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Parenting Practices among Depressed Mothers in the Child Welfare System Patricia L.

Kohl, Jacqueline Njeri Kagotho, and David Dixon The purpose of this study was to analyze a nationally representative sample of families referred to Child Protective Services (CPS) agencies, the National Survey of Child and Adolescent Weil-Being, to examine the association between maternal depression and parenting practices over a 36-month follow-up period.Three hypotheses were tested: (1) Depressed mothers are' more likely to demonstrate harsh parenting than are nondepressed mothers; (2) depressed mothers are more likely to demonstrate neglectful parenting than are nondepressed mothers; and (3) depressed mothers are more likely to demonstrate emotional maltreatment than are nondepressed mothers. The interaction between depression and time was also analyzed for each parenting practice to determine how changes in maternal depression affected changes in parenting. The sample for this study was 1,536 mother-child dyads in which the child was age three to 10 years and remained in the home after a CPS investigation. Depression remained high across time points and was associated with increased risk of emotional maltreatment and neglect over a 36-inonth period. In addition, self-reported emotional maltreatment remained high across time points. Implications of this work are the needs for better identification of mental health needs for mothers entering the child welfare system and parent training to specifically address positive parenting.

KEY WORDS: child welfare; maternal depression; National Survey of Child and Adolescent Well-Being; parenting M aternal depression, a critical public health concern, is prevalent among mothers referred to Child Protective Services (CPS) agencies. In fact, nearly a quarter of adults entering the child welfare system meet the diagnostic criteria for a major depressive episode in the preceding 12 months (U.S. Department of Health and Human Services, Administration on Children.Youth and Families [HHS, ACYF], 2005), compared with only 7% of adults in the general population (Kessler, Chiu, Demier, & Walters, 2005).

Furthermore, w^omen have an increased likelihood of experiencing depression compared with men (Kessler et al., 2003), and women exposed to a high number of chronic Stressors—as many women referred to CPS agencies are—are three times more likely than women with less exposure to Stressors to experience maternal depression (Orr,James, Burns, & Thompson, 1989). Given that women comprise the vast majority of primary caregivers among the child welfare population (HHS, ACYF, 2005), it is important to understand how maternal depression affects outcomes after a CPS referral.

The high rate of maternal depression in the child welfare system is a concern given its influence on parenting practices. Symptoms of depression may impede a woman's capacity to provide care for her children, placing her at risk to engage in neglectful parenting practices.

For instance, depressed mothers may lack sensitivity to their children's physical and emotional needs (Campbell et al., 2004; Trapolini, Ungerer,&McMahon,2008) ormay be unavailable or otherwise unresponsive to their children (Cum- mings & Cicchetti, 1993).

The literature also demonstrates that maternal depression is related to a higher risk of other harmful parenting behaviors, including emotional maltreatment and harsh parenting. Depressed moth- ers are more likely than are nondepressed mothers to have conflict-related interactions with their children, including feeling aggravated with the child, yelling at the child, and spanking the child (Lyons-Ruth,Wolfe, Lyubchik, & Steingard, 2o[)2).

Maternal depression increases the likelihood of corporal punishment toward children (Chung, Mc- CoUum, Elo, Lee, & Culhane, 2004; Shin & Stein, CCCCode: 1070-5309/11 $3,00 62011 National Association of Social Workers 215 2008).

Using meta-analysis techniques to examine reported findings about maternal depression and parenting behavior across 46 studies, Lovejoy, Crac- zyk, O'Hare, and Neunian (2000) found a moderate effect size {d = .40) for negative parenting behav- iors (for example, coercive, hostile, or threatening gestures), indicating a fairly strong relation between depression and harmful parenting.

Additional studies have shown that maternal depression places children at risk of abuse.

Longi- tudinal analysis of the National Institute of Mental Health's Epidemiologie Catchment Area Survey {N = 7,103) revealed that, among cases with no reported abuse at baseline, depressed respondents (parents) were more than three times as likely to report physical abuse toward their child at wave 2 than were nondepressed parents (ChafEn, Kelleher, & Hollenberg, 1996). Finally, symptoms of mental illness, including depression, were associated with higher scores on the Child Abuse Potential In- ventory in the Women, Co-occurring Disorders and Violence Study, indicating an elevated risk of future abuse (N = 371) (Rinehart et al., 2005).

In summary, these studies have clearly demonstrated that maternal depression adversely affects parent- ing among community-based samples.

The extent to which maternal depression influences parent- ing practices among one of the country's most vulnerable populations—mother and child dyads referred to CPS agencies for allegations of abuse or neglect—is not yet known.

The aim of child welfare intervention is to improve the safety and well-being of children, a goal that is adversely affected by maternal depres- sion. There is currently a dearth of information on the association of depression and changes in parenting behaviors after referral to CPS agencies.

Unanswered questions remain.

Do the parenting behaviors of depressed mothers improve at similar or different rates than do those of nondepressed mothers? Does a change in depression status affect parenting behaviors? Underst:anding which, if any, parenting behaviors remain a risk will help child welfare professionals better target limited resources to more accurately address specific parenting be- haviors. Furthermore, this understanding could be used to inform policy and practice decisions about the mental health service needs of mothers referred to CPS agencies.

The objective of this study was to analyze a land- mark nationally representative sample of children and families referred to CPS agencies, the National Survey of Child and Adolescent Well-Being (NS- CAW),to examine the association between maternal depression and changes in self-reported parenting practices over a 36-month period after referral to CPS agencies. Specifically, these three hypotheses were tested:

1.

On average, depressed mothers would be more likely to demonstrate harsh parenting over a 36-month period than would nondepressed mothers.

2.

On average, depressed mothers would be more likely to demonstrate neglectful parenting over a 36-month period than would nondepressed mothers.

3.

On average, depressed mothers would be more likely to demonstrate emotional maltreatment over a 36-inonth period than would nonde- pressed mothers.

In addition, we analyzed the interaction between depression and time for each parenting practice to determine how changes in maternal depression between baseline and 36-month follow-up affected changes in parenting behaviors. Finally, other child, family, and case characteristics associated with par- enting practices were determined.

RESEARCH METHOD The NