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Matern Child Health J (2013) 17:907917

DOI 10.1007/s10995-012-1071-2

Reported Maternal Postpartum Depression and Risk of Childhood


Psychopathology
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 and
often persist into adulthood. Previous literature investigating the potential influence of postpartum depression
(PPD) is inconsistent. The present study examined the
association between PPD and childhood behavioural/emotional 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 criteria of the DSM-IV-TR. Four behavioural/emotional outcomes were analyzed at each follow-up. For both age
groups, logistic regression models were used to estimate
the 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]. Among
23 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/ineffective parenting was associated with Hyperactivity-Inattention [OR = 2.34, 95 % CI 1.22, 4.47], Emotional
Disorder-Anxiety [OR = 2.16, 95 % CI 1.00, 4.67], Physical 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 psychology, though the symptoms of PPD may be giving way
to other important mediating factors such as parenting style.
Keywords Childhood behaviour  Behavioural disorders 
Emotional disorders  Postpartum depression  Parenting

M. J. Walker (&)
Division of Epidemiology, Faculty of Medicine, Dalla Lana
School of Public Health, University of Toronto, Toronto, Canada
e-mail: meghan.walker@utoronto.ca
M. J. Walker
Prevention and Cancer Control, Cancer Care Ontario,
620 University Avenue, 11th Floor, Toronto, ON M5G 2L7,
Canada
C. Davis
Department of Psychiatry, Faculty of Medicine, University
Health Network, Toronto, Canada
C. Davis
Centre for Addiction and Mental Health, Toronto, Canada
C. Davis  B. Al-Sahab  H. Tamim
Faculty of Health Sciences, School of Kinesiology and Health
Science, York University, Toronto, Canada

Introduction
Behavioural and emotional disorders are prevalent among
children and can cause significant impairment and maladaptation in familial, social, academic and community settings. 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

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908

later psychopathology [3], and are associated with unemployment, substance abuse and suicide [4]. The burden
upon the Canadian economy is extensive. In 2008 it was
estimated that the direct and indirect costs attributed to
mental health disorders in Canada among adults totalled
more than $51 billion in 2003 [5]. Consequently, the World
Health Organization (WHO) has indicated that early prevention is the only sustainable approach in significantly
reducing this burden [6]. Largely due to substantial gaps in
knowledge regarding the implicated risk, protective and
mediating factors, a majority of current interventions are
therapeutic as opposed to preventive [7].
The etiology of psychiatric disorders has been widely
studied and appears to be highly multifactorial [8]. The
potential influence of maternal psychological morbidity has
been examined at great length. Pregnancy and the postpartum
period represent a time of increased vulnerability for women,
particularly for the development of mood disorders [9]. Specifically, postpartum depression (PPD) is perhaps the most
commonly experienced. PPD is defined by the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition-Text
Revision (DSM-IV-TR) [4] as a major depressive episode
lasting longer than two weeks, depressed mood or loss of
interest, somatic symptoms, guilt or suicidal ideation [10].
North American and European literature commonly suggests
prevalence rates of approximately 1025 % [1116].
A number of studies have focused on the potential
influences of prenatal and postpartum depression on the
offspring of depressed mothers. Few studies have focussed
specifically upon childhood psychological disturbances,
however outcomes including Oppositional-Defiant Disorder
and Conduct Disorder [17], inattention-hyperactivity, separation anxiety [18, 19], lower cognitive scores [2022],
violent behaviour and substance abuse [19, 20] have been
reported. Others have reported that the adverse effects
reported in childhood appear to attenuate with age [23, 24],
while some have reported no evidence that PPD is associated with adverse effects [2527]. Studies thus far have been
unable to clearly establish a direct link between mothers
PPD and psychopathological outcomes in offspring.
Behavioural and emotional disorders constitute a major
public health concern in Canada and the U.S. The epidemiological evidence regarding the influence of PPD on
childhood behavioural/emotional outcomes is equivocal
and research which considers a comprehensive range of
potentially important confounders is lacking. Such research
may ultimately guide the development of more effective
prevention practices, as called for by the WHO [6]. Thus,
the objective of the present study was to investigate, across
the Canadian provinces and territories, the most prevalent
behavioural/emotional outcomes in relation to PPD in the
biological mother, among children aged 23 and 45 while
adjusting for a number of potentially important covariates.

