The Relationship Among Caregiver Depressive Symptoms, Parenting Behavior, and Family-centered Care

Deborah Winders Davis, PhD; John Myers, PhD; M. Cynthia Logsdon, PhD, C-WHNP, FAAN; Nerissa S. Bauer, MD, MPH


J Pediatr Health Care. 2016;30(2):121-132. 

In This Article

Abstract and Introduction


Background: Parental depression has been associated with adverse child outcomes. However, the specific parenting behaviors that may result in such child outcomes and the effect of family-centered care (FCC) on positive parenting behavior of depressed parents has not previously been examined.

Methods: Data from the National Survey of Early Childhood Health was used (n = 2,068). Groups were stratified by the presence of parental depression and compared with regard to demographics and the mean number of specific positive parenting behaviors. Generalized linear models were developed based on testing whether individuals performed more or less than the median number of positive behaviors. Lastly, we tested whether depression independently predicted each outcome after adjustment for FCC, coping, social support, and ethnicity to evaluate if depression independently predicted each outcome after adjustment.

Results: No difference was found in demographic variables between parents who were depressed and not depressed. Parents who were not depressed performed significantly more routines (p = .036); reported coping better with parenting (p < .001); performed significantly less punitive behaviors (p = .022); and needed/had less social support (p = .002) compared with parents who were depressed. Individual items and scale scores were associated in the expected directions. FCC was independently associated with study variables but did not moderate the effect of depression.

Conclusions: These data identify specific parenting behaviors that differ between parents who report depressive symptoms compared with parents who do not have depressive symptoms. More targeted interventions coordinated through a medical home are needed for parents with depressive symptoms to reduce the child health disparities often associated with parental depression.


Major depressive disorders occur in approximately 20% of adult women (Yonkers, Vigod, & Ross, 2011). Women of childbearing age have been reported to be of particular risk, especially during the first postpartum year (Viguera et al., 2011; Yonkers et al., 2011). The prevalence of less severe forms of depression is less well known, but one study reported the presence of depressive symptoms in almost 40% of a sample of inner-city mothers (Heneghan, Silver, Bauman, Westbrook, & Stein, 1998). It has been well-established that maternal depression is associated with numerous adverse child health and developmental outcomes (Cornish et al., 2005; Gartstein & Fagot, 2003; Kurstjens & Wolke, 2001; Logsdon, Wisner, & Pinto-Foltz, 2006; NICHD Early Child Care Research Network, 1999; Petterson & Albers, 2001; Teti, O'Connell, & Reiner, 1996; Tronick & Reck, 2009). In general, the mechanisms through which depression influences child outcomes are related to the interference of optimal parent-child interactions and with maternal-role functioning (Berkule et al., 2014; Logsdon et al., 2006; NICHD Early Child Care Research Network, 1999). Most of the research to date focuses on maternal depression, but the mental health of fathers also has been reported to be a risk factor for adverse child outcomes (Fletcher, Feeman, Garfield, & Vimpani, 2011; Ramchandani et al., 2011; Ramchandani, Stein, Evans, O'Connor, & ALSPAC Study Team, 2005).

More data are needed to identify specific parenting behaviors that may be influenced by parental depression in order to target preventive interventions that support positive parenting in the face of parental depression. For example, it has been shown that mothers who are depressed have interaction styles characterized as withdrawn or intrusive (Field, 1998). Each of these interaction styles has consequences for how parents with depression manage day-to-day parenting tasks necessary for child health, safety, and development (Berkule et al., 2014). The relationships are complex, and parental depression interacts with other factors such as socioeconomic status, race and ethnicity, maternal sensitivity, and social support (Campbell, Matestic, von Stauffenberg, Mohan, & Kirchner, 2007; Clare & Yeh, 2012; Logsdon, McBride, & Birkimer, 1994; Wang, Wu, Anderson, & Florence, 2011).

It is clear from the literature that parental depression, especially maternal depression, is a serious problem and that depression affects parental functioning and child outcomes. Some national organizations recommend screening and initial management of postpartum depression in primary care settings ((Earls & The Committee on Psychosocial Aspects of Child and Family Health, 2010; National Institute for Health Care Management, 2010), whereas others have suggested that there is not yet enough evidence to recommend universal screening but suggest that it should be considered (American College of Obstetricians and Gynecologists, 2010). Because of the detrimental effects that parental depression has on childhood development and other health-related outcomes (Kurstjens & Wolke, 2001; Maughan, Cicchetti, Toth, & Rogosch, 2007; Ramchandani et al., 2005; Santos, Matijasevich, Domingues, Barros, & Barros, 2010), pediatricians and pediatric nurse practitioners (PNPs) are often assuming a primary role in identifying and referring caregivers for suspected depression. However, few interventions aimed specifically at depressed mothers exist for delivery within pediatric primary care settings (Bauer, Stanton, Carroll, & Downs, 2013; Berkule et al., 2014).

Family-centered care (FCC) is an approach to planning and coordinating care that ensures comprehensive health management for children and families and is individualized to meet the needs of each family (Committee on Hospital Care and Institute for Patientand Family-Centered Care, 2012; National Association of Pediatric Nurse Practitioners [NAPNAP] Health Policy Committee, 2015). High-quality FCC has been shown to improve health-related resource utilization and reduce costs (Cox, Buman, Woods, Famakinwa, & Harris, 2012; DeVries et al., 2012; Long, Bauchner, Sege, Cabral, & Garg, 2012; Romaire, Bell, & Grossman, 2012). Although not specific to depression, family-based approaches within primary care have the potential for effectively intervening with families affected by parental depression (Beardslee, Gladstone, Wright, & Cooper, 2003). More data are needed to better understand the role of specific models of care, such as FCC, in the provision of optimal care and targeted anticipatory guidance for families in which one or more parent experiences depression. However, previous examinations of data contained within the National Survey of Early Childhood Health (NSECH) 2000 dataset did not adjust for this important potential confounder when examining the relationship between parental depression and parenting behaviors (Blumberg & O'Connor, 2004; Kogan et al., 2004; Mistry, Stevens, Sareen, De Vogli, & Halfon, 2007; Regalado, Sareen, Inkelas, Wissow, & Halfon, 2004).

The current study evaluated whether parental depression independently predicted specific parenting behaviors (routines, enrichment, punitive disciplinary behaviors, positive disciplinary strategies, and home safety [childproofing]) after adjusting for FCC and traditional risk factors (coping, social support, and ethnicity). Our hypothesis is that the association of suboptimal parenting among caregivers who experience depressive symptoms would be lessened if the family received FCC delivered in the context of a primary care home.