Infant Behavior & Development 35 (2012) 803–814

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Infant Behavior and Development

Maternal depression and sex differences shape the infants’ trajectories

of cognitive development
Schale Azak a,b,∗
a
Department of Psychology, University of Oslo, Norway
b
Nic Waal’s Institute, Lovisenberg Hospital, Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Article history: The effect of maternal depression on the trajectories of cognitive development was studied
Received 3 May 2011 in 26 infants with depressed mothers as compared to a group of 24 infants with non-
Received in revised form
depressed mothers. The infants were tested on Mullen Scales of Early Learning when they
29 December 2011
were 6, 12 and 18 months old. Mothers reported their depressive symptoms over the follow
Accepted 26 July 2012
ups. The study also investigated if there were sex differences in the cognitive trajectories.
Multilevel modeling analyses revealed that infants of depressed mothers had a stable lower
Keywords:
Maternal depression cognitive score over the period 6–18 months of age as compared to the infants of non-
Infant depressed mothers, and that the girls tended to increase their cognitive scores as compared
Cognitive development to the boys over the same time period. The results are discussed in light of the stability of
Cognitive trajectories depression symptoms over the follow up and sex differences in cognitive development.
Sex differences, Multilevel modelling © 2012 Elsevier Inc. All rights reserved.
Longitudinal

1. Introduction

The effects of maternal postnatal depression on child cognitive functioning are inconsistent. Some research shows a
relation between maternal depression and reduced cognitive performance (Hay et al., 2001; Murray, 1992). Others find a
relation under specific conditions such as chronic depression, or for specific groups such as male infants or low educated
parents (Hay & Kumar, 1995; Murray, Kempton, Woolgar, & Hooper, 1993). In an attempt to explain the inconsistency in
results, researchers have looked to the timing and duration of depression and gender interactions. Different types of studies
have demonstrated that maternal depression of longer duration in infancy is contributing to poorer cognitive development
in infants and older children (Cicchetti, Rogosch, & Toth, 2000; NICHD SECC, 1999a, 1999b; Petterson and Alison Burke, 2001;
Sutter-Dallay et al., 2011). The impact of brief and less chronic depression on child cognitive development is less clear, but
there are some studies indicating that even brief postnatal depression may have long lasting effect on cognitive development
(Hay et al., 2001).
Still, it is unclear how maternal postnatal depression is related to individual change in cognitive abilities since few have
done longitudinal studies with repeated measures of cognitive capacity. One exception is a stud by Feldman and Eidelman
(2009) who investigated if vagal tone and maternal postpartum depressive symptoms influenced premature infants’ tra-
jectory of cognitive development assessed at infant corrected ages 6, 12 and 24 months and again at 5 years. Their results
showed different timing of the two factors: higher vagal tone increased the rate of cognitive development across the first
years of life, whereas maternal postpartum depressive symptoms interfered with development in the preschool years.

∗ Correspondence address: Department of Psychology, University of Oslo, Norway, Post Box 1094, Blindern, NO-0317 Oslo, Norway. Tel.: +47 47286661.
E-mail address: schale.azak@psykologi.uio.no

0163-6383/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.infbeh.2012.07.017
804 S. Azak / Infant Behavior & Development 35 (2012) 803–814

Unfortunately, they did not track depressive symptoms during the follow-up period, neither did they use clinical inter-
view for depression, so it is uncertain which aspect of maternal depression, the early timing or the severity or chronicity
that was influencing the change in cognitive development in the preschool years. The current study aimed to investigate
if maternal clinical depression and gender are related to change in infant cognitive abilities through the first 18 months of
life.

1.1. Maternal depression and change in infant cognitive development

Murray, Hipwell, Hooper, Stein, and Cooper (1996) and Murray (1992) measured object permanence tasks in a group of 9
months old infants with postnatal depressed mothers, and tested their cognitive abilities at 18 months and again at 5 years
of age. At 9 months infants with depressed mothers performed less well than infants in a control group with healthy mothers
on the object permanence task. At 18 months of age there were no overall effects of maternal depression, although boys
and infants in families with lower socioeconomic status were affected by maternal depression. At follow-up at 5 years of
age there were no relations between concurrent maternal depressions and the severity or duration of postnatal depression,
also the boys and disadvantaged groups exposed to maternal postnatal depression were accomplishing as well as the non-
depression group. Even though the infants of depressed mothers were initially inferior on the object permanence tasks they
were gradually performing as well as the comparison group on the cognitive tests.
In another longitudinal study (Hay et al., 2001) it was shown that children exposed to maternal postnatal depression
had lower cognitive abilities when assessed on WISC at 4 and 11 years of age as compared to children with non-depressed
mothers. The difference persisted after control for both concurrent depression and maternal IQ. The differential results
may partly be due to differential social contexts, such as the quality of education that might have influenced the children’s
cognitive performance (Bronfenbrenner, 1979; Murray et al., 1996).
Sutter-Dallay and colleagues (2010) assessed both maternal depressive symptoms and infant cognitive development
repeatedly during the infants’ two first years of life. They found a significant relation between maternal depressive symptoms
at infant age 6 weeks and infant cognitive development over the two first years of life. When taking into account the mothers’
subsequent depressive symptoms over the two first years of life, this relation was reduced to a statistically insignificant trend.
They also found that depressive symptoms at infant age 6 weeks strongly predicted the symptoms levels in mothers at all
follow up assessments. The results suggest that the effect of early maternal depression on infant cognitive development is
partly mediated by subsequently elevated depressive symptoms.
In summary, the results from the previous longitudinal studies suggest that there is a change in children’s cognitive
abilities over time that is related to maternal postnatal depression, but it is unclear how this change is taking place. It is
also unclear how early it is possible to assess a relation between maternal depression and change in children’s cognitive
performance. The human brain is developing structurally and functionally over a much longer time span as compared to
other primates (Johnson, 2005). This implies that the developing child will be affected differentially by the environment at
different phases in development.
The influence of maternal depressive symptoms on the young child’s cognitive performance could vary as a function
of timing in brain development and the duration of exposure to maternal depression. The very young infant’s brain and
perceptual system are tuned to detecting contingency between its own reactions and environmental events. Also, the young
infants’ immobility demands that caregivers in some way bring the social and physical environment to them. Exposure
to an insensitive and depressed mother from a very early age and for a longer period may turn the infant into a state of
learned helplessness (Seligman, 1975). Kaplan and colleagues (2011) showed that 1-year old infants of currently depressed
mothers with prenatal depression onset, to a lesser degree took advantage of infant-directed speech produced by a non-
depressed mother as compared to infants with currently exposure to maternal depression with later onset. Their results
suggested that the infants had generalized their response to infant-directed speech from the depressed mothers’ to the non-
depressed mothers’ speech. A depressed mothers’ speech to her infant is less pitched (Kaplan, Bachorowski, Smoski, & Zincer,
2001) and refers less to the infants’ agency (Murray et al., 1993). Infants exposed to a self-occupied mother may gradually
tune out from her because there are less reinforcing activities like imitation and expansion of the infants’ experience.
Infants exposed to maternal depression for a longer time may generally come to expect less stimulating responses from
women.
On the other hand, exposure to maternal depression may also fail to support later developing functions, such as the
child’s autonomy (Kochanska & Leon, 1991), verbal IQ (Cicchetti et al., 2000) and executive functions in toddlerhood and
childhood (Rohrer, Cicchetti, Rogosch, Toth, & Maughan, 2011). Feldman and Eidelman (2009) found that maternal depressive
symptoms measured before discharge had its strongest impact on infants’ trajectories of cognitive development between 2
and 5 years of age. The researchers concluded that depressive mothers may have special difficulties in supporting functions
emerging at preschool age, such as the child’s independence, executive functions and peer friendships.
It is also possible that changes in the environment like recovery from depression or healthy paternal care will allow
the child to catch up in development, though some treatment studies have failed to document any change in cognitive
development (Grace, Evindar, & Stewart, 2003; Gunlicks & Weissman, 2008). Alternatively there might be a stable relation
between maternal depression and infant cognitive ability. If postnatal maternal depression is stable throughout infancy it
may be expected to exert a stable influence on infant cognitive abilities.
 S. Azak / Infant Behavior & Development 35 (2012) 803–814 805

1.2. Sex differences and change in infant cognitive development

Researchers who have claimed early sex differences in cognitive development have argued that boys are more oriented
towards objects and systemizing as compared to girls (Baron-Cohen, 2003; Maccoby & Jacklin, 1974; Spelke, 2005). There
are indeed some differences between boys and girls in cognitive development where the boys tend to lag behind girls with
several weeks of development. Boys’ depth vision mature later, and boys are generally slower in the emergence of knowledge
about moving objects (Kotovsky & Baillargeon, 1998). Moreover, girls seem to have better recall memory when searching for
an object in a new place (Piaget’s AB-error) as compared to boys (Diamond, 1985). The pointing gesture is emerging earlier
in girls, and girls have been found to use gesture–word combinations and two word utterances 3 months earlier than do
boys (Özçalýþkan & Goldin-Meadow, 2010).
Boys also seem to be more negative, show less interest in social play and need more external scaffolding in emotion
regulation, which may leave them less time to explore the world. Girls need less scaffolding in emotion regulation and
potentially have more time to spend on cognitive stimulating activities when they interact with their caregivers (Tronick &
Reck, 2009; Weinberg, Tronick, Cohn, & Olson, 1999).
Even though the boy is performing within the normal range of development it may be more difficult for a depressed
mother to meet his enhanced needs for emotion regulation. Therefore boys with a disengaged, depressed mother may be
left more alone with their negative emotions. They may require more time in coping and thus give boys less opportunity to
take part in stimulating activities as compared to female infant (Grace et al., 2003; Hay et al., 2001; Murray et al., 1993).
The present report originates from a longitudinal study of two groups of infants – one with clinically depressed mothers
and a group with non-depressed mothers. The depressed mothers in the present study were offered treatment in the public
health system for maternal depression available to all depressed mothers in Norway. This treatment consists of various forms
of therapeutic interventions as psychotherapy, medical treatment and/or parent–infant therapy implemented to reduce the
impact of maternal depression on children. Nearly all of the depressed mothers took part in some therapeutic interventions
(96.2%) and the majority of the depressed mothers took part in parent–infant therapy with their infant (84.6%).
In the present study we investigated the relation between change in cognitive abilities during a period of infancy and
maternal depression. Since male infants generally tend to lag behind the females a few months in development, infant gender
was included in the analysis as a covariate. It was expected that girls would have higher rate of cognitive development
as compared to the boys. The few published studies of the effect of maternal depression symptoms on infant cognitive
trajectories have reported mixed findings at which age maternal depression symptoms exert greatest influence, throughout
infancy (Sutter-Dallay et al., 2011) or in the preschool period (Feldman & Eidelman, 2009). In present study it was expected
that infants of clinically depressed mothers at 6 months would show lower cognitive abilities, but that the two groups would
become more similar over time.

2. Method

2.1. Participants and recruitment

Fifty-seven families were recruited from psychiatric hospitals and general health care institutions, and well baby clinics
and shopping centers in the Oslo area, Norway. Participants from psychiatric hospitals and general health care were recruited
to the depression group as they were referred for treatment of mental illness during the postpartum period. Participants
from well baby clinics and shopping centers were recruited to a comparison group. Participants were recruited in the period
from 2006 to 2009. Mothers were recruited when their babies were between 4 and 6 months old.
The infants were mainly Caucasian (94.6%). The majority of the mothers were married or cohabitating (89.3%). Mean
maternal age was 32.1 years (SD = 3.7).
The level of education of the mothers was quite high: 53.6% had completed a Master’s or PhD degree, 19.6% had completed
a Bachelor degree, 14.3% had started at university, 10.7% had completed high school and 1.8% had not completed high
school. Since low birth weight represents a biomedical risk for development, infants with birth weight less than 2500 g were
excluded. All mothers were able to speak and read Norwegian.
The infants were given inexpensive toys for participating in the study. The Medical Ethics Committee and the Norwegian
Data inspectorate approved this study and all mothers and fathers provided written informed consent.

2.2. Maternal measures

2.2.1. Maternal depression

The mothers were screened for depression by completing the Center for Epidemiological Studies Depression Scale (CES-
D) (Radloff, 1977). CES-D is a 20-item scale, with scores ranging from 0 to 60. The respondents were asked to rate the
frequency of 20 symptoms within the last week. Reliability and validity of this scale has been demonstrated for various
demographic groups, with the test–retest reliability ranging from .51 to .67 over a two to eight week period and from .32 to
.54 over a three to 12 month period (Radloff, 1977). Studies have shown that a score of 16 or above differentiates between
clinically depressed and nondepressed individuals (Irwin, Artin, & Oxman, 1999; Radloff, 1991). In community samples this
instrument had a 6% false positive and 36% false negative rate (Myers & Weissman, 1980). CES-D has been successfully used
806 S. Azak / Infant Behavior & Development 35 (2012) 803–814

Fig. 1. Overview of the recruitment of participants.

as a self-report assessment of depression in a number of studies including postpartum women (Diego et al., 2004). Among
postpartum women, the CES-D is prone to produce a number of false positive results (Mosack & Shore, 2006), and this offered
the researchers the opportunity to further examine potentially marginal cases with a diagnostic interview. In addition, all
mothers were asked to indicate earlier and current somatic and mental health problems as well as the type of treatment.
As shown in Fig. 1, 29 mothers were recruited to the depression group. Mothers who scored above the threshold on
CES-D (≥16) including one mother recruited to the comparison group and mothers who reported to be under treatment
for depressive disorder (n = 30) were interviewed by a licensed psychiatrist using the MINI International Neuropsychiatry
Interview Plus (Sheehan et al., 2002, Norwegian translation by Leiknes, Malt & Leganger, 2005) and the Structured Clinical
Interview for DSM Diagnosis axis II (First, Gibbon, Spitzer, Williams, & Benjamin, 1997, Norwegian translation by Friis,
Havik, Monsen & Torgersen). Both instruments have been validated in Norway. Mothers who scored above 16 on the CES-D
or reported to be in treatment for a depression disorder, but did not fulfill the criteria for ongoing depression disorder due
to the diagnostic interview, were excluded from the study (n = 2). None of the mothers were diagnosed as depressed with
psychoses. Thus, only mothers diagnosed with a depression disorder without psychoses were allocated to the depression
group (n = 28). One of the depressed mothers withdrew from the study, leaving 27 depressed mothers to be included in
the analyses. Most of the depressed mothers (70.4%) also received an anxiety diagnosis, and four of the mothers with
both depression and anxiety disorders also fulfilled the criteria for a personality disorder. Nearly all depressed mothers
were under some kind of treatment for their depression (96.2%) and the majority of the mothers received parent–infant
interaction therapy (84.6%).
A total of 28 mother–infant dyads were recruited from well baby clinics and shopping centers. Two mothers from this
group scored above the threshold on CES-D: One was allocated to the diagnostic interview mentioned above; the second was
 S. Azak / Infant Behavior & Development 35 (2012) 803–814 807

not accessible to schedule time for the clinical interview or infant follow-up at age six months and was excluded from this
study. Thus, a total of twenty-six nondepressed dyads participated in the first assessment and all of these mothers scored
13 or lower on the CES-D.
Infants in both groups with birth weight less than 2500 g were excluded from further analyses (n = 3, one from the
depression and two from the nondepressed group). Thus the total sample consisted of 50 dyads, 26 depressed dyads and 24
non-depressed dyads. In the depressed group there were 13 girls and 13 boys and in the nondepression group there were
12 girls and 12 boys.
Maternal depression symptoms were sampled again at infant age 12 and 18 months with CES-D.

2.2.2. Demographic information and obstetrical health history

Mothers reported their highest educational level and whether they lived together with the child’s father. Educational lev-
els were coded into five levels (1 = not completed high school, 2 = completed high school, 3 = started university, 4 = completed
Bachelor degree, 5 = completed Master or PhD degree). Mothers were asked about the infant’s birth weight, gestational age,
any illness during pregnancy, and exposure to medication, alcohol and nicotine. Prematurity was coded as gestational age
less than 37 weeks. The use of antidepressants or anxiolytics during pregnancy was reported as psychotropic medication.
The mothers’ use of medication was registered close to and during pregnancy.

2.2.3. Life stress

Life stress was assessed with the subscale Life Stress of the questionnaire Parenting Stress Index (PSI), long version
(Abidin, 1995). The PSI has norms developed from parent populations with children in the age range 1 month to 12 years
in the US. The PSI scale has been shown to be reliable and valid for various demographic groups, with test–retest reliability
ranging from .71 to .82 over a three weeks period and .63 to .96 over a period of one to three months (Abidin, 1992, 1995),
it is also considered to be valid across cultures (Abidin, 1995).
The mothers completed the whole long version of PSI when the infant was 6 and 12 months old but in this paper we only
report on the subscale Life Stress. Life Stress scale consists of 19 original items each rated as yes or no. In the current study a
Norwegian version of the PSI long version was applied. This version contains three extra items on the Life Stress scale (Abidin,
1995; translated and back-translated by Abidin and Rønning: During the last 12 months has your family experienced: (121)
Old/sick parents/grandparents demanding care and attention, (122) A serious accident or health problem and/or (123) Chronic
somatic illness (diabetes, etc.)?).

2.2.4. Maternal parenting style

Maternal and infant interaction behaviors were observed when the infant was 6 months old by using a coding system for
parent–infant interaction developed for the National Institute of Child Health and Human Development (NICHD Early Child
Care Research Network, 1999a, 1999b). Mother–child interaction was videotaped during 15 min of semi structured play in
the laboratory. Mothers were instructed to bring with them 3–5 of their child’s favorite toys or none at all if the mother
choose not to use toys for the first 7 min. For the next 8 min the mothers were given a standard set of toys to use in play.
Maternal behaviors were assessed on a scale from 1 to 5, generally reflecting “not at all” to “highly” characteristic of the
interaction using a series of 5-point scales (Likert scales) in the coding protocol Qualitative Ratings for Parent–Child Interaction
at 3–15 months of age, developed for the NICHD study (Owen, 1992) and modified by Cox and Crnic (2003, revised 2006).
A higher score reflected both the frequency and the quality of the mothers’ behaviors during the interaction. The following
maternal behaviors were rated: Sensitivity/responsiveness (characterised by appropriate, well-attuned responsiveness to
the infant, parent responds quickly and appropriately to the child’s distress, shared positive affect, evidence of good timing
paced to the child’s interest and arousal level, contingent vocalizations by the parent, facilitating the manipulation of an
object or child movement), intrusiveness (failing to modulate behavior that the child turns from, defends against, or expresses
negative affect to, not allowing the child to influence the pace or focus of play or interaction), detachment (the parent
appearing disengaged from the infant, and failing to register and respond to infant cues), positive regard for the child (general
enjoyment of the child, smiling, speaking in a warm tone), negative regard (negative voice when correcting, threatening
the child or punishing without explanation, calling the child unflattering names, disapproval), animation (facial expressions
such as opening mouth wide, eyes open wide, and an enthusiastic tone of voice) and stimulation of development (verbally
responding to or expanding the child’s verbalizations or vocalizations, focusing the child’s attention on perceptual qualities of
objects, encouraging the child to actively participate in activities, assisting in motor movement or coordination). A 30-point
scale of maternal parenting behavior maternal style was created by aggregating the ratings of sensitivity/responsiveness,
intrusiveness (reversed), detachment/disengagement (reversed), stimulation of development, positive regard/positive affect
for the child and animation, where a higher score reflected higher quality in maternal parenting behavior (Sarfi, Smith, Waal,
& Sundet, 2011).
Inter-rater reliabilities were calculated on 50% of the sample. The maternal behaviors coded (with intraclass correlations
in parentheses) were sensitivity (.88), intrusiveness (.74), detachment/disengagement (.89), positive regard (.72), negative
regard (.55), animation (.78), and stimulation of cognitive development (.82). Intraclass correlations were acceptable (>.70)
for all subscales except negative regard (.55), which was infrequently rated higher than 1. Negative regard was excluded
from further analyses.
808 S. Azak / Infant Behavior & Development 35 (2012) 803–814

2.3. Infant assessment: Mullen Scales of Early Learning (MSEL)

Infant cognitive development was assessed using Mullen Scales of Early Learning (MSEL) (Mullen, 1995) administrated
by two trained psychologists not blind to the maternal depression diagnosis. An Early Learning Composite Score (M = 100
SD = 15) can be computed based on the following four subscales: Visual Reception, Fine Motor, Receptive Language and
Expressive Language. There is also a Gross Motor subscale that is not included in the Early Learning Composite Score. Raw
scores on the subscales are converted to T-scores (M = 50, SD = 10). The test can be administrated to children aged 0–68
months. The MSEL has good test–retest reliability (.78–.96) within 1–2 weeks and good interrater reliability (.91–.99) for the
age group 1–44 months (Mullen, 1995). Present study reports the Early Learning Composite Score since this is a measure of
global cognitive ability and is found to correlate .70 with Bayley Mental Developmental Index (Mullen, 1995).
Depending on the instruction in the manual the infants were either seated on the parents lap or lay on the table during
administration. Visual Reception were tested by items that involved visual organization, visual sequencing and visual spatial
awareness e.g. localize a figure near and far, look for dropped spoon, recall of object in a new place. Fine Motor was tested
by tasks involving visual directed motoric planning and unilateral and bilateral manipulation e.g. grasping and playing with
block, switching a object from one hand to another, building tower with blocks. Receptive Language involved auditory
organization, auditory sequencing, auditory memory and included items as responding to own name called from the back,
differentiate objects/pictures by their name, follow sequential instructions. Expressive Language involved the child’s ability
to use language productively, and was tested by observation of combinations of sounds and gestures, vocalizations and
words used by the child spontaneously during the administration, and the child’s words as a response to naming tasks.