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Matern Child Health J (2013) 17:907917

Methods
Study Design
The study proceeded as a secondary longitudinal analysis of
Canadian children aged 25, utilizing data from Cycles 1
through 3 of the National Longitudinal Survey of Children
and Youth (NLSCY). The NLSCY is a Canadian population-based household survey of child health, development
and well-being [28]. The study began with a representative
sample of children aged 011 years from the 10 Canadian
provinces. From 1994 to present, the children have been
followed at 2-year intervals. At all cycles, the NLSCY
administers questionnaires to the person most knowledgeable (PMK) about the index child and/or to the index child.
The NLSCY has been previously described [28]. Baseline
data were collected at Cycle 1 in 19941995, when children
were 011 months and follow-up data were gathered at
Cycle 2 in 19961997, when children were 23 years of age
and at Cycle 3 in 19981999, when children were 45 years
of age. Data were collected through telephone interviews.
All interviews were conducted by Statistics Canada staff
trained through self-study materials and classroom sessions
[28]. Data were accessed through the Statistics Canada
Toronto Region Research Data Centres.
Sample
All variables in the NLSCY pertaining to the present study
were collected by self-report by the Person Most Knowledgeable (PMK) about the child. Cases where the PMK
was not the biological mother were excluded. However, the
PMK was the biological mother for a majority of children
at all data cycles. At Cycle 2, n = 1709 children were
eligible, however children for whom the PMK was not the
birth mother or had missing data on mothers PPD status
were excluded (n = 257), leaving a final sample of 1452.
At cycle 3, n = 1,630 children were eligible, however
children for whom the PMK was not the birth mother, had
missing data on mothers PPD status were excluded
(n = 273), leaving a final sample of 1,357.
Measures
The main exposure variable was presence of PPD at cycle
1. The PMK was asked whether they had PPD within the
first year following birth and asked to quantify the number
of days, weeks or months. Only PMKs of children
011 months of age were asked about the mothers PPD
status, limiting the recall period to a maximum of 1 year. A
derived variable was created, consistent with diagnostic
criteria of the DSM-IV-TR [4]; mothers who reported
14 days or less were grouped as not having PPD and those

Matern Child Health J (2013) 17:907917

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 properties to operationalize the diagnostic criteria for the corresponding 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 Montreal Longitudinal Survey (MLS)], Emotional-Disorder
Anxiety (from the OCHS), Physical Aggression-Opposition (from the OCHS and MLS), and Separation Anxiety
(from Achenbachs Child Behavior Checklist) [28]. For
children aged 45 years of age, the following four outcomes were considered: Hyperactivity-Inattention (from
the OCHS and MLS), Emotional Disorder-Anxiety (from
the OCHS), Physical Aggression-Conduct Disorder (from
the OCHS and MLS) and Indirect Aggression (from Lagerspetz, Bjorngvist and Peltonen of Finland) [28]. Consistent 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 parenting style, family functioning, current maternal depression
and single parent status. Parenting styles, including positive 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 consistency, 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 of C15 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 of C13 was indicative of moderate to severe depression [32, 34]. Socio-demographic
factors include income adequacy, maternal education and

909

immigration status. Income Adequacy takes into account


household income and size [28], corresponding closely to
Canadas poverty line [32]. Presence of a comorbid outcome and childs outcome history were also analyzed.
Statistical Analyses
Statistics Canadas microdata publication guides were
followed 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 nonresponse 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 tabulated. 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 similar
proportion 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 1 and 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].
Table 2 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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Table 1 Unadjusted analysis of postpartum depression and behavioural/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
Emotional disorder-anxiety

1.69 [0.93, 3.09]


1.59 [0.78, 3.26]

Physical aggression-conduct disorder

2.00 [1.04, 3.86]

Indirect aggression

1.42 [0.75, 2.67]

[OR = 4.09, 95 % CI 2.41, 6.93] and hostile/ineffective


parenting [OR = 1.88, 95 % CI 1.14, 3.11] were significantly associated with a high degree of HyperactivityInattention. 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 HyperactivityInattention [OR = 4.17, 95 % CI 2.49, 6.96] and Separation Anxiety [OR = 3.09, 95 % CI 1.93, 4.93] were significantly more likely to display Physical AggressionOpposition. 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 DisorderAnxiety 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.
Table 3 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 HyperactivityInattention at 45 years of age.
In regards to Emotional Disorder-Anxiety, children with
high 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 DisorderAnxiety. Low Positive Interaction and high hostile/ineffective parenting were associated with approximately two
times the likelihood of reporting a high degree of Emotional Disorder-Anxiety [OR = 1.95, 95 % CI 1.02, 3.74
and OR = 2.16, 95 % CI 1.00, 4.67].

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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-Inattention [OR = 2.85, 95 % CI 1.62, 5.03], Emotional Disorder-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 AggressionConduct Disorder. Children of parents who exhibit high
degrees 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 DisorderAnxiety [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 Indirect
Aggression. 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 Disorders 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 relationship 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-hyperactivity, 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

Matern Child Health J (2013) 17:907917

911

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

Emotional
disorder-anxiety

Physical
aggression-opposition

Separation
anxiety

Female

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]

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]

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]

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
35?

2.11 [0.96, 4.63]


1.00 Reference

1.69 [0.83, 3.45]


1.00 Reference

0.67 [0.27, 1.63]


1.00 Reference

1.01 [0.52, 1.96]


1.00 Reference

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]

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]

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]

Child factors
Childs sex

Obstetric factors
Preterm birth

Birthweight

Maternal age at birth

Smoking status during pregnancy

Drinking status during pregnancy

Postpartum depression

Environmental factors
Parenting 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]

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

1.18 [0.74, 1.86]

1.10 [0.72, 1.68]

1.68 [1.01, 2.78]

1.53 [0.99, 2.36]

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]

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]

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]

Parenting style: consistency


High
Low
Parenting style: hostile/ineffective

Parenting style: punitive/aversive

Family functioning

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]

1.00 Reference
1.18 [0.50, 2.77]

1.00 Reference
1.68 [0.91, 3.12]

1.00 Reference
0.45 [0.18, 1.14]

1.00 Reference
0.68 [0.36, 1.29]

Single parent status


Lives with 2 parents
Lives with single parent

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Table 2 continued
Odds ratios [95 % confidence intervals]
Hyperactivity-inattention

Emotional
disorder-anxiety

Physical
aggression-opposition

Separation
anxiety

Socio-demographic factors
Income adequacy
High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

1.76 [0.79, 3.94]

0.82 [0.44, 1.55]

1.01 [0.39, 2.59]

1.18 [0.65, 2.14]

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]

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]

Low
Maternal education

Maternal immigration status

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]

1.00 Reference

1.00 Reference

1.00 Reference

1.15 [0.72, 1.83]

3.75 [2.48, 5.68]

3.09 [1.93, 4.93]

Comorbid separation anxiety


No
Yes

[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 adverse
effects 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 populationlevel sample of children and utilize a more liberal characterization of emotional and behavioural symptomatology.
The present study also incorporated a number of important
covariates, which may be predictively important. Several
studies which have examined more than one type of outcome 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 behavioural/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

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DSM-IV-TR [4]. Attention-Deficit/Hyperactivity Disorder


(ADHD) and Conduct Disorder (CD) are more frequently
observed among male children [4] and indirect aggression
is 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 consistent 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 outcome 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 the
behavioural/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 outcomes 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/

Matern Child Health J (2013) 17:907917

913

Table 3 Multivariable analysis of child, obstetric, environmental and socio-demographic factors of behavioural/emotional outcomes at cycle 3
(ages 45, N = 1,357)
Odds ratios (95 % confidence intervals)
Hyperactivityinattention

Emotional
disorder-anxiety

Physical aggressionconduct disorder

Indirect
aggression

Female

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Male

1.80 [1.12, 2.89]

0.88 [0.50, 1.57]

1.80 [1.04, 3.12]

0.54 [0.35, 0.85]

Child factors
Childs sex

Worry/unhappiness
No worry/unhappiness

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Worry/unhappiness

1.32 [0.75, 2.34]

1.60 [0.84, 3.04]

1.38 [0.72, 2.65]

1.25 [0.75, 2.09]

Obstetric factors
Preterm birth
Not preterm

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Preterm

0.55 [0.18, 1.70]

1.32 [0.51, 3.39]

0.85 [0.29, 2.50]

1.14 [0.51, 2.57]

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

1.07 [0.31, 3.75]

0.66 [0.07, 6.14]

1.27 [0.37, 4.36]

0.56 [0.17, 1.84]

1524

1.18 [0.44, 3.17]

1.36 [0.35, 5.25]

0.49 [0.16, 1.48]

0.61 [0.29, 1.28]

2534

0.88 [0.38, 2.02]

0.90 [0.27, 3.02]

1.17 [0.47, 2.89]

0.68 [0.36, 1.28]

35?

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Birthweight
Normal
Low
Maternal age at birth

Smoking status during pregnancy


Did not smoke

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Smoked

1.08 [0.62, 1.86]

0.68 [0.32, 1.42]

1.25 [0.69, 2.24]

1.85 [1.10, 3.12]

Drinking status during pregnancy


Did not drink

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Drank

1.05 [0.59, 1.86]

1.85 [0.91, 3.75]

0.73 [0.38, 1.40]

0.81 [0.49, 1.33]

Postpartum depression
No PPD

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

PPD

1.08 [0.46, 2.56]

0.86 [0.31, 2.36]

1.42 [0.61, 3.32]

0.76 [0.37, 1.59]

Environmental factors
Parenting style: positive interaction
High
1.00 Reference
Low

0.72 [0.43, 1.22]

1.00 Reference

1.00 Reference

1.00 Reference

1.95 [1.02, 3.74]

1.15 [0.65, 2.05]

1.29 [0.79, 2.09]

Parenting style: consistency


High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

1.34 [0.79, 2.27]

1.15 [0.61, 2.15]

0.92 [0.51, 1.67]

1.27 [0.79, 2.05]

Parenting style: hostile/ineffective


Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

2.34 [1.22, 4.47]

2.16 [1.00, 4.67]

1.96 [1.09, 3.53]

1.87 [1.09, 3.21]

Parenting style: punitive/aversive


Low

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

High

1.08 [0.62, 1.88]

1.26 [0.60, 2.63]

2.08 [1.18, 3.66]

0.88 [0.53, 1.45]

Family functioning
High

1.00 Reference

1.00 Reference

1.00 Reference

1.00 Reference

Low

0.51 [0.19, 1.41]

1.29 [0.44, 3.77]

0.77 [0.33, 1.81]

0.88 [0.40, 1.92]

1.00 Reference
2.38 [0.90, 6.28]

1.00 Reference
2.17 [0.80, 5.89]

1.00 Reference
1.16 [0.50, 2.72]

1.00 Reference
0.93 [0.41, 2.09]

Current maternal depression


Low
Moderate to severe

123

914

Matern Child Health J (2013) 17:907917

Table 3 continued
Odds ratios (95 % confidence intervals)
Hyperactivityinattention

Emotional
disorder-anxiety

Physical aggressionconduct disorder

Indirect
aggression

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]

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 hyperactivity-inattention

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]

1.00 Reference

1.00 Reference

2.42 [1.10, 5.33]

2.37 [1.32, 4.26]

Comorbid physical aggression-conduct disorder


No
1.00 Reference
Yes

2.36 [1.30, 4.27]

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 outcome
No

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]

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 intrusiveness, 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-administration 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 parenting behaviours and development of certain mental disorders. Both ADHD and Oppositional Defiant Disorder/
Conduct Disorder have been linked to inconsistent, unresponsive, coercive, critical and rejecting parenting patterns
[4850], as well as hostile and punitive disciplinary patterns

123

[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 to
childrens 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

Matern Child Health J (2013) 17:907917

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 reliably 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 often
highly 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 behavioural/emotional outcomes.
It is important to consider several limitations. Perhaps
the most important is reliance upon self-report by biological 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 that
maternal 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 collected 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 the
potential 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 nonnormal distribution would make elevated scale scores rare
and equal scale division problematic. Lastly, factors such
as familial history of psychiatric disorders were not collected and could not be adjusted for. One population-based
study indicated that approximately 4 % of fathers experience 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 psychology, though the symptoms of PPD may be giving way
to other important mediating factors such as parenting
style. Specifically, the present study has highlighted

915

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 on
data from Statistics Canada, the opinions expressed do not represent
the views of Statistics Canada. The authors would like to thank the
NLSCY study participants, Statistics Canada, Human Resources and
Skills Development Canada (HRSDC) and the staff at the Toronto
RegionStatistics Canada Research Data Centre.

References
1. Waddell, C., Offord, D. R., Shepherd, C. A., Hua, J. M., &
McEwan, K. (2002). Child psychiatric epidemiology and Canadian public policy-making: The state of the science and the art of
the possible. Canadian Journal of Psychiatry, 47, 825832.
2. Waddell, C., McEwan, K., Shepherd, C. A., Offord, D. R., &
Hua, J. M. (2005). A public strategy to improve the mental health
of Canadian children. Canadian Journal of Psychiatry, 50,
226233.
3. Loeber, R., Burke, J., & Pardini, D. A. (2009). Perspectives on
oppositional defiant disorder, conduct disorder, and psychopathic
features. Journal of Child Psychology Psychiatry, 50, 133142.
4. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edn, Text Revision.
Arlington: American Psychiatric Publishing Inc.
5. Lim, K. L., Jacobs, P., Ohinmaa, A., Schopflocher, D., & Dewa,
C. S. (2008). A new population-based measure of the economic
burden of mental illness in Canada. Chronic Diseases in Canada,
28, 9298.
6. World Health Organization. (2004). Prevention of mental disorders: Effective interventions and policy options. Geneva, Switzerland: World Health Organization.
7. Waddell, C., McEwan, K., Peters, R. D., Hua, J. M., & Garland,
O. (2007). Preventing mental disorders in children: A public
health priority. Canadian Journal of Public Health, 98, 174178.
8. Hill, J. (2002). Biological, psychological and social processes in
the conduct disorders. Journal of Child Psychology and Psychiatry, 43, 133164.
9. Dennis, C.-L. E., Janssen, P. A., & Singer, J. (2004). Identifying
women at-risk for postpartum depression in the immediate
postpartum period. Acta Psychiatrica Scandinavica, 110,
338346.
10. Bashiri, N., & Spielvogel, A. M. (1999). Postpartum depression:
A cross-cultural perspective. Primary Care Update for OB/GYNS,
6, 8287.
11. Paulson, J. F., Dauber, S., & Lieferman, J. A. (2006). Individual
and combined effects of postpartum depression in mothers and
fathers on parenting behaviour. Pediatrics, 118, 659668.
12. Moehler, E., Brunner, R., Wiebel, A., Reck, C., & Resch, F.
(2006). Maternal depressive symptoms in the postnatal period are
associated with long-term impairment of mother-child bonding.
Archives of Womens Mental Health, 9, 273278.
13. Bennett, H., Einarson, A., Taddio, A., Koren, G., & Einarson, T.
R. (2004). Prevalence of depression during pregnancy: Systematic review. Obstetrics & Gynecology, 103, 698709.

123

916
14. Hiltunen, P., Jokelainen, J., Ebeling, H., Szajnberg, N., &
Moilanen, I. (2004). Seasonal variation in postnatal depression.
Journal of Affective Disorders, 78, 111118.
15. Meredith, P., & Noller, P. (2003). Attachment and infant difficultness in postnatal depression. Journal of Family Issues, 24,
668686.
16. Chung, T. K. H., Lau, T. K., Yip, A. S. K., Chiu, H. F. K., & Lee,
D. T. S. (2001). Antepartum depressive symptomatology is
associated with adverse obstetric and neonatal outcomes. Psychosomatic Medicine, 63, 830834.
17. Pawlby, S., Sharp, D., Hay, D., & OKeane, V. (2008). Postnatal
depression and childhood outcome at 11 years: The importance of
accurate diagnosis. Journal of Affective Disorders, 107, 241245.
18. Lusskin, S. I., Pundiak, T. M., & Habib, S. M. (2007). Perinatal
depression: Hiding in plain sight. Canadian Journal of Psychiatry, 52, 479488.
19. Hay, D. F., Angold, A., Pawlby, S., & Harold, G. T. (2003). Pathways to violence in the children of mothers who were depressed
postpartum. Developmental Psychology, 39, 10831094.
20. Johnson, P. L., & Flake, E. M. (2007). Maternal depression and
child outcomes. Psychiatric Annals, 37, 404410.
21. Sharp, D., Hay, D. F., Pawlby, S., Schmucker, G., Allen, H., &
Kumar, R. (1995). The impact of postnatal depression on boys
intellectual development. Journal of Child Psychology and Psychiatry, 36, 13151336.
22. Kurstjens, S., & Wolke, D. (2001). Effects of maternal depression
on cognitive development of children over the first 7 years of life.
Journal of Child Psychology and Psychiatry, 42, 623636.
23. Murray, L., Hipwell, A., Hooper, R., Stein, A., & Cooper, P.
(1996). The cognitive development of 5-year old children of
postnatally depressed mothers. Journal of Child Psychology and
Psychiatry, 37, 927935.
24. Murray, L. (1992). The impact of postnatal depression on infant
development. Journal of Child Psychology and Psychiatry, 33,
543561.
25. Hay, D. F., Pawlby, S., Waters, C. S., & Sharp, B. (2008).
Antepartum and postpartum exposure to maternal depression:
Different effects on different adolescent outcomes. Journal of
Child Psychology and Psychiatry, 49, 10791088.
26. Philipps, L. H. C., & OHara, M. W. (1991). Prospective study of
postpartum depression: 4-year follow-up of women and children. Journal of Abnormal Psychology, 100, 151155.
27. Caplan, H. L., Cogill, S. R., Alexandra, H., Robson, K. M., Katz, R., &
Kumar, R. (1989). Maternal depression and the emotional development of the child. British Journal of Psychiatry, 154, 818822.
28. Human Resources Development Canada and Statistics Canada.
(2005). National Longitudinal Survey of Children and Youth:
Users Handbook and Microdata Guide. Cycle 6. Ottawa: Minister of Industry.
29. Hotton, T. (2003). Childhood aggression and exposure to violence in the home. Statistics Canada, Crime and Justice Research
Paper Series. Ottawa: Minister of Industry.
30. Strayhorn, J. M., & Weidman, C. S. (1988). A parent practices
scale and its relation to parent and child mental health. Journal of
the American Academy of Child and Adolescent Psychiatry, 27,
613618.
31. Charach, A., Cao, H., Schachar, R., & To, T. (2006). Correlates
of methylphenidate use in Canadian children: A cross-sectional
study. Canadian Journal of Psychiatry, 51, 1726.
32. To, T., Cadarette, S. M., & Liu, Y. (2001). Biological, social, and
environmental correlates of preschool development. Child: Care,
Health and Development, 27, 187200.
33. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The
McMaster family assessment device. Journal of Marital and
Family Therapy, 9, 171180.

123

Matern Child Health J (2013) 17:907917


34. Landy, S., Tam, K. K. (1998). Understanding the contribution of
multiple risk factors on child development at various ages.
Gatineau: Applied Research Branch, Strategic Policy, Human
Resources Development Canada.
35. Radloff, L. S. (1977). The CES-D scale: A self-report depression
scale for research in the general population. Applied Psychological Measurement, 1, 385404.
36. Halligan, S. L., Murray, L., Martins, C., & Cooper, P. J. (2007).
Maternal depression and psychiatric outcomes in adolescent
offspring: A 13-year longitudinal study. Journal of Affective
Disorders, 97, 145154.
37. Halligan, S. L., Herbert, J., Goodyer, I. M., & Murray, L. (2003).
Exposure to postnatal depression predicts elevated cortisol in
adolescent offspring. Biological Psychiatry, 55, 376381.
38. Cornish, A. M., McMahon, C. A., Ungerer, J. A., Barnett, B.,
Kowalenko, N., & Tennant, C. (2005). Postnatal depression and
infant cognitive and motor development in the second postnatal
year: The impact of depression chronicity and infant gender.
Infant Behavior and Development, 28, 407417.
39. Boyle, M. H., & Pickles, A. R. (1997). Influence of maternal
depressive symptoms on ratings of childhood behavior. Journal
of Abnormal Child Psychology, 25, 399412.
40. Hess, N. H., & Hagen, E. H. (2006). Sex differences in indirect
aggression: Psychological evidence from young adults. Evolution
and Human Behavior, 27, 231245.
41. Osterman, K., Bjorkqvist, K., Lagerspetz, K. M. J., Kaukiainen,
A., Landau, S. F., Fraczek, A., et al. (1998). Cross-cultural evidence of female indirect aggression. Aggressive Behaviour, 24,
18.
42. Bjorkqvist, K., Lagerspetz, K. M. J., & Kaukiainen, A. (1992).
Do girls manipulate and boys fight? Developmental trends in
regard to direct and indirect aggression. Aggressive Behavior, 18,
117127.
43. Marshall, T., & Ramchandani, P. (2008). Emotional disorders and
children and adolescents. Medicine, 36, 478481.
44. Shaw, D. S., Schonberg, M., Sherrill, J., Huffman, D., Lukon, J.,
Obrosky, D., et al. (2006). Responsivity to offsprings expression
of emotion among childhood-onset depressed mothers. Journal of
Clinical Child and Adolescent Psychology, 35, 490503.
45. Edhborg, M., Lundh, W., Seimyr, L., & Widstrom, A. M. (2001).
The long-term impact of postnatal depressed mood on motherchild interaction: A preliminary study. Journal of Reproductive
and Infant Psychology, 19, 6171.
46. Hart, S., Field, T., & del Valle, C. (1998). Depressed mothers
interactions with their one-year-old infants. Infant Behavior and
Development, 21, 519525.
47. Beck, C. T. (1999). Maternal depression and child behaviour problems: A meta-analysis. Journal of Advanced Nursing, 29, 623629.
48. Patterson, G. R. (1982). Coercive family process. Eugene, Oregon: Castalia Publishing Company.
49. Harrington, R. (2004). Behavioural disorders in children and
adolescents. Medicine, 32, 5557.
50. Morrell, J., & Murray, L. (2004). Parenting and the development
of conduct disorder and hyperactive symptoms in childhood: A
prospective longitudinal study from 2 months to 8 years. Journal
of Child Psychology and Psychiatry, 44, 489508.
51. Nix, R. L., Pinderhughes, E. E., Dodge, K. A., Bates, J. E., Pettit,
G. S., & McFadyen-Ketchum, S. A. (1999). The Relation
between mothers hostile attribution tendencies and childrens
externalizing behavior problems: The mediating role of mothers
harsh disciplining practices. Child Development, 70, 896909.
52. Rey, J. M., Walter, G., Plapp, J. M., & Denshire, E. (2000).
Family environment in attention deficit hyperactivity, oppositional defiant and conduct disorders. Australian and New Zealand
Journal of Psychiatry, 34, 453457.

Matern Child Health J (2013) 17:907917


53. Pettit, G. S., Bates, J. E., & Dodge, K. A. (1997). Supportive
parenting, ecological context, and childrens adjustment: A
seven-year longitudinal study. Child Development, 68, 908923.
54. Jung, V., Short, R., Letourneau, N., & Andrews, D. (2007).
Interventions with depressed mothers and their infants: Modifying interactive behaviours. Journal of Affective Disorders, 98,
199205.
55. Bussing, R., Gary, F. A., Mason, D. M., Leon, C. E., Sinha, K., &
Garvan, C. W. (2003). Child temperament, ADHD, and caregiver
strain: Exploring relationships in an epidemiologic sample.
Journal of the American Academy of Child and Adolescent
Psychiatry, 42, 184192.

917
56. Costello, E. J. (1989). Developments in child psychiatric epidemiology. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 836841.
57. Taylor, T. K., Burns, G. L., Rusby, J. C., & Foster, E. M. (2006).
Oppositional defiant disorder toward adults and oppositional
defiant disorder toward peers: Initial evidence for two separate
constructs. Psychological Assessment, 18, 439443.
58. Ramchandani, P., Stein, A., Evans, J., OConnor, T. G., & The
ALSPAC Study Team. (2005). Paternal depression in the postnatal period and child development: A prospective population
study. The Lancet, 365, 22012205.

123

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