You are on page 1of 11

Matern Child Health J (2012) 16:336–345 DOI 10.

1007/s10995-010-0715-3

Maternal Depressive Symptoms and Participation in Early Intervention Services for Young Children
Emily Feinberg • Sara Donahue • Robin Bliss Michael Silverstein

Published online: 8 December 2010 Ó Springer Science+Business Media, LLC 2010

Abstract Many young children with developmental delay who are eligible for early intervention (EI) services fail to receive them. We assessed the relationship between depressive symptoms in mothers, a potentially modifiable risk, and receipt of EI services by their eligible children. We conducted multivariable analyses of a nationally representative sample of children eligible for EI services at 24 months using data from the Early Childhood Longitudinal Study-Birth Cohort. Maternal depressive symptoms were assessed at 9 and 24 months. Birthweight \1,000 g,

Electronic supplementary material The online version of this article (doi:10.1007/s10995-010-0715-3) contains supplementary material, which is available to authorized users.
E. Feinberg (&) Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 4th Floor, Boston, MA 02118, USA e-mail: emfeinbe@bu.edu S. Donahue Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA R. Bliss Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA R. Bliss Osteoarthritis and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA E. Feinberg Á M. Silverstein Division of General Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA

genetic and medical conditions associated with developmental delay, or low scores on measures of developmental performance defined EI eligibility. Service receipt was ascertained from parental self-report. Models were adjusted for sociodemographic and child risk. Among the 650 children who were eligible to receive EI services as infants, 33.2% of children whose mothers were depressed received services compared to 27.0% whose mothers were not depressed (aOR 1.8; 95% CI 0.8, 4.0). Among the 650 children who became eligible to receive services as toddlers, 13.0% of children whose mothers were depressed received services compared to 2.6% whose mothers were not depressed (aOR 4.6, 95% CI 1.5, 14.6). Among children receiving EI services, prevalence of depressive symptoms was 23.0% for mothers whose children became eligible as infants and 57.5% for mothers whose children became eligible as toddlers. Depressive symptoms in mothers of children eligible to receive EI services did not appear to limit participation. EI programs may be an appropriate setting in which to address maternal depressive symptoms. Keywords Early intervention Á Maternal depression Á Developmental delay Á Part C services Á Early Child Longitudinal Study

Introduction Early intervention (EI) programs, authorized under Part C of the Individuals with Disabilities Educational Act (IDEA), provide services to children from birth to three who are identified as having or being at risk for developmental delay. In 2009, almost 340,000 infants and toddlers received EI services. This number, which represents 2.9%

123

1 Study Design and Sample We used a cross-sectional design to examine the associations between depressive symptoms in mothers and receipt of EI services at 24 months of age among eligible children. To date.ed. and information from birth certificates. Based on documented state eligibility policies. This latter group is referred to as ‘‘newly eligible. with the aim of increasing its specificity. 3] studies suggest that many young children. non-Hispanic black. direct cognitive and All unweighted N’s are rounded to the nearest 50 subjects in accordance with the ECLS-B restricted data use license. Despite an increase in the number of children obtaining services and documented effectiveness of early intervention. has almost doubled in the past 10 years [1]. 29]. The ECLS-B cohort included 10. Data used in this analysis were collected during the 9. 11–19]. which is already of concern among children who receive early intervention services [6. such as poverty and low maternal educational attainment [28.Matern Child Health J (2012) 16:336–345 337 of US children birth to three. We sought to use a nationally representative sample of young children to further understand this relationship.700 infants at 9 months and 9. 5]. and Hispanic mothers who met the EI eligibility criteria described below. we selected children of non-Hispanic white. determining definitions of developmental delay and criteria for service eligibility has been a major challenge to states responsible for delivering these services. Twenty percent of children receiving EI services have four or more social risk factors associated with maternal depressive symptoms. To create a cohort of eligible children. Although states have developed methods to define developmental delay and developmental risk.850 children at 24 months. Maternal depressive symptoms are one potentially modifiable risk that may impact child participation in early intervention programs. who have or are at risk for developmental delays fail to receive them [4. The ECLS-B draws from a nationally representative probability sample of the nearly 4 million US children born in 2001. particularly Black children. Details of the ECLS sampling strategy are available at http://nces. The demographic characteristics of families whose children receive EI services suggest that mothers of enrolled children are at increased risk for depressive illness. [2. Having a child with a condition that qualifies her for early intervention services is associated with elevated depressive symptom prevalence in mothers. developmental assessments.asp (last accessed 13 July 2010).’’ Measures Eligibility for Early Intervention Services Under Part C of IDEA Children ages birth to 3 years with demonstrated developmental delays or a diagnosed physical or mental condition known to increase risk of developmental delay are entitled to receive services through state-run EI programs as defined by Part C of the federal Individuals with Disabilities Education Act. Depression is negatively associated with parental behaviors and practices critical to promoting the health and development of at-risk children. Depressed mothers have been shown to be less sensitive to lags in their child’s development [6–8] and they are less likely to engage their children in age-appropriate activities [9] and to adhere to recommended care and follow-up services [10]. the impact of such symptoms is unknown. no population-based studies have examined the relationship between maternal depressive symptoms and receipt of early intervention services. Birth Cohort (ECLS-B). and cerebral palsy [20–27]. Children were stratified based on the age when they first became eligible for EI services: (A) children who became eligible to receive services as infants (ascertained at the 9 month assessment) and continued to meet eligibility criteria at 24 months and (B) children who did not meet eligibility criteria at 9 months but did so at the 24 month assessment based on their developmental performance at that time.and 24-month rounds of data collection. The prevalence approaches 50% among mothers of subpopulations of children with conditions such as prematurity. We defined eligibility for EI services to be consistent with the major existing study that used ECLS-B data to examine participation in EI [4]. 1 Methods Data Source This study used data from the Early Child Longitudinal Study. A substantial body of literature documents the negative impact of maternal depression on a child’s developmental trajectory. However. We made minor changes to the algorithm. 123 . there is wide variability in such criteria. autism spectrum disorders. It includes data from face-to-face parent interviews. The published eligibility algorithm was validated using 44 states and the District of Columbia and demonstrated 94% sensitivity and 68% specificity in appropriately classifying eligible children. Although the majority of studies assessing the effect of maternal depressive symptoms on parenting practices suggest that the children of depressed mothers might be less likely to receive appropriate EI services.gov/ecls/birth.

or genetic condition associated with developmental delay (see above for examples). child’s insurance status. which was quantified as an ECLS-B composite variable and comprised parental education. we also identified the subset of women who met diagnostic criteria for a major depressive episode. or some other source. [34] a valid reliable measure of depressive symptoms [35–37]. The four criteria used for study inclusion were (1) birth weight \1. We used individual level weights from ECLS-B to account for the study’s complex sampling design and to yield valid national estimates. child temperament. On weighted data we used the chi-square test to describe sample characteristics by EI service receipt. (3) genetic and congenital conditions associated with developmental delay.300 children who met inclusion criteria were stratified by the age at the time the child first became eligible to receive EI services: either eligible as infants based on the 9 month assessment or newly eligible as toddlers based on the 24 month assessment. Child and Family Characteristics Child and family characteristics hypothesized to affect both the likelihood of enrollment in EI and a mother’s depressive symptoms were included as covariates in multivariable models. and social prestige of parental occupations. The interview used two stem questions to evaluate the respondents’ experience of depressed mood or anhedonia since the last interview (on average. the 1. depressive symptoms were measured by a 12 item abbreviated form of the Center for Epidemiologic Studies Depression Scale (CES-D). presence of partner in the home. Child characteristics included: birthweight. Hispanic). We combined responses to individual CES-D items to create a raw symptoms score. the ECLS-B study team changed the instrument used to measure depressive symptoms to the World Health Organization’s Composite International Diagnostic Interview short form (CIDI-SF) [40]. Data Analysis For analysis.338 Matern Child Health J (2012) 16:336–345 we decreased birthweight eligibility from 1. Receipt of services was coded as yes or no independently at 9 and 24 months. non-Hispanic black. having a medical. ascertained based on information from the birth certificate. employing Taylor series estimation to accommodate ECLS-B’s sampling 123 . corresponding with the most commonly used clinical cut point (score [15) indicative of depression on the full CES-D [38]. and child health status as rated by the maternal respondent. state. congenital. The BSF-R includes a subset of items from the Bayley Scales of Infant Development. At 9 months.5 SD below the mean on the Motor Scale. At 24 months. 2nd Edition (BSID-II). evaluated through direct assessment separately at the 9 and 24 month interviews using the Bayley Short Form-Research Edition (BSF-R) Mental Scale and Motor Scales. such as Down syndrome and fetal alcohol syndrome. Because the CIDI-SF was designed for diagnostic classification. We considered those with raw score [9 to have clinically significant depressive symptoms. We considered those who had depressed mood or anhedonia for at least a 2-week period to have clinically significant depressive symptoms. based the approach used in the Patient Health Questionnaire 2 [41].000 g and included children with medical conditions that automatically qualify children for EI services [30]. Receipt of Part C Early Intervention Services Receipt of EI services was determined based on parent response at the 9 and 24 month interviews. At each assessment. We used the BSF-R Scale Scores based on guidance from the ECLS-B study team [33] and included children who scored [1. determined from parental self-report at the 9 month and 24 month interviews. during the previous 15 months). and major congenital anomalies such as cleft lip and palate. household income. (2) medical conditions associated with developmental delay. Family characteristics included maternal race/ethnicity (non-Hispanic white. Scores [9–15 (equivalent to scores of 16–26 on the full CES-D) were considered moderate symptoms and scores [15 (equivalent to scores [26 on the full CES-D) were considered severe [39]. health or social service agency. score on the BSF-R Motor or Mental Scales.000 g.500 to 1. We elected to stratify eligible children in this manner because of differences in the pattern of service receipt. respondents were asked whether or not their child was participating in an early intervention program or regularly receiving services to help with their child’s special needs from their local school district. Maternal Depression Maternal depressive symptoms were measured at child age 9 and 24 months using two different validated scales. Follow-up questions queried the duration and intensity of the symptoms and their impact on overall functioning. such as blindness and deafness.5 SD below the mean on the Mental Scale or [1. [31] scores are similar to those obtained from the full BSID-II [32]. and household socioeconomic status (SES quintile). defined by maternal response that the child was very difficult to raise. We used multivariable logistic regression models to examine associations between maternal depressive symptoms and receipt of EI services at 24 months. and (4) developmental delay. or [1 SD below the mean on both scales. health care provider.

