Symptoms of anxiety and depression among mothers of pre-school children: effect of chronic strain related to children and child care-taking

Abstract

Background: Factors that affect maternal mental health were studied when the children were 30 and 50 months old, and changes in the importance of these factors over time were analyzed. A specific aim was to elucidate the role of chronic strain related to children and child care-taking. This study follows up previous work on the influence of social class, strain and social support on maternal mental distress when the children were 18 months old. Methods: The sample is population based, and 1,081 parents were invited to fill out questionnaires. Maternal mental distress was measured by the Hopkins Symptom Checklist (SCL-25). Multiple regression analyses were conducted at each time point and chi-square tests were used to analyze the changes between the estimated regression coefficients over time. Results: Chronic strain related to children and child care-taking consistently predicted maternal mental distress. Among the specific child related strains, problems with child care-taking were significantly associated with maternal symptom levels at all time points. The importance of two specific child problem behaviors (activity level and the child being a worrier) on maternal mental health changed over time. Limitations: Conclusions about causality can not be drawn based on cross-sectional analyses. The self-report measures used here may be biased by the current mood state. Conclusions: Problems with child care arrangements and combining work and child care-taking are predicive of maternal mental health when the children are 18, 30 and 50 months old. The risk and protective factors found here may have implications for prevention and intervention.

Introduction

Parenthood is generally considered to be one of the most fulfilling experiences for a woman (Brown et al., 1994). Indeed, more women than men consider being a parent of major importance for a satisfying life (Lips, 1983). Despite the positive effects associated with motherhood, it may also have negative consequences for mental health, including an increased risk for depression in the years following childbirth.

Depression is the most common severe mental disorder among women. Contrary to beliefs that depression affects women primarily during the menopausal years, it is most prevalent during childbearing and early childrearing years (Paykel, 1991, Leon et al., 1993, Horton, 1995, Weissman and Olfson, 1995). There is a substantial literature demonstrating that mothers are at an increased risk for mental distress both during the postpartum period (Kumar and Robson, 1984, Kendell et al., 1976, Kendell et al., 1987, Whiffen, 1988, O’Hara and Swain, 1996, Lane et al., 1997) and in the years following postpartum (Moss and Plewis, 1977, Richman, 1974, Richman, 1977, Brown and Harris, 1978, Bebbington et al., 1981, Bebbington et al., 1984, Ensel, 1982, Olson and DiBrigida, 1994, Weissman and Olfson, 1995). The reported prevalences in the years following postpartum vary according to the definitions used and the sample being considered. A study based on a birth cohort of children aged four indicated that 27% of the mothers were depressed (Williams and Carmichael, 1991), whereas depressive symptomatology presented a major problem for 42% of the mothers of toddlers aged 15 to 24 months from a middle class pediatric practice (Olson and DiBrigida, 1994). A recent Task Force on women and depression concludes that the association between the collective demands of parenthood and depression has not yet been ascertained (McGrath et al., 1990).

A number of putative causes, mainly those derived from general models of depression, have been investigated for maternal mental health status, including genetic, hormonal, biological, psychosocial and reproductive-related factors (Weissman and Klerman, 1977, McGrath et al., 1990, Horton, 1995). Among the psychosocial factors studied, evidence suggests that stress and social support are important mediators. Self-reported stressful events seem to predict subsequent depression (Kessler, 1997) and chronic events are considered by some to be even more potent stressors than acute major events (Kanner et al., 1980), however methodological problems hamper causal inferences. Mothers of toddlers face unique stresses as parents and caring for young children could, in itself, be a chronic strain that requires considerable adaptability in that minor, typical or normal, parenting hassles appear to be an important source of stress (Richman, 1976, Weinberg and Richardson, 1981, D’Arcy and Siddique, 1984, Crnic and Greenberg, 1990). Parenting infants and toddlers is perceived as a difficult task, even by relatively affluent and well-educated middle class parents with healthy and normally developing children (O’Brien, 1996). It has been suggested that the mother becomes more vulnerable to physical and psychological problems due to daily pressures of her child’s needs (Kitzinger, 1980 as cited in D’Arcy and Siddique, 1984). Parental demands can place mothers of toddlers in particular need of emotional and instrumental support. Maternal mental health has been found to be more closely connected to the mother’s social support system than to either her own, or to her baby’s physical health (Oakley et al., 1994). Social support can, alternatively, be viewed as a buffer that protects individuals from the potentially negative effects of stressful events or as a benefactor regardless of whether or not one are under stress (Cobb, 1976, Cohen and Wills, 1985, Ladewig et al., 1990, Dalgard et al., 1995). Some studies find that social support provided by the spouse seems to be especially important in the postpartum period (Paykel et al., 1980, Crnic et al., 1983, O’Hara et al., 1983, O’Hara, 1986, Boyce et al., 1991) but this is not a consistent finding (Hall et al., 1985). Furthermore, mothers of pre-school children who have close, intimate and confiding relationships with their spouse experience far lower levels of depression and anxiety than mothers who view their relationships as lacking in trust and closeness (Brown and Harris, 1978, D’Arcy and Siddique, 1984).

Measures of chronic parental strain, associated with the child’s behavior and medical status, are not often included in studies of maternal mental health in the years following childbirth. Rather, most research on mental health based on mother-child dyads has focused on outcomes for the child. However, child characteristics may be a source of stress contributing to maternal mental health problems (Hopkins et al., 1984). The few studies to analyze the role of child characteristics for postpartum depression and anxiety find important influences due to: the number of childcare related strains (Cutrona, 1983, O’Hara et al., 1984), having temperamentally difficult children (Cutrona and Troutman, 1986, Whiffen and Gotlib, 1989), and the level of neonatal risk (Blumberg, 1980). Although there is evidence that the child’s behavior and medical status affect maternal mental distress during the postpartum period, it is difficult to draw conclusions about the role of child characteristics in the period after the postpartum period due to the lack of research in this area. Studies that did include childrens physical health in the period following post partum report that it is an important predictor of maternal mental health (Hahn and Schone, 1996, Bernbaum and Hatcher, 1992). Most of the literature concerned with identifying specific factors that affect maternal mental health is, however, based on clinical samples of physically or mentally ill children and there are few studies of normal populations.

Research investigating age related changes in the child’s behavior on maternal mental health is important but rare. The impact of children on the mental health of their parents is thought to be greatest when the children are young and most dependent and diminishes as their autonomy increases (Pitman et al., 1989, Umberson and Gove, 1989). Mothers caring for one or more pre-school children seem to be more likely to become depressed than those with older children (Richman, 1976, Moss and Plewis, 1977) and children younger than six seem to have the strongest impact on maternal mental health (Gove and Geerken, 1977, Brown and Harris, 1978). Some studies reveal that women perceive mothering to be especially demanding during the child’s first year of life, and the most commonly mentioned reason for feeling less depressed at follow-up is that the child is getting older (Small et al., 1994). Other studies have described the ages from one to two years to be the most demanding on the mothers (Olson and DiBrigida, 1994) with the highest parental ratings of behavior problems among children at age two (O’Brien, 1996). Epidemiological studies reveal a steady increase in the number and intensity of problem behavior in pre-school children (Richman et al., 1975, Richman et al., 1982, Stallard, 1993). According to the results of one study, it is common for parents to be worried about their childrens’ behavior, with 82% of the parents reporting either “a lot of concern” (16%) or “some concern” (66%) about problem behavior in their three-year-old children (Stallard, 1993).

The present study examines developmental differences for how child problems affect maternal mental health. This is a follow-up to a previous study on the influence of social class, strain and social support on maternal mental distress 18 months after the birth of a child (Mathiesen et al., 1999). In that study findings suggested that behavioral problems and physical health problems among the children and problems with child care-taking affected maternal mental health as measured by self-reported symptoms of anxiety and depression. This paper focuses on the effects of child-related strain on maternal mental health using population-based data at 30 and 50 months after the birth of the child. Because most states of mental distress are accompanied by anxiety and/or depression and there is a very high degree of comorbidity between the two disorders (Kendler et al., 1992, Brown et al., 1993, Bijl et al., 1998, Regier et al., 1998) we wanted to include them both in the outcome measure. The purpose of the study is to: (a) examine levels of maternal symptoms of anxiety and depression at each time point and to test for differences in symptom levels across time, (b) identify predictors of maternal mental distress at 30 and 50 months following the childbirth, (c) explore whether the effects of sociodemographic measures are mediated through stress, support and maternal physical health, (d) test whether specific child related strains are related to maternal mental health, and (e) test for changes in the effects of predictors of maternal mental health over time.