mon-
treal Longitudinal Survey (MLS)], Emotional-Disorder
Anxiety (from the OCHS), Physical Aggression-Opposi-
tion (from the OCHS and MLS), and Separation Anxiety
(from Achenbachs Child Behavior Checklist) [28]. For
children aged 45 years of age, the following four out-
comes were considered: Hyperactivity-Inattention (from
the OCHS and MLS), Emotional Disorder-Anxiety (from
the OCHS), Physical Aggression-Conduct Disorder (fromthe OCHS and MLS) and Indirect Aggression (from Lag-
erspetz, Bjorngvist and Peltonen of Finland) [28]. Consis-
tent with previously utilized scoring schemes, children with
a scale score above the 80th percentile were classified as
having a high degree of that outcome [29].
Covariates were identified a priori as a result of a
comprehensive review of the literature. Child factors
include the childs sex and presence of worry/unhappiness.
Obstetric factors include preterm birth (gestational
age B 258 days), low birthweight (B2499 g), maternal age
at childs birth and mothers smoking and alcohol status
during pregnancy. Environmental factors included parent-ing style, family functioning, current maternal depression
and single parent status. Parenting styles, including posi-
tive interaction, hostile/ineffective parenting, consistency
and punitive/aversive parenting, were measured by a
revised version of the Strayhorn and Weidmans Parenting
Practices Scale [30]. Consistent with previous scoring
schemes, a scale score in the lowest quartile was indicative
of having a low degree of positive interaction and consis-
tency, while a score in the highest quartile was indicative
of having a high degree of hostile/ineffective parenting and
punitive/aversive parenting [31, 32]. Family functioning
was measured with the General Functioning subscale of the
McMaster Family Assessment Device [33]. Consistent with
previous scoring-schemes, a score ofC15 was indicative of
low family functioning [32,34]. An abbreviated version of
the Centre for Epidemiologic Studies Depression Scale
(CES-D) [35] was used to determine severity of current
maternal depressive symptoms. Consistent with previous
scoring schemes, a score ofC13 was indicative of mod-
erate to severe depression [32, 34]. Socio-demographic
factors include income adequacy, maternal education and
immigration status. Income Adequacy takes into account
household income and size [28], corresponding closely to
Canadas poverty line [32]. Presence of a comorbid out-
come and childs outcome history were also analyzed.
Statistical Analyses
Statistics Canadas microdata publication guides werefollowed throughout all analyses [28]. Data were weighted
to the population level according to longitudinal survey
weights derived by Statistics Canada to account for
unequal probabilities of sample selection, including non-
response and attrition. Rescaled sample weights were
applied to preserve the original sample sizes and correct for
variance estimation bias. Due to the complex sampling
design of the NLSCY, bootstrapping was performed to
estimate all confidence intervals (CIs). Analyses were
undertaken at Cycle 2 when children were 23 years of age
and Cycle 3 when children were 45 years of age.
Descriptive frequencies of the study population were tab-ulated. Crude and adjusted odds ratios (ORs) and 95 % CIs
were calculated with logistic regression to estimate the
associations between PPD and each of the behavioural and
emotional outcomes. All analyses were performed with
SPSS Version 16.0, with the exception of bootstrapping,
which was performed utilizing SAS, Version 9.2.
Results
A reported 8.4 % (n = 122) of mothers were affected by
PPD in the year following birth of the child. A similarproportion reported being currently depressed when the
child was 23 years of age (8.3 %) and a slightly lower
proportion reported being depressed when the child was
45 (6.6 %). There were approximately equal proportions
of male (50.8 %) and female (49.2 %) children in the
sample. A majority of mothers were 2534 years of age
(68.4 %), with a smaller proportion 1524 years of age
(18.8 %) and 12.8 % of mothers C35.
Crude analyses are reported in Table 1and revealed that
PPD was not significantly associated with most childrens
behavioural/emotional outcomes. However, children of
mothers who had PPD were 2.61 times more likely to
display high degrees of Emotional Disorder-Anxiety
[OR = 2.61, 95 % CI 1.40, 4.86] and twice as likely to
display high degrees of Physical Aggression-Conduct
Disorder [OR = 2.00, 95 % CI 1.04, 3.86].