9 and mean Bayley mental score was 112.0% whose mothers were not depressed (P = 0.8% fell within the lowest 2 SES quintiles. There were no differences in child illness severity. We performed analyses using SAS v9. or [1. The mean Bayley motor score among eligible 123 . All models were adjusted for child and family risk characteristics. In the population of children receiving services. Overall. At 9 months. over 10% of eligible children received EI services. In models that adjusted for child risk and sociodemographic factors. and 150 children whose mothers were of Asian. criteria that meet or exceed EI eligibility standards in all states [30]. maternal depressive symptoms.Matern Child Health J (2012) 16:336–345 339 design and arrive at valid confidence intervals.8. 4. Based on our stratification scheme.4% nonHispanic white. 650 became eligible for EI services as infants (ascertained at the 9 month assessment) and 650 were newly eligible at the 24 month assessment based on their developmental performance. and (2) examine the effect of depressive symptom severity on EI service receipt.8.500 g. The Boston University Medical Center Institutional Review Board reviewed the study and determined it to be exempt from further review based on the fact that we used existing data that is publicly available and the information was recorded in such a manner that subjects cannot be identified.5% at 9 months and 21.5%. and among mothers whose children were newly eligible at 24 months the prevalence was 57. 95% CI 0. the difference in service receipt between depressed and non-depressed mothers did not reach statistical significance (aOR 1. 84% met criteria of having a current or past major depressive episode.2% at 24 months. 33. with marked difference in service receipt between children eligible as infants (28. Because we believed that the effect of maternal depressive symptoms on enrollment might differ depending on the child’s birthweight. 55% of depressed mothers had moderate symptoms and 45% severe.39) (Table 2). Pacific Islander. children was 73.001). In models that included depressive symptom 9 significant covariate interaction terms.3% Hispanic. Among mothers whose children became eligible as infants the prevalence was 23. Maternal Depressive Symptoms and Service Receipt Among Children who Became Eligible for EI Services as Infants Among the 650 children who were eligible to receive EI services as infants. we tested for a differential effect of maternal depressive symptoms on enrollment by significant child and family characteristics by including interaction terms in multivariable models.2%) and children newly eligible as toddlers (4. 46. and EI service receipt between excluded and included children. Of these mothers with chronic symptoms.0%.0% of children whose mothers reported clinically significant depressive symptoms at 24 months received services compared to 2. 16. or family demographic characteristics.3% had birthweight \1.0%. We conducted additional exploratory analyses to (1) test the stability of study findings in a sample that restricted eligibility based on developmental delay to children who scored [2 SD below mean on the BSF-R Mental Scale or [2 SD below mean on the Motor Scale. 1. Maternal report of clinically significant depressive symptoms was 18. medical condition. 50 children whose mothers had incomplete information on depressive symptoms.600 met the study’s eligibility criteria for EI services. 69% of the mothers with clinically significant depressive symptoms met criteria for a major depressive episode. or American Indian backgrounds due to insufficient numbers to conduct planned analyses.1 [42]. household demographics. separate models were estimated for children who became eligible for EI services as infants and children newly eligible as toddlers.300 children in our sample. at 24 months. we found no evidence of effect modification.850 infants included in the ECLS-B cohort at 24 months. and 33. we excluded 100 children whose mothers were not the survey respondent. Of these.9. 13. the prevalence of clinically significant maternal depressive symptoms was 35.3% non-Hispanic black. which corresponds to scores approximately 1. Of the 1.2% of children whose mothers reported depressive symptoms at the 24 month assessment received services compared to 27. Maternal Depressive Symptoms and Service Receipt Among Children Newly Eligible for EI Services as Toddlers Among the 650 children who were newly eligible to receive services as toddlers. In Results Population Among the 9. Overall.0) (Table 3). Alaskan native.5 SD below the mean on both scales.6% whose mothers were not depressed (P \ 0. Almost 8% of the mothers reported depressive symptoms at both 9 and 24 months. 6. the sample was 50. and 53% had medical or genetic condition associated with developmental delay (Table 1). This manuscript was reviewed for compliance with the terms of the ECLS-B restricted data use license by the National Center for Educational Statistics prior to publication.5 SD below the population mean for both scores.9%).

4. 25. 96.3 33.9) (0.9. 50.4 16.4. 7.6.4 (18.3.300) % Maternal and household demographic characteristics Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Household SES Lowest two quintiles Highest three quintiles Partner present in household Insurance status (none or public insurance) Child risk characteristics Birthweight (BW) BW B1.0.2) (46.9) 650 300 350 50. Similar to the models examining service receipt among children eligible as infants. 24.1 7.1) 74. 25.2.6 19.4.6) 47. Fair/poor) Temperament (very difficult to raise) 9 months postpartum 24 months postpartum 9 and 24 months postpartum Received EI services at 24 months CI confidence interval.4. 25. 95% CI 1.5 20.3 94.7) (68.6 36. 66.9. or [1.35–174.0. 86. eligible as toddlers: aOR 2.9 18. Maternal Depressive Symptoms and EI Service Receipt Among Children With Greater Development Delays We replicated our analyses using a sample that restricted eligibility based on developmental delay to children who scored [2 SD below the mean on the Mental Scale or [2 SD below the mean on the Motor Scale.7 84.7 2.4 21.500 g Qualifying medical/genetic condition Yes No Developmental risk Bayley motor score (mean.3.6.0) (11.2.5 21.500 g BW [2. 51.8.8 112.7) (49.7.5 (40. 5.0. 14.4) (45.9) (71.5) (1. 57.6 (0. range 92. Numbers may not add to total due to rounding * Population scaled scores on BSF-R assessment: motor: mean 81. 7.6.7 15.6 51.43–108.6.3.1) (44.1.1) (69. The relationship between maternal depressive symptoms and service receipt mirrored the findings from the less restrictive sample.53.3.8. 54.6.2) (0. 9.5) (2.2.9.2 74.5) (0.8) (12.9. 4.4 73. 56. 93.5) (12.3) (26.7 75.3 (42.4) (2.2 2 Complete data available from authors on request.4) (5.1 16. 85. SE)* Health status (parent-rated.5 23.7) CI Eligible as infants (N = 650) % CI Newly eligible (N = 650) % CI Maternal clinically significant depressive symptoms adjusted models.4.3) (1.4.5.9 3.5 61.0) (49.9. 56. 82.5.5 4.3 52.6 53.500–2. children whose mothers had depressive symptoms were over 4 times as likely to receive EI services as children of nondepressed mothers (aOR 4.5) (17. 7.7) 21. 8.7) (55. 4.2) (0. 25.4) (92.4.0 18.4.9) (8. 20. 19.07. 29. 57. 2. 19. 3.5.6 (42.8) (45.5 SD below the mean on both scales. we found no evidence of effect modification by any of the significant child risk or demographic characteristics. weighted percentages.6 52.8. 78.2.9 5.1.2) (12.5. 44.4 (0.09.8 10.1).7. range 56. 67. 95% CI 1. mental: mean 127.4 91. 24.9 2. by child age at initial eligibility N Total (N = 1.8.9) (4.7. 57.3) (22. 28.6) (Table 3).4.500 g BW 1. 6.3 (14.4 8. 1.3. 11.9) (4.6. 10.2 7. 60. SE)* Bayley mental score (mean. 40. 78.9) (2. 34.1) (70.6 (39.1) (17. SE standard error Unweighted N’s.8.3) (1.0 (5.9.2) 22.3.6 2.2) 600 700 950 700 46. 55. All unweighted N’s are rounded to the nearest 50 subjects in accordance with the ECLS-B restricted data use license. 22.3) 1. 123 .7.0. 7.47.6) (15.8) 47.5.200 5.14 (source: Andreassen and Fletcher [33]) 100 50 250 250 100 200 73.0) (16. 95% CI 0.9 (0.0) 73.340 Matern Child Health J (2012) 16:336–345 Table 1 Characteristics of children eligible for early intervention services at 24 months. standard deviation (SD) 5.2 113.5.2) (89. 10.4.8) (11.0.3) 100 1.7 78.3. SD 10.7. We found no difference in service receipt among children of depressed mothers eligible for EI services as infants and an increased likelihood of service receipt among children who were newly eligible to receive services as toddlers (eligible as infants: aOR 1.6.5) 46.65.3) (81.9 7.3) (8. 60.4) 58.9 112.3 9.6 (49.3.6.5) 500 200 600 6. 12. 13.2 (0.1 51.7 (3.5) (14.6) (14.7) (28.9 15.5 28. 20.3 (43.0) (4.8 53.4 3.

12.8 10.5 SD below mean (raw score range 56.8) (3.6) * 25.8) (22.4.9.2.3 (18.7) (3.2. 19.9.3.3) 123 . 1.3 0.0 9. range 56.4) (7.43–108.5) 13.0. 6.5) (17.2) (2.0.0 (7.1.0 12.2 CI (22.9 10.9 26.1 (0. 18.5) * 8.0 (28. 33.9 (25. 42.8) (1.8.4) (0. All unweighted N’s are rounded to the nearest 50 subjects in accordance with the ECLS-B restricted data use license.5.3.9.8.3 (3. 9.1 29.9 (3.5 SD below mean (raw score range 92.53. 12. 6.7. 64.3) (2.2) (4.6. by child age at initial eligibility and child and family risk characteristics Total (n = 1. 6.0.3.0 5.7.2) * 6. 13. range 92.0) (24.7) (9.0.4.9) (6.3. 49.1 33.4 (13. 36.4 (13.8. 49. standard deviation (SD) 5.0) 27. SD 10. mental: mean 127.4) 31.7.0 (7.1) Health status (parent-rated) Fair/poor Excellent/very good/good Temperament Very difficult to raise Not at all/not very/average/somewhat difficult to raise Maternal and household demographic characteristics Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Household SES Lowest two quintiles Highest three quintiles Partner in household No Yes Insurance status None or public insurance Private insurance CI confidence interval Unweighted N’s.4 (0.5 (10. 9. 12.500 g BW 1. 6.3 4.3.1 (1.1. 38.4 (16.3.3) (0.6 points) B1.6 CI (8.8) 9. 37.0 (8.14 (source: Andreassen and Fletcher [33]) 9. 16.4 34.3 (22.2) * 33.3.07.0.6) * 10.1) Eligible as infants (n = 650) % EI 28.3 6. 12.6) (22.2 10. 33. 28.9 CI (2.8. 12. 28.1.8. 34. 11. 33.9) 32.7.5.1 20.2 (10. 47.7.9.7) 24.0 (11.6 (5.0 (12.6.8) 19.0) (8.5) (1.4.7 (10. 13.0) (0. 10.0 (19.0 20.1) * 34.5) (1.1.0) (20.7) (5.65. 48.3 (9.4) (11.5) * 14. 6.1) (1.9) 28.3. 57.500–2.6.1.1 8.3) * 9. 17.7 (6. 46. 35. 32.6) (21.6 (4.4 6. 7.4.3 28. 27.500 g Qualifying medical/genetic condition Yes No Developmental risk Bayley motor score** [1.5 8.8) 14. 16. 50.Matern Child Health J (2012) 16:336–345 341 Table 2 Receipt of early intervention (EI) services among children eligible for EI at 24 months.0 (24. 28.0 2.3. 6.2.2) (12.9. 11.7) 30.3. 34. 4.50 * 34.4) (22.2) * 38.8. 9.0) (6.9.0 1. 7. 32.5 SD = 16 points) B1.5.3 20. 39.4 (14.4.5) (7.5.3 27.1.2 (6.2) (2.9. 41.0) Newly eligible (n = 650) % EI 4.9) (21. 12.1.9. 11.500 g BW [2.6 28.6 8. 56.6. 34. 12.9 (1.47. 14.2.1) (12.2 27.6 4.6 23. 1.6) (5.5.300) % EI Total sample Risk characteristic Maternal depressive symptoms at 24 months postpartum Yes No Child risk characteristics Birthweight (BW) BW B1.1.4) (20.2.5 SD = 7.9 (1.4) 4.4) 4.7 4. Numbers may not add to total due to rounding * Chi square P value \ 0.9) * 31.4 11.0 (1. 33.9.7.9.9) 31.0) 7.4.2 4. 2. 8.6) (0.5) 27. 2.7 14. 21.0.7 4. weighted percentages.05 ** Population scaled scores on BSF-R assessment: motor: mean 81.1 10.3) (12. 24.9.0) (0.0.4. 6.5 SD below mean (raw score [73.7 5.3) * 31.9) Bayley mental score** [1.7) * 17. 35.1.35–174.9) 11.7 28.1.4–111.2.09.7) 19.1) (7.4) (7. 18.0. 42. 43.5 SD below mean (raw score [111.0.3 9. 6.2 4. 12. 9.7) * 29.4–73.2 (22.5) 3.9.

8.8.500. partner) None or public insurance (vs. range 56.500 g Population scaled scores on BSF-R assessment: motor: mean 81.342 Matern Child Health J (2012) 16:336–345 Table 3 Association of maternal depressive symptoms with child receipt of early intervention (EI) services at 24 months aOR Children eligible for EI as infants Maternal depressive symptoms Child risk characteristics Birthweightà Qualifying medical or genetic condition Bayley motor score  (per-10 points) Bayley mental score  (per-10 points) Child fair/poor health Very difficult to raise Maternal and household demographic characteristics Race/ethnicity Non-Hispanic black (vs. 2.5) 0.43–108.07. 1.0.2) (0.4 3.1 4.3.47.4) (0.7.1.8.6. highest 3 quintiles) No partner present in household (vs. 5.3.9. 4. non-Hispanic white) Hispanic (vs.6 2. CI confidence interval * Results based on multivariable logistic regression models (separate models by child age at eligibility entrance).5 4. highest 3 quintiles) No partner present in household (vs.6) (1.65. non-Hispanic white) Hispanic (vs. standard deviation (SD) 5.43) (0.5 2.5.2.6) (0. Results suggested the likelihood of service receipt increased as depressive symptom severity increased (among children eligible for EI services as infants: aOR 1.9 (0.8.1) (1.0) (1. 95% CI 1. among children newly eligible for services at 24 months: aOR 2. 1. 0. private insurance) Children newly eligible for EI Maternal depressive symptoms Child risk characteristics Birthweightà Bayley motor score** (per-10 points) Bayley mental score** (per-10 points) Child fair/poor health Very difficult to raise Maternal and household demographic characteristics Race/ethnicity Non-Hispanic black (vs.5 1.3. 1.0 3. 1.500.7 0.4) (0.09.05 0.6 0.5) (0.3. We found that among children who first became eligible for EI services as infants there was no difference in receipt of EI service by mothers’ depression status.6 0. partner) None or public insurance (vs. 5.3 0. 43.2) (0.5. 95% CI 1.500–2. 4.2.0) (1. 1. 2.6) (0. non-Hispanic white) Household SES (lowest 2 quintiles vs.9 2.2) (1.5 0.14 (source: Andreassen and Fletcher [33]) Maternal Depressive Symptom Severity and EI Service Receipt Exploratory analyses that examined the relationship between depressive symptom severity and receipt of EI services at 24 months were conducted by modeling depressive symptoms as an ordered variable.9) 0. private insurance) aOR adjusted odds ratio. SD 10. non-Hispanic white) Household SES (lowest 2 quintiles vs.53. 2.8 1.1. range 92. 14.4. 2. with each model adjusted for the other variables in the table à   (95% CI) 1.8 0.7. 4.2.1) (0.8 1. Among children who were 123 .2 Discussion We found that clinically significant depressive symptoms in mothers of children eligible to receive EI services did not appear to limit participation in early intervention programs.35–174.6) (1.8) (1. Our analyses controlled for child risk and demographic factors and stratified children by the age when the child became eligible to receive EI services.7 11.0 (0. 4.0) Birthweight is modeled as an ordered variable with 3 categories: [2. 6.01.2.2. 3. 2.0.3. 10. 7.4 1.4 (0.6.9) (0.0) (2.5 2.0) (1. 1. 0.0) (0. B1.4. mental: mean 127. 18.6).

While our study cannot determine the mechanism by which maternal depressive symptoms are linked to a child’s receipt of EI services. children whose mothers were depressed were. community-based initiatives to reduce barriers to care for parents experiencing depressive symptoms. Given the varied models of early intervention service delivery. Based on research describing decreased health management skills among depressed women [43– 48] and less utilization of preventive health services among their children. which emphasized providing a developmentally supportive environment and enhancing the overall quality of family life. This explanation is consistent with findings of increased utilization of pediatric acute care services among depressed and emotionally stressed mothers [10. One possible explanation of the positive association between EI participation and maternal depressive symptoms is suggested by Janicke in their study of factors related to child health care use [50]. However. our data do not support this hypothesis. [10. Our study has several limitations. Some studies have invoked this theory to explain increased service use among children likely to be eligible for EI services [55. parents may be unclear of whether they are receiving Part C services or developmental services provided through other mechanisms. ECLS-B used different measures to ascertain depressive symptoms at 9 and 24 month interviews. as is typical of cross-sectional cohort studies. delays associated with autism spectrum diagnoses.0%) and mothers of enrolled children who became eligible as toddlers (57. The high level of depressive symptoms among mothers of children with ASD is well documented and could contribute to the observed prevalence [57–60]. Beginning in 2004. Alternatively. First. Early intervention programs represent such a setting. This group generally qualifies for EI services based on expressive language delays and impairments in social interaction and communication. and residual confounding may exist. we conducted additional exploratory analyses and our results were confirmed when we used more stringent criteria to define eligibility for EI services and modeled depressive symptoms based symptom severity. the study relies on parent report of receipt of early intervention services. motivation. Parenting. making it difficult to ensure symptom severity equivalence at the two time points. the associations reported in this study are not necessarily causal.5%). This conceptual shift. and organization associated with depressive illness. Originally described in 1964 by Green and Solnit [54] the vulnerable child syndrome describes a constellation of phenomena in which a child with real or imagined illness early in life is viewed by the caregiver. generally the child’s mother. Furthermore. we cannot quantify the duration or number of depressive episodes or address the issue of whether or not depressed mothers received treatment for their condition. We identified differences in depressive symptom prevalence between mothers of enrolled children who became eligible as infants (23. the elevated symptom burden among mothers of children enrolled in EI programs identified in our analyses suggests a need to address maternal mental health as part of Part C early intervention programs. we examined the experience of children born in 2001. Finally. on average. 29]. depression tends to be a waxing and waning illness. and Children [62] called for the development of innovative. The authors postulate that a mother’s depressive symptoms may limit the personal resources that she can dedicate to her child. Our study is the first to describe the overall prevalence of depressive symptoms among mothers whose children are receiving EI services at 2 years (35. expanding the program’s sole focus from child outcomes to broader family functioning [61].Matern Child Health J (2012) 16:336–345 343 newly eligible for EI services at 24 months. Second. Because of the unexpected direction of our findings. enrolled children may be related to the characteristics of children who enter EI programs as toddlers. 49] one might expect that children whose mothers experienced depressive symptoms would be less likely to receive EI services as a result of the lack of energy. all states were required to report on activities related to supporting family capacities in their performance report. 50–53]. It is possible that with new American 123 .0%). is one that fits well with the provision of maternal mental health services within the program model. Additionally. The overall prevalence is consistent with studies of depressive symptoms among women whose children have conditions that make them eligible for EI services [20–27] and those with high social risk [28. The IOM specifically called for interventions that take place in venues capable of integrating services for parents and children. Third. the 2009 Institute of Medicine (IOM) landmark report Depression in Parents. early intervention services—for assistance. 4 times more likely to receive services compared to children of nondepressed mothers. the theoretical paradigm of vulnerable child syndrome may provide an explanation for the study findings. Thus. as having increased susceptibility to illness. Fourth. it is possible that the criteria we used to determine EI eligibility overestimate the number of eligible children and could bias study findings if the proportion of mothers with depressive symptoms among misclassified children differed from the proportion among children truly eligible. Our test of the stability of study findings in a more restricted sample addressed this limitation. 36. Although we document depressive symptoms at 9 months and the interval between the 9 and 24 month interviews. 56]. The elevated prevalence of depression among mothers of these newly eligible. she may be more likely to turn to other sources of support—in this case.

. Increased psychopathology and early onset of major depression. 19. & White.. Acknowledgments This project was supported by a grant from the Maternal and Child Health Bureau R40 MC08593. and Milton Kotelchuck. Journal of Child Psychology and Psychiatry.gov. (1990). C. Academy Pediatrics guidelines regarding developmental screening. et al. 543–561. Journal of Developmental and Behavioral Pediatrics. & Pawlby. Cited 6 Jan 2010. C.ezproxy. 21. 44. (1984). et al. 70. 74. O’Brien. Hammen.edu/pubmed/19482532. 12. 7. Child Development.asp.org/PartCTrendDataFiles. 1314–1327. [63] enrollment in early intervention services has changed during the intervening period. M. Minkovitz. MD. 1315–1336. Zhang. Study findings have the potential to assist states and EI programs to develop strategies to increase improve child and family outcomes by identifying and addressing maternal mental health needs.gov. We thank Howard Bauchner. et al. (2003). Pediatrics. (2009).bu. 5. Attentiondeficit/hyperactivity disorder in school-aged children: Association with maternal mental health and use of health care resources.. (1999). et al. et al. et al. D. Psychological functioning and coping among mothers of children with autism: A population-based study. M. P. (2008)..edu/pubmed/14982248. S. Rosenberg.. 74(5). For the group of children newly eligible for EI services as toddlers. C. The impact of postnatal depression on infant development. Failure to thrive in the term and preterm infants of mothers depressed in the postnatal period: A population-based birth cohort study. The impact of very premature birth on the psychological health of mothers. R. Children of depressed parents. A. 736–741. Maternal affective disorders. Journal of Child Psychology and Psychiatry.ideadata. A.. 111(5 Part 2). et al. et al. D. Child Development. Evindar. The impact of postnatal depression on boys’ intellectual development. 2. T. B. Murray. American Journal of Psychiatry. 185–189. 17. 25. Murray.ncbi. Early Human Development. Psychological Medicine.. 281(9).. 18. Pediatrics. (2003). 1242–1247. (2002). D. Journal of Affective Disorders. Hay. S. S. (1997). J.. et al. C. N. 359–366. Weissman. C. e1503– e1509. Development of a family-based program to reduce risk and promote resilience among families affected by maternal depression: Theoretical basis and program description.. 9. Stress and adaptation in mothers of children with cerebral palsy. Visser. 28(3).. et al. (2005). 2512–2526. 27. S. (2009). Journal of Child Psychology and Psychiatry.. 1346–1352. Archives of Women’s Mental Health. e1040–e1046.bu. L. C. PhD. (2004). (2003).. (2007). 291–306.. L. L. 113. The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature.ncbi. Pediatrics. & Cooper. Maternal depressive symptoms and children’s receipt of health care in the first 3 years of life. Silverstein K23MH074079). (1992). et al. et al. 13. Postpartum depression and mother-infant relationship at 3 months old. Overall. Additional support was provided by K23 career development awards (Feinberg K23NR010588. Righetti-Veltema. 9(4). MPH. 24. %U http://www. 11(1–2).. et al. Maternal depression in an urban pediatric practice: Implications for health care delivery. %U http://www. Data Accountability Center.. & James. for their thoughtful review of the manuscript. Postpartum depression and child development.bu. 45(2). 39(3). W. (2004). M. S. American Journal of Public Health. (1996). P. Davis. E. Prosocial development in relation to children’s and mothers’ psychological problems. 6.edu/pubmed/12728144. Pediatrics. These limitations not withstanding.nlm. 23. & Stewart. C. 10. 36... Clinical Child and Family Psychology Review.. Journal of Affective Disorders. PhD.344 Matern Child Health J (2012) 16:336–345 intervention program. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. (2003). (2003). Cox. Singer. 263–274. nih. Maternal depressive symptoms during pregnancy. nationally representative data set regarding maternal depressive symptoms and participation in Part C early intervention services. L. particularly children newly enrolled as toddlers. J. study findings support an increased likelihood of service receipt among children whose mothers reported depressive symptoms. 3. Additionally. S. illness. Howard Cabral. S. Zuckerman. M. JAMA. 11. Wang. 1232–1237. J. D. and Allied Disciplines. 283–287. L. 123 . 4. Given the low level of service receipt among eligible children. References 1. Journal of Pediatric Psychology. These data can be used to advocate for expanded maternal mental health services within EI programs.ezproxy. and newborn irritability.. (1987). Grace. Montes. 61–70. Prevalence of developmental delays and participation in early intervention services for young children. Bailey. L. Lesesne. Factors influencing the enrollment of eligible extremely-low-birth-weight children in the part C early 20.gov.nlm.nlm. Postnatal depression and faltering growth: A community study. Academic Pediatrics. 8. 306–314. 116(6). our findings document a high prevalence of depressive symptoms among the mothers of children receiving EI services. L.ncbi. 6.. 847–853. 121(6). Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant. 33. it is encouraging that children of mothers with clinically significant depressive symptoms participated in EI programs given the increased risk conferred by such symptoms on children with existing developmental risk. Orr. 11.. 73(1–2). 22. 799–805. 14. PhD. & Halterman. Archives of General Psychiatry. Drewett. F.. J. 16. et al. Eugene Declercq. et al. A. (2005). 12–29. our findings suggest that a mother’s depressive symptoms did not interfere with her child’s receipt of early intervention services. and stress: Risk for children’s psychopathology. A.. (1987). we believe our study provides new information from a rigorously tested. Jr. Manuel. & Robinson.ezproxy. Murray. (1995). 15. %U http://www. 363–365. 197–201. 190–194. Individuals with disabilities education act data: Part C trend data. 115.nih. Riley. 144. 253–260. Available from: http:// www. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women.. Pediatrics. (2008). G. Pediatrics. S. Thirty-six-month outcomes for families of children who have disabilities and participated in early intervention.. 119(5). B. Sharp. 67. et al.nih. D. (1996).

et al. E. Children’s health care use: A prospective investigation of factors related to care-seeking. Thorax. 34. 58.1. during. & Mallik. The impact of child symptom severity on depressed mood among parents of children with ASD: The mediating role of stress proliferation. D. Early Childhood Longitudinal Study. Pediatrics. 36(5). 259–277. D. et al. V. (2001). Green. Maternal depressive symptoms and emergency department use among inner-city children with asthma. Medical Journal of Australia. W. Depression in mothers and fathers of children with intellectual disability. 266–271. (2002–2003). & Riley. (2008). 956–963. Katon. et al. et al. Pediatrics. 914–919. TX: Psychological Corporation. Bailey. 385–401.. 32. Pediatrics. L. Medical Care. 808–813. The functioning and well-being of depressed patients.. (2003) National early intervention longitudinal study: Demographic characteristics of children and families entering early intervention. Rimington. Applied Psychological Measurement. Journal of Autism and Developmental Disorders. Issue No. Postpartum physical symptoms in new mothers: Their relationship to functional limitations and emotional well-being. 33. and children: Opportunities for to improve identification. Olsson. Medical Care. Early Childhood Longitudinal Study.. 46. 20. & Fletcher. function. (1993). (2001). Maternal depressive symptoms and infant health practices among low-income women. Division of Behavioral and Social Sciences and Education (Eds. NC. NECTAC Notes. C. depression. J. J.. Council on Children with Disabilities. Kroenke. Zajicek-Farber. K. Early Childhood Longitudinal Study. Archives of Pediatrics and Adolescent Medicine. Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample. et al. D. J. Andreassen. (2005). S. 179–187. P. Birth Cohort (ECLS-B) user’s manual for the ECLS-B nine-month public-use data file and electronic code book. 29. R. (2006). 52. 55. M. (2010). (2008). M. 31. C. SRI International. 35. 118(1). (2001). National early intervention longitudinal study: Family outcomes at the end of early intervention. R. (18). Radloff. (2006).. G. K.. Journal of Intellectual Disability Research. MD: ED Pubs. The World Health Organization Composite International Diagnostic Interview short-form (CIDISF). and Healthy Development of Children. 3. Bromley. Autism. L.... 35(3). (2003). Birth Cohort (ECLS-B) methodology report for the nine-month data collection (2001?02). & Russo. 155–169. DC: National Academies Press. Depression and diabetes: Impact of depressive symptoms on adherence. Determinants of health and service use patterns in homeless and low-income housed children. 62.Matern Child Health J (2012) 16:336–345 26. self-care. (1998). et al.. and costs. 3278–3285. K. Depression. Vulnerable children: Parents’ perspectives and the use of medical care. 30(9). Pediatrics. 178(9).. & Solnit. Allen. International Journal of Methods in Psychiatric Research. J. 47–57. M. 49. 347–353. (2000). Civic. Archives of Pediatrics and Adolescent Medicine. In NEILS data report no. 45(Pt 6). E. Hebbeler. 2222–2227. 7(4).. C. et al. P. 63. D. 14(1). D. 164(10). and medication adherence in type 2 diabetes: Relationships across the full range of symptom severity. 8(4). Reactions to the threatened loss of a child: A vulnerable child syndrome. (1999). 171–185. 113(6). A. (1990).. 262. 4. B. D. A. 113(2). S. Screening for depression in primary care clinics: The CES-D and the BDI. P. 215–221. (1998). et al. 47. et al. Bayley. C. B. Depressive symptom burden as a barrier to screening for breast and cervical cancers. Dietz. 153. Interactive Autism Network Community.P. (2006). et al. D. Washington. In P. 990–1001. Mothers supporting children with autistic spectrum disorders: Social support. Postnatal depression and infant health practices. 36.. Janicke. Meta-analysis of comparative studies of depression in mothers of children with and without developmental disabilities. M. Bayley scales of infant development (2nd ed. 111(3). Spiker. Wells.. Gonzalez. 39(9). M. (2008). Jessup. J. Pirraglia. American Journal of Mental Retardation. 57. US Department of Education. Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics. San Antonio. part III. 409–423. SAS Institute Inc. J. 1. NCES 2005-100.. treatment. Finney. Zich. Results from the Medical Outcomes Study. 27. The CES-D Scale: A self-report depression scale for research in the general population. 60.. P. Journal of Child and Family Studies. 56(4). R. Singer. Vol. Mandl. 405–420. mental health status and satisfaction with services. & Holt. Spitzer. 554–562. (2005). 731–738. et al... Pediatric management of the dying child. 39. Maternal and Child Health Journal. Andreassen. J. 58–66. Churchill. 123 . Weinreb. Parents of children with special health care needs who have better coping skills have fewer depressive symptoms. Goldney. 38. S. Depression in parents. et al. et al. Shackelford. K.. P. 437–441. (2004). Maternal and Child Health Journal.. 1284–1292. Bartlett. P. Relationship between anxiety. et al. 236–245. 37. 44. Kessler. Birth. L. National Center for Education Statistics. (2004). 51. Webb. State and Jurisdictional Eligibility Definitions for Infants and Toddlers with Disabilities under IDEA. 13(6). N. Youth. 54. P. 345 45. (1980). (2001). (1989).). et al. NCES 2005-013.. and Families. e523–e529. Attkisson. 56. C. J. Pediatrics. K. Journal of Womens Health (Larchmt). S. (1977). & Williams. 34. K. Ciechanowski. Cary. Birth Cohort (ECLS-B): Psychometric report for the 2-year data collection. SAS for windows version 9. C. 48.. Committee on Depression. (2000). 43. (2009). JAMA. Methodology report. et al. 20. S. A.. 155.. 102(3 Pt 1).. J. (2007). & Greenfield.. A. E. M. Board on Children. 59. 41. 267–273. Benson. & Fletcher. The patient health questionnaire-2: Validity of a two-item depression screener. (2004). International Journal of Psychiatry in Medicine. Levy. (2004). Diabetes Care.. et al. National Early Childhood Technical Assistance Center (NECTAC). S. 41. 1: Psychometric characteristics. Infant health care use and maternal depression. 30. 28. 61. W. 160(21). NCES 2007-084. J. Clinically identified maternal depression before. L.. and prevention.). Nord. National Research Council and Institute of Medicine. and morbidity in adult asthma patients. T. 535–543. C. C.. L. W. (2004). 65(5). C. 50. (1964). J. Chung. D. R. et al. (2003).. American Journal of Psychiatry. 40. & Hwang. 1515–1520. (2007). and after pregnancies ending in live births. (2007). Archives of Internal Medicine. Asthma symptoms associated with depression and lower quality of life: A population survey. 42. 685–695. (2006). parenting. Parental depression history: IAN Research Report #7—October 2008. Perception of child vulnerability among mothers of former premature infants. B. 53.

However. . users may print. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. or email articles for individual use.V.Copyright of Maternal & Child Health Journal is the property of Springer Science & Business Media B. download.