2.4. Study design and procedures

Participants were assessed when the infant were 6, 12 and 18 months old. Each session comprised several different
assessments of the infants and the parents in the lab in addition to administration of questionnaires. The assessments were
done in the Infancy laboratory at the Department of Psychology, University of Oslo. The infants and their parents spent
approximately 1.5–2 h in lab at each assessment point. The cognitive assessment of the infants was administrated after
they had played with their mothers in the mother–infant interaction procedure. Prior to the mother–infant interaction the
mother and infant were assessed on stress procedure for 10–15 min and had a break. All children went through the same
schedule at each assessment point.

2.5. Data analyses

Differences in demographic variables were analysed by t-test, chi-square or nonparametric Mann–Whitney test and exact
tests were applied. Maternal reports of depression symptoms were highly skewed and were therefore log10-transformed.
The relations between birth weight and MSEL scores were analyzed by Pearson product moment correlations and relations
between maternal education level and MSEL scores was analyzed by Spearman’s rho correlation.
At 6 months of age MSEL was missing from two infants due to fussiness. At 12 months of age six infants missed
their MSEL score (one due to attrition, and five because the infant was too fussy to complete all four subscales). At 18
months eight infants missed their MSEL score (three due to attrition, five were too fussy). Non-response analyses were
conducted at each age separately to check for differences between children with and without MSEL composite score. Due
to small sample size multiple logistic regressions with one independent variable in each run was applied. Group affilia-
tion, depression symptoms, life stress, negative reactivity, sex and maternal education were run as independent variables
at each age and showed to be unrelated to missing in MSEL at all three ages. So there were no indications that the group
of children that missed MSEL composite scores was different from the group of children who had MSEL scores on these
variables.
Multilevel analysis was chosen to calculate changes in MSEL because it handles missing data in the dependent variable
under the MAR assumption, and treats repeated observations as nested within individuals (Hox, 2010). Repeated observa-
tions are nested within individuals and allow for separate estimates of within subject (level 1) and between subject (level
2) variations. The total rate of missing in MSEL was 10.7%. Since the total rate of missing exceeded 5%, it was necessary
to do multiple imputations of the missing data before further analyses in SPSS (Heck et al., 2010). Multiple imputation
using a quite high number of imputed datasets is a statistically valid approach, in the presence of high rates of missing
data (Schafer & Graham, 2002; van Buuren, 2011; Wayman, 2003). Guided by Schafer and Graham (2002) ten datasets were
generated in SPSS 18.0. Reported results were from the pooled estimates over the ten imputed data sets for each of the
tested models. The Akaike’s Information Criterions (AIC) reported were the median AIC’s of the 10 imputations in each
model.
The average developmental trajectories based on MSEL scores over time were estimated. The time coefficients “months”
were coded as months since the infants were 6 months old and these coefficients were treated as numeric. Then the
measurements at infant age 6, 12 and 18 months were coded as 0, 6 and 12 respectively and treated as a continuous
variable.
Two unconditional models and one conditional model were tested and the parameters were predicted by maximum
likelihood estimates (ML). The two first models were on level 1. The first model, the empty model, included the intercept
 S. Azak / Infant Behavior & Development 35 (2012) 803–814 809

Table 1
Between groups comparisons of demographic variables.

Non-depressed Depressed Statistics

Mean (SD) (n = 24) Mean (SD) (n = 26)

Mother age (years) 32.08 (3.64) 32.19 (3.96) t(48) = −.10 p = .92
Education Master/PhD Master/PhD z = −1.176, p = .24
Living with two parents (%) 100 88.5 2 (1) = 2.95, p = .24
Mental illness during pregnancy (%) 0 80.8% 2 (1) = 33.42, p < .001
Prenatal smoking (%) 0 3.8 2 (1) = .94, p = .33
Psychotropic medication close to pregnancy (%)
0 7.7 2 (1) = 1.92, p = .17
Prematurity (<37 GAa week, %) 4.2 11.5 2 (1) = .92, p = .34
Baby birth weight (g) 3738 (538) 3299 (449) t(48) = 3.14, p = .003
Baby age (days) 192.67 (15.75) 199.50 (26.98) t(48) = −1.08, p = .29
Boys (%) 50 50 2 (1) = 0.07, p = .79
Baby birth weight (g) 3738 (538) 3299 (449) t(48) = 3.14, p = .003
Siblings (%) 50 26.9 2 (1) = 2.82, p = .15
Number of children 1.58 1.42 t(48) = .71, p = .48
Mother–infant interaction therapy (%) 0 84.6 2 (1) = 36.26, p = .00
a
GA, gestational age.

and months (linear) as fixed effects and intercept as random effect. The second model also included the quadratic parameter
of months (months2 ) in the fixed effects and months (linear) in the random part of the model. The focus was primarily on
the model’s fixed effects, and in order to stabilize the model a diagonal covariance matrix of random effects for intercept
and slope was assumed (Pinheiro & Bates, 2000). Model three, the conditional model, was on level 2 and evaluated if
maternal depression (1 = depressed, 0 = non-depressed) could account for individual variation in parameter estimates both in
intercept and by interaction with months. Model three also added infant gender as a covariate (boy = 0, girl = 1) in intercept
and interaction with months. Both maternal depression and infant gender were entered in the model as dummy variables.
There was no theoretical expectation of an interaction between the covariates and the quadratic term in the model, so this
interaction was not tested out. All statistical analyses were conducted in SPSS 18.0.

3. Results

3.1. Diagnostic information

A total of 57 mother infants-dyads were recruited. As shown in Fig. 1, 29 were recruited to the depression group. Mothers
who fulfilled the criteria for a clinical depressive episode when their infants were between 4 and 6 months old, were included
in the depression group (n = 27), and two mothers were excluded as they did not fulfill criterion for an ongoing depression
disorder. Most of the depressed mothers (70.4%) also received an anxiety diagnosis and four of the mothers with both
depression and anxiety disorders also fulfilled the criteria for a personality disorder. Nearly all depressed mothers were
under treatment for their depression (96.2%). Most of the depressed mothers took part in parent–infant therapy (84.6%). A
total of 28 mother–infant dyads were recruited to the nondepressed group. Two mothers from this group scored above the
threshold on CES-D. One was excluded from the study since she were not reachable to schedule the time for assessment
at infant age 6 months. The second mother was allocated to the diagnostic interview mentioned above. Thus, a total of 26
dyads participated at the first assessment and all of these mothers scored 13 or lower on the CES-D and constituted the
nondepressed group. Infants with birth weight less than 2500 g were excluded from further analyses (n = 3, one from the
depression group and two from the nondepressed group). The total sample then consisted of 50 dyads; 26 depressed and
24 non-depressed dyads. In the depressed group there were 13 girls and 13 boys, in the nondepression group there were 12
girls and 12 boys.

3.2. Demographic information and obstetric health history

As shown in Table 1, the depressed mothers and the non-depressed mothers were not significantly different in age or in
education level (p = .24). Mothers in both groups had overall high level of completed education. The most frequent degree
earned among mothers in the non-depressed and the depressed group was Master/PhD degree (50.0% and 42.3%, respec-
tively). Most of the children were living with two parents. There were no significant differences between the infant groups if
they had siblings or not (p = .15) or in number of children in the family (p = .48). The majority, 80.8% of the depressed moth-
ers reported to have been mentally ill during pregnancy as compared to none in the non-depressed group. Also, the infants
with depressed mothers had significant lower birth weight as compared to infants of non-depressed mothers (t(48) = 3.14,
p = 003).
810 S. Azak / Infant Behavior & Development 35 (2012) 803–814

Table 2
Between groups comparisons of CES-D.a

CES-Da Non-depressed Depressed Statisticsc [95% CI]d

b b
n Mean (SD) n Mean (SD)

6 months 24 5.58 (3.17) 26 25.51 (12.55) t(48) = −7.93*** [.51, .85]

12 months 24 6.33 (3.97) 25 18.96 (12.23) t(47) = −4.75*** [.28, .68]
18 months 24 6.54 (5.04) 23 18.74 (12.06) t(45) = −4.64*** [.28, .71]
a
Center for Epidemiological Studies Depression Scale.
b
Raw scores of CES-D displayed for easier interpretation.
c
log10 transformed values are applied in statistic test.
d
95% confidence interval.
***
p < .001.

Table 3
Correlations between study variables.

Study variable 1 2 3 4 5 6 7
a
1. MSEL 18 months
2. MSELa 12 months .654**
3. MSELa 6 months .216 .233
4. Birth weight .201 .271 .162
5. Maternal educationb .259 .193 −.024 −.146
6. Maternal parenting style .101 .140 .108 .221 .026
7. Life stress 6 months −.222 −.092 .011 .055 −.341* −.036
8. Life stress 12 months −.172 .217 .102 .167 −.355** .014 .573**
a
MSEL, Mullen Scales of Early Learning Composite Score.
b
Spearman’s rho correlation.
*
p < .05.
**
p < .01.

3.3. Maternal depression symptoms measured by CES-D

One self-report of maternal depressive symptoms was missing at infant age 12 months (due to attrition), and three were
missing at 18 months. All missing self-reports stemmed from the depressed group (2 due to attrition and 1 did not return
the questionnaire).
As expected, the depressed mothers reported significantly more symptoms of depression at 6, 12 and 18 months of age
as compared to the non-depressed group (p < .001) (see Table 2). Even though the depressed mothers tended to report lower
levels of depression symptoms at the follow-ups as compared to levels reported at infant age 6 months old, they continued
on average to report clinical levels of depression symptoms (>18). The non-depressed mothers reported on average low
levels of symptoms at all three assessment points.

3.4. Life stress

The depressed and non-depressed mothers reported on average Life Stress below clinical range when the infants were
6 and 12 months old; the depressed mothers reported Life Stress at 6 months mean = 10.24, SD = 7.66 and at 12 months
mean = 8.15, SD = 9.46 where as the nondepressed mothers reported mean = 9.04, SD = 7.28 at 6 months and mean = 7.54,
SD = 6.90 at 12 months of age. There were no significant differences between the depressed and non-depressed mothers in
reported Life Stress at 6 nor 12 months of age (p = .58 and p = .81).

3.5. Maternal parenting style at infant age 6 months

Depressed mothers were rated as significantly lower in parenting style (M = 3.03 SD = .74) during play with their 6 moth
old infant as compared to the non-depressed mothers (M = 3.85 SD = .54) (t(45.47) = 4.5 p = .000).

3.6. Preliminary analyses of MSEL

As shown in Table 3, relations between maternal education, birth weight, maternal parenting style, life stress at 6 and 12
months and MSEL was not significant. Life stress at 6 and 12 months were negatively correlated with maternal education
(p = .016 and p = .018, respectively) indicating that mothers with higher education were experiencing less life stress. Maternal
education, birth weight, life stress and maternal parenting style were dropped from further analyses of MSEL.
 S. Azak / Infant Behavior & Development 35 (2012) 803–814 811

Table 4
Results of longitudinal multilevel modeling predicting MSEL.a

Parameter Model 1 Model 2 Model 3

Est (SE) Est. (SE) Est. (SE)

Fixed effect
Intercept 98.07*** (1.87) 95.50*** (1.53) 100.24*** (2.40)
Month −.319 (.22) 2.25** (.64) 1.82** (.71)
Month × month −.21*** (.05) −.21*** (.05)
Girl −2.49 (2.73)
Depression −6.73** (2.72)
Girl × month 1.12** (.42)
Depression × month −.33 (.42)
Random parameters
Variance between individuals 42.97* (21.18) 20.25 (16.78) 10.07 (13.87)
Variance within individuals 1.01** (.37) .72* (.30)
Residual 142.25** (22.48) 89.68** (16.91) 87.37** (16.11)
AIC median 1210.870 1184.463 1172.967
a
MSEL, Mullen Scales of Early Learning Composite Score; AIC, Akaike’s Information Criterion.
*
p < .05.
**
p < .01.
***
p < .001.

3.7. Cognitive trajectories

As shown in Table 4, the empty model, model 1, showed significant intercept (estimate = 98.07 SE = 1.87) and non-
significant linear time coefficient (estimate = −.32, SE = .22). In the second model the quadratic time coefficient was included
in the fixed effect, and a linear time coefficient was added to the random effects. Model 2 demonstrated better fit to data
as expressed in a lower median AIC than did model 1; it also explained 40% of the total variance in model 1. Since model 2
did not include any covariates it estimated the average growth curve in MSEL. This model indicates that the entire sample,
on average, was within the normal range at 6 months of age (estimate = 95.50, SE = 1.53), and that the entire sample, on
average, tended to increase their scores on MSEL over development from 6 to 12 months of age as expressed in the “month”
parameter (estimate = 2.25 SE = .64), thus performing lower on MSEL over time from 12 to 18 months of age as expressed in
the quadratic parameter “months × months” (estimate = −.21 SE = .05).
In model 3 maternal depression and infant gender were added as covariates. This model demonstrated a better fit, median
AIC was 1172.967, and explained 49.6% of total unexplained variance on level 2 in model 2.
Model 3 showed that maternal depression was significantly related to MSEL (estimate = −6.73, SE = 2.72). There was no
significant interaction between depression and time, so the prediction of a different time course for infants with depressed
mothers was not supported. Since the infants with the depressed mothers had a stable lower MSEL over the follow up
as compared to the infants with nondepressive mothers, the estimated decrease in MSEL as expressed in the quadratic
parameter “month × month” (estimate = −.21, SE = .05), may be especially severe for infants with depressed mothers, pushing
them into the lower normal range of MSEL from age 12 to 18 months. As expected, there was a significant interaction between
infant gender and time (estimate = 1.12, SE = .42), indicating that the girls increased more in MSEL from 6 to 18 months as
compared to the boys. So boys with depressed mothers seemed to have the lowest trajectories in MSEL over the follow-up.

4. Discussion

This study is one of the first to describe the trajectories of cognitive development in infancy in relation to maternal clinical
depression and infant gender.
Maternal depression diagnosed when infants were 4–6 months old exerted a constant negative effect on infant cognitive
development as measured by the MSEL. Most of the depressed mothers reported to have been mentally ill during pregnancy.
There were no significant differences between the depressed and non-depressed group in variables typically associated
with maternal depression as life stress, maternal education, number of children, prematurity and marital status which could
have confounded the relation between maternal depression and cognitive development (Sameroff, Seifer, Barocas, Zax, &
Greenspan, 1987). Nearly all of the depressed mothers were under treatment for their depression and the majority took
part in parent–infant therapy as part of the ordinary health services offered to depressed mothers in Norway. At study start,
when the infants were 6 months old, the depressed mothers were lower on maternal parenting style as compared to the
non-depressed group but correlation analyses showed that maternal parenting behavior at this age was not significantly
related to the scores on MSEL. Also, the depressed mothers continued to report significantly higher levels of depression
symptoms in the clinical range (>18) over the over the follow up as compared to the non-depressed mothers, indicating that
the depressed mothers continued to be depressed.
Our results are in line with longitudinal studies showing effect of stability of maternal depression symptoms on infant
cognitive development (Sutter-Dallay et al., 2011) but differed from Feldman and Eidelman’s findings (2009) showing that
maternal depressive symptoms did not interfere with trajectories of cognitive development before two years of age. There are
812 S. Azak / Infant Behavior & Development 35 (2012) 803–814

several differences between present study and the last mentioned study that might explain the discrepant results. Feldman
and Eidelman (2009) based their study on self report of depressive symptoms among postpartum mothers and the mothers
reported depressive symptoms only prior to discharge, whereas the present study included clinically depressed mother that
reported depressive symptoms in the clinical range at the follow up. Further, most of the depressed mothers in present
study reported to have been mentally ill during pregnancy. Taken together, it is possible that the infants in present study
were exposed to prenatal and postnatal maternal depression for a longer period of time and experienced a less stimulating
environment which in turn could have resulted in weaker cognitive development before entering the preschool age.
It is important to note that the main goal in this study was to describe the relation between pathways of cognitive devel-
opment in infants and maternal clinical depression. Due to a small sample size potential mediating effects were not analyzed.
Though, we suggest some potential mediators that could be involved; genetic factors, prenatal exposure of depression or
less optimal parenting behavior. Research suggests that genetic factors contribute both to stability as well as change in
cognitive ability in the child’s second year of life (Cherny et al., 1994). It is possible that the association between maternal
depression and cognitive abilities in current study could be mediated by genetic factors in the child. Alternatively, could
common genetic factors be the cause of both maternal depression and infant trajectories in cognitive development.
Also, the majority of the depressed mothers reported to be mentally ill during pregnancy and this could have effected
the infants’ cognitive development (Deave, Heron, Evans, & Emond, 2008).
Maternal parenting behaviors have been reported to mediate the influence of maternal depression on infant of cognitive
development (NICHD, Murray et al., 1996). In present study the depressed mothers showed less optimal parenting in play
with their 6 months old infants, but maternal parenting behavior at this age was not significantly correlated with MSEL.
The no significant relation between maternal parenting behavior and MSEL could be explained in several ways. First, the
measurement of maternal behavior was a composite score of several different maternal behaviors and it could be too global to
be related specifically to cognitive development. Second, it is likely that the depressed mothers’ parenting behavior changed
over the follow up (NICHD, 1999a, 1999b; Mills-Koonce, Gariepy, Sutton, & Cox, 2008; Feldman & Eidelman, 2009) and then
concurrent maternal behavior is likely more related to cognitive development than earlier maternal behavior. Alternatively,
maternal depression could have caused both less optimal parenting and lower cognitive performance.
Almost all mothers and infants in the depression group (84.6%) took part in parent–infant therapy, and this type of
intervention has demonstrated enhanced cognitive development among toddlers of depressed mothers (Cicchetti et al.,
2000). Though, changing the behavior of the dyad often takes prolonged time. Even if the depressed mother alters her
behavior, the infant’s responses may maintain. Infants with depressed mothers are reported to fail to discriminate between
neutral and positive faces (Bornstein, Arterberry, Mash, & Manian, 2011) and often do not take advantage of infant-directed
speech (Kaplan, Danko, & Diaz, 2010). This may in turn discourage a depressed mother from being child centered and thus
the dyad sustains a non-optimal kind of mother–infant interaction. Infants might also generalize their behavior from being
together with a depressed mother to other caregivers, and ignore the stimulation provided by other grown ups, especially
females (Field et al., 1988; Kaplan, Dungan, & Zincer, 2004).
On the other hand, since the infants of depressed mothers did not evince a decrease in cognitive performance over time,
it is possible that the different treatment they participated in prevented further decline. A different explanation is that
treatments targeting maternal depressive symptoms or the quality of interaction may improve infant attention regulation
(Bornstein & Tamis-LeMonda, 1997) instead of general cognitive capacities (Clark, Tluczek, & Wenzel, 2003; Forman et al.,
2007).
The current study also investigated if girls and boys have different growth trajectories in cognitive abilities as measured
on MSEL. As expected, the girls were increasing their scores over time as compared to the boys. The results correspond
with other studies showing that female infants both reach cognitive milestones earlier, and evidence qualitatively better
performance than do males (Diamond, 1985; Kotovsky & Baillargeon, 1998; Özçalýþkan & Goldin-Meadow, 2010). This
suggests that the boys with depressed mothers were especially disadvantaged since they started out with lower performance
and subsequently did not improve their performance over time as did the girls. The period from 6 to 18 months of age harbors
increased understanding of intentionality, extended use of symbols and increased memory, abilities that are propelling
cognitive development. When an infants exits this stage with lower MSEL, this may slow down the development even
further.

4.1. Limitations

The following limitations should be acknowledged when interpreting the study’s results. The present study had relative
few participants limiting the possible explanatory variables in the analyses of trajectories of cognitive development. Even
though the maternal depression symptoms were tracked over the three waves with CES-D (Radloff, 1977) it was not possible
to combine the results from the CES-D and MSEL due to small sample size.
The screening instrument CES-D is a valid and reliable instrument for detecting depression but not other psychiatric
disorders. This implies that the mothers in the non-depressed group could have other psychiatric disorders not screened
for. Also, there was a high rate of comorbidity of anxiety and depression among the clinical depressed mothers the but the
low sample size made it difficult to disentangle if the observed effect on infants trajectories of cognitive development it was
attributable to the depression, the anxiety or the combination of those two disorders.
 S. Azak / Infant Behavior & Development 35 (2012) 803–814 813

Another shortcoming was the missing of data on MSEL. The non-response analyses showed that missing was not sig-
nificantly related to group status, depression symptoms, infant gender, life stress or maternal education. Also we tried to
compensate for missing by using Multiple Imputation (Schafer & Graham, 2002; van Buuren, 2011).
Further, fitting a growth curve model with quadratic time parameters may probably be unreliable with only three waves.

5. Conclusions

Despite the above-mentioned limitations we venture to draw some conclusions. The current study is among the first
to track the developmental path in cognitive development from age 6 to 18 months among infants exposed to maternal
clinical depression. Waddington (1975) proposed that early in life, development is canalized and that a strongly atypical
environment is needed to force the infant’s development out of a normal track. Nevertheless, when a small deviation from
the normal path has occurred early in life, this may be sufficient to cause a different developmental path.
The infants exposed to maternal depression continued to have a stable lower performance as compared to infants with
non-depressed mothers. Even though the infants with depressed mothers followed a normal path of cognitive development
they may be vulnerable for subsequent delay. Overall, the boys tended to evince a lower growth rate than did the girls. This
suggests that already during the first 18 months of life, boys exposed to postnatal depression are pushed toward the “edge” of
the normal trajectories of cognitive development. Future studies should include more participants, enabling growth models
of cognitive abilities to disentangle the change in maternal depression over time and include several waves of assessments
from infancy into toddlerhood.

Acknowledgements

This study was supported by “The National Program for Integrated Clinical Specialist and PhD-training for Psychologists”
in Norway. The program is a joint cooperation between Universities of Bergen, Oslo, Tromsø, The Norwegian University of
Science and Technology (Trondheim), the Regional Health Authorities, and the Norwegian Psychological Association. The
program is funded jointly by The Ministry of Education and Research and The Ministry of Health and Care Services. This
study was also supported by South-Eastern Norway Regional Health Authority Grant 2007032. I thank Sabine Raeder, Anne
Mari Torgersen and Lars Smith for advice and comments on the article. Above all, I am grateful to families who took part in
the study.

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