Table2 depicts the multivariable analysis of child,
obstetric, environmental and socio-demographic factors of
behavioural/emotional outcomes at Cycle 2 (ages 23).
Comorbid Emotional Disorder-Anxiety [OR = 1.69, 95 %
CI 1.03, 2.78], comorbid Physical Aggression-Opposition
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[OR = 4.09, 95 % CI 2.41, 6.93] and hostile/ineffective
parenting [OR = 1.88, 95 % CI 1.14, 3.11] were signifi-
cantly associated with a high degree of Hyperactivity-
Inattention. Comorbid Hyperactivity-Inattention [OR =
1.73, 95 % CI 1.03, 2.78], Separation Anxiety [OR = 3.75,95 % CI 2.48, 5.68] and PPD in the mother [OR = 2.38,
95 % CI 1.15, 4.91] was significantly associated with a
high degree of Emotional Disorder-Anxiety.
In regard to Physical Aggression-Opposition, results
indicate that children with high degrees of Hyperactivity-
Inattention [OR = 4.17, 95 % CI 2.49, 6.96] and Separa-
tion Anxiety [OR = 3.09, 95 % CI 1.93, 4.93] were sig-
nificantly more likely to display Physical Aggression-
Opposition. Low degrees of consistent parenting [OR =
1.68, 95 % CI 1.01, 2.78] and high hostile/ineffective
parenting [OR = 2.95, 95 % CI 1.77, 4.92] were also
significant. Children with comorbid Emotional Disorder-Anxiety and Physical Aggression-Opposition were more
likely to display high degrees of Separation Anxiety
[OR = 3.77, 95 % CI 2.49, 5.71] and [OR = 3.01, 95 %
CI 1.87, 4.84], respectively.
Table3 shows results of the multivariable analysis of
PPD and behavioural/emotional outcomes at Cycle 3 (ages
45). Male sex [OR = 1.80, 95 % CI 1.12, 2.89], comorbid
Physical Aggression-Opposition [OR = 2.36, 95 % CI
1.30, 4.27] and hostile/ineffective parenting [OR = 2.34,
95 % CI 1.22, 4.47] were associated with Hyperactivity-
Inattention at 45 years of age.
In regards to Emotional Disorder-Anxiety, children withhigh degrees of Physical Aggression-Conduct Disorder
[OR = 2.42, 95 % CI 1.10, 5.33] and Indirect Aggression
[OR = 1.94, 95 % CI 1.05, 3.61] were approximately
twice as likely to have high degrees of Emotional Disorder-
Anxiety. Low Positive Interaction and high hostile/inef-
fective parenting were associated with approximately two
times the likelihood of reporting a high degree of Emo-
tional Disorder-Anxiety [OR = 1.95, 95 % CI 1.02, 3.74
and OR = 2.16, 95 % CI 1.00, 4.67].
Male children are close to twice as likely to exhibit high
degrees of Physical Aggression-Conduct Disorder [OR =
1.80, 95 % CI 1.04, 3.12]. Comorbid Hyperactivity-Inat-
tention [OR = 2.85, 95 % CI 1.62, 5.03], Emotional Dis-
order-Anxiety [OR = 2.70, 95 % CI 1.27, 5.75] and
Indirect Aggression [OR = 2.53, 95 % CI 1.38, 4.64] were
also significantly associated with Physical Aggression-
Conduct Disorder. Children of parents who exhibit highdegrees of hostile/ineffective parenting [OR = 1.96, 95 %
CI 1.09, 3.53] and punitive/aversive parenting [OR = 2.08,
95 % CI 1.18, 3.36] were approximately twice as likely to
exhibit high degrees of Physical Aggression-Conduct
Disorder.
Lastly, in the case of Indirect Aggression, male children
were less likely to exhibit Indirect Aggression [OR = 0.54,
95 % CI 0.35, 0.85]. Comorbid Hyperactivity-Inattention
[OR = 1.75, 95 % CI 1.08, 2.84], Emotional Disorder-
Anxiety [OR = 2.03, 95 % CI 1.10, 3.75] and Physical
Aggression-Conduct Disorder [OR = 2.37, 95 % CI 1.32,
4.26] were also associated with a high degree of IndirectAggression. Children of mothers who reported high
degrees of hostile/ineffective parenting were close to twice
as likely to display high Indirect Aggression [OR = 1.87,
95 % CI 1.09, 3.21].
Discussion
With the exception of Emotional Disorder-Anxiety among
23 year olds, PPD does not appear to be associated with
the outcomes measured. However, multivariable analyses
revealed that parenting style may be an important factor,given the magnitude and consistency of the associations
observed. The persistence of the association between PPD
and Emotional Disorder-Anxiety following adjustment is
not unforeseen, given that PPD is of the same class of
clinical disorders that the Emotional Disorder-Anxiety
scale seeks to measure. Clinical Mood and Anxiety Dis-
orders have a moderate heritable component, specifically
among first-degree relatives [4], therefore symptomatology
may be expected in the offspring of afflicted parents.
A number of studies have previously assessed the rela-
tionship between mothers PPD status and behavioural/
emotional outcomes in children, with inconsistency in the
emotional, attentional and cognitive disturbances reported
[12]. In contrast to the results of the present study, a number
have reported significant positive associations between PPD
and childhood outcomes, including Oppositional-Defiant
Disorder and Conduct Disorder [17], inattention-hyper-
activity, separation anxiety [18,19], several depressive and
anxiety disorders [36], elevated cortisol levels which have
predicted major depression [37], lower cognitive scores
[2022, 38], violent behaviour and substance abuse
Table 1 Unadjusted analysis of postpartum depression and behav-ioural/emotional outcomes
OR [95 % CI]
Cycle 2 outcomeages 23 (n = 1,452)
Hyperactivity-inattention 1.65 [0.89, 3.04]
Emotional disorder-anxiety 2.61 [1.40, 4.86]
Physical aggression-opposition 1.94 [0.98, 3.81]Separation anxiety 1.34 [0.75, 2.40]
Cycle 3 outcomeages 45 (n = 1,357)
Hyperactivity-inattention 1.69 [0.93, 3.09]
Emotional disorder-anxiety 1.59 [0.78, 3.26]
Physical aggression-conduct disorder 2.00 [1.04, 3.86]
Indirect aggression 1.42 [0.75, 2.67]
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Table 2 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 2(ages 23, N = 1,452)
Odds ratios [95 % confidence intervals]
Hyperactivity-inattention Emotionaldisorder-anxiety
Physicalaggression-opposition
Separationanxiety
Child factors
Childs sexFemale 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Male 1.17 [0.73, 1.87] 1.44 [0.96, 2.16] 1.31 [0.82, 2.11] 0.75 [0.52, 1.07]
Obstetric factors
Preterm birth
Not preterm 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Preterm 0.99 [0.44, 2.22] 1.15 [0.49, 2.67] 0.53 [0.18, 1.58] 1.28 [0.63, 2.59]
Birthweight
Normal 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 0.82 [0.26, 2.66] 0.71 [0.21, 2.37] 3.18 [0.97,10.45] 0.80 [0.35, 1.85]
Maternal age at birth
1524 2.44 [1.01, 5.90] 2.05 [0.93, 4.51] 0.50 [0.20, 1.31] 1.00 [0.48, 2.10]
2534 2.11 [0.96, 4.63] 1.69 [0.83, 3.45] 0.67 [0.27, 1.63] 1.01 [0.52, 1.96]
35? 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Smoking status during pregnancy
Did not smoke 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Smoked 1.47 [0.92, 2.35] 0.51 [0.31, 0.82] 1.08 [0.62, 1.87] 1.04 [0.69, 1.58]
Drinking status during pregnancy
Did not drink 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Drank 1.08 [0.64, 1.81] 1.42 [0.86, 2.35] 1.12 [0.60, 2.07] 1.02 [0.66, 1.59]
Postpartum depression
No PPD 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
PPD 1.32 [0.58, 3.00] 2.38 [1.15, 4.91] 1.00 [0.46, 2.18] 0.94 [0.49, 1.78]
Environmental factorsParenting style: positive interaction
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 0.90 [0.55, 1.49] 0.51 [0.33, 0.79] 1.40 [0.87, 2.25] 0.86 [0.57, 1.31]
Parenting style: consistency
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 1.18 [0.74, 1.86] 1.10 [0.72, 1.68] 1.68 [1.01, 2.78] 1.53 [0.99, 2.36]
Parenting style: hostile/ineffective
Low 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
High 1.88 [1.14, 3.11] 1.22 [0.76, 1.98] 2.95 [1.77, 4.92] 1.41 [0.87, 2.28]
Parenting style: punitive/aversive
Low 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
High 1.51 [0.94, 2.43] 1.13 [0.71, 1.80] 1.29 [0.81, 2.05] 0.93 [0.60, 1.45]Family functioning
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 1.09 [0.39, 3.06] 1.60 [0.76, 3.38] 1.27 [0.49, 3.29] 1.79 [0.89, 3.55]
Current maternal depression
Low 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Moderate to severe 1.79 [0.78, 4.09] 1.27 [0.61, 2.64] 0.94 [0.43, 2.09] 1.30 [0.60, 2.82]
Single parent status
Lives with 2 parents 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Lives with single parent 1.18 [0.50, 2.77] 1.68 [0.91, 3.12] 0.45 [0.18, 1.14] 0.68 [0.36, 1.29]
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[19,20]. Other studies however, have reported that effects
found in earlier ages may attenuate [23, 24, 39], while
others have reported that PPD is not associated with adverseeffects among offspring [2527]. These inconsistencies
may be due to methodological differences. Studies often
employ clinic-based recruitment strategies or diagnostic
interviews to determine their samples [17, 36]. While the
latter are viewed as the gold standard of psychometric
evaluation, their use would limit generalizability to children
who experience mental health outcomes at clinically
important levels. By contrast, the objective of the present
study was to employ a nationally-representative population-
level sample of children and utilize a more liberal charac-
terization of emotional and behavioural symptomatology.
The present study also incorporated a number of importantcovariates, which may be predictively important. Several
studies which have examined more than one type of out-
come have not included a measure to adjust for the
comorbidity of these outcomes [26,36]. This may have led
to the distortion of the true effect of PPD.
The finding that high degrees of several of the behav-
ioural/emotional outcomes assessed differed by the childs
sex at ages 45 is consistent with what is known about
each of the corresponding mental disorders within the
DSM-IV-TR [4]. Attention-Deficit/Hyperactivity Disorder
(ADHD) and Conduct Disorder (CD) are more frequently
observed among male children [4] and indirect aggressionis more commonly observed among female children [40
42]. The finding that Emotional Disorder-Anxiety did not
differ by sex in children at ages 23 or 45 is also con-
sistent with the literature. Rate differentiation by sex of
Mood and Anxiety Disorders typically only begins to
emerge following puberty [4, 43].
A consistent pattern emerged among the other covariates
assessed. Having a comorbid behavioural/emotional out-
come or previous history of the behavioural/emotional
outcome was significantly associated with each of the
outcomes assessed. A number of statistically significant
results emerged among parenting techniques and thebehavioural/emotional outcomes. These findings suggest
that while PPD itself may not be associated with adverse
child psychiatric outcomes, parenting styles do appear to
be. Hostile/ineffective parenting appeared to be most
important, significantly associated with two of four out-
comes at ages 23 and all outcomes assessed at ages 45. It
is important to note however, that previous literature lends
evidence to the possibility that parenting may be on the
causal pathway between PPD and childhood behavioural/
Table 2 continued
Odds ratios [95 % confidence intervals]
Hyperactivity-inattention Emotionaldisorder-anxiety
Physicalaggression-opposition
Separationanxiety
Socio-demographic factors
Income adequacy
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 1.76 [0.79, 3.94] 0.82 [0.44, 1.55] 1.01 [0.39, 2.59] 1.18 [0.65, 2.14]
Maternal education
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 1.21 [0.59, 2.51] 1.50 [0.79, 2.86] 0.39 [0.17, 0.88] 1.40 [0.74, 2.62]
Maternal immigration status
Non-immigrant 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Immigrant 1.04 [0.45, 2.43] 0.86 [0.41, 1.80] 1.15 [0.52, 2.54] 2.27 [1.15, 4.49]
Comorbid hyperactivity-inattention
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.73 [1.07, 2.78] 4.17 [2.49, 6.96] 1.18 [0.74, 1.86]
Comorbid emotional disorder-anxiety
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.69 [1.03, 2.78] 1.39 [0.84, 2.29] 3.77 [2.49, 5.71]
Comorbid physical aggression-opposition
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 4.09 [2.41, 6.93] 1.39 [0.84, 2.30] 3.01 [1.87, 4.84]
Comorbid separation anxiety
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.15 [0.72, 1.83] 3.75 [2.48, 5.68] 3.09 [1.93, 4.93]
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emotional outcomes. The literature on PPD and subsequent
maternal depression indicates that child management may
be one of the areas wherein the depressive state of the
mother may manifest. This evidence comes from a number
of studies which have noted increased levels of intrusive-
ness, dysfunctional attachment and interactive patterns [15,
4446]. As reviewed by Beck (1999) [47], depressed
mothers may be more inconsistent and ineffective in their
child management, monitoring and discipline-administra-tion techniques. These mothers are also more likely to
submit to a childs non-compliance and use forceful control
strategies [47].
There is also evidence of the relationship between par-
enting behaviours and development of certain mental dis-
orders. Both ADHD and Oppositional Defiant Disorder/
Conduct Disorder have been linked to inconsistent, unre-
sponsive, coercive, critical and rejecting parenting patterns
[4850], as well as hostile and punitive disciplinary patterns
[51,52]. Research has also indicated that positive, involved
and supportive parenting and lower levels of harsh, punitive
parenting may predict more optimal behavioural, academic
and social adjustment and appears to buffer the effects of
psychological adversity in school-aged children [53]. Other
findings from a study of Canadian infants have indicated
that parenting interventions with depressed mothers can
result in improvements in mother-infant interactions [54].
However, while parenting practices may be related tochildrens mental health outcomes, the causal chain of
events is unclear. The childhood outcomes discussed in the
present study are often associated with significant caregiver
stress and strain [55]. Therefore it is possible that these
parenting styles may be a reaction to a childs previously
established troubled behaviour.
The present study has a number of strengths. Data were
utilized from a nationally representative dataset, making
results generalizable to Canadian children aged 25. The
Table 3 continued
Odds ratios (95 % confidence intervals)
Hyperactivity-inattention
Emotionaldisorder-anxiety
Physical aggression-conduct disorder
Indirectaggression
Single parent status
Lives with two parents 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Lives with single parent 0.77 [0.34, 1.77] 1.50 [0.56, 4.03] 1.12 [0.51, 2.43] 1.54 [0.75, 3.17]
Socio-demographic factors
Income adequacy
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 0.84 [0.31, 2.27] 0.74 [0.24, 2.26] 1.55 [0.70, 3.44] 1.13 [0.53, 2.41]
Maternal education
High 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Low 1.74 [0.69, 4.39] 0.29 [0.09, 0.95] 0.60 [0.22, 1.63] 1.07 [0.46, 2.49]
Maternal immigration
Non-immigrant 1.00 Reference 1.00 Reference 1.00 Reference 1.00 Reference
Immigrant 0.96 [0.28, 3.35] 2.08 [0.11, 38.33] 0.17 [0.01, 2.54] 1.61 [0.70, 3.72]
Comorbid hyperactivity-inattention
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.53 [0.76, 3.07] 2.85 [1.62, 5.03] 1.75 [1.08, 2.84]
Comorbid emotional disorder-anxiety
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.80 [0.88, 3.71] 2.70 [1.27, 5.75] 2.03 [1.10, 3.75]
Comorbid physical aggression-conduct disorder
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 2.36 [1.30, 4.27] 2.42 [1.10, 5.33] 2.37 [1.32, 4.26]
Comorbid indirect aggression
No 1.00 Reference 1.00 Reference 1.00 Reference
Yes 1.69 [0.99, 2.88] 1.94 [1.05, 3.61] 2.53 [1.38, 4.64]
History of outcomeNo 1.00 Reference 1.00 Reference 1.00 Reference
Yes 3.90 [2.16, 7.05] 2.65 [1.31, 5.35] 3.62 [2.14, 6.12]
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large sample allowed for ample statistical power in the
analysis of multivariable relationships. The present study
accounted for outcome comorbidity and a previous history
of outcome. Including such measures is important in reli-
ably assessing the relationship between PPD and mental
health outcomes in epidemiological research given that
comorbidity is common in psychiatric illness [43], and
childrens early and later mental health status are oftenhighly correlated. To the authors knowledge, this is the
first study to consider parenting style while investigating
the relationship between postpartum depression and
childhood outcomes, a factor which has been associated
with both postpartum depression and childhood behav-
ioural/emotional outcomes.
It is important to consider several limitations. Perhaps
the most important is reliance upon self-report by biolog-
ical mothers to obtain measures of exposure and outcomes,
instead of the use of clinically-trained assessors. While
biological mothers are generally recognized as reliable
informants regarding their offspring, a concern exists thatmaternal PPD may cause mothers to over-report disordered
behaviours among their children [39]. It is also generally
recognized in the field of child psychiatric epidemiology
that reports from multiple informants are optimal [56] and
it may have been beneficial to supplement PMK reports
with those of a second party. While the NLSCY also col-
lected data on behavioural/emotional outcomes from
school-aged childrens teachers, a majority of these data
were missing. Missing data was also present due to the
longitudinal nature of this study. Among all the NLSCY
participants, the response rate at cycle 2 was 91.7 and
89.6 % at cycle 3. An additional limitation was thepotential for misclassification introduced by utilization of
the 80th percentile cut-off for classifying children into
outcome groups. While it would have been ideal to treat
these variables as linear, the distribution of scale scores
demonstrated high levels of skewness, as is commonly
found in ratings of problematic behaviour [57]. The non-
normal distribution would make elevated scale scores rare
and equal scale division problematic. Lastly, factors such
as familial history of psychiatric disorders were not col-
lected and could not be adjusted for. One population-based
study indicated that approximately 4 % of fathers experi-
ence PPD and paternal PPD may be associated with
behavioural/emotional disorders among offspring [58].
Residual confounding is likely to exist, as familial history
could not be accounted for in the analysis.
The findings of the present study do not suggest that
PPD is independently associated with any enduring
sequelae in the realm of child behavioural/emotional psy-
chology, though the symptoms of PPD may be giving way
to other important mediating factors such as parenting
style. Specifically, the present study has highlighted
positive parenting techniques and practices as a potential
area for intervention, as negativistic parenting techniques
may be a function of PPD and appear to be associated with
childhood emotional/behavioural outcomes. The results
have also demonstrated the need for further research in
clarifying the relationship between these factors to identify
where prevention efforts should be targeted to reduce the
burden of childhood psychiatric illness.
Acknowledgments While the research and analyses are based ondata from Statistics Canada, the opinions expressed do not representthe views of Statistics Canada. The authors would like to thank theNLSCY study participants, Statistics Canada, Human Resources andSkills Development Canada (HRSDC) and the staff at the TorontoRegionStatistics Canada Research Data Centre.
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C o p y r i g h t o f M a t e r n a l & C h i l d H e a l t h J o u r n a l i s t h e p r o p e r t y o f S p r i n g e r S c i e n c e & B u s i n e s s
M e d i a B . V . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a
l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t ,
d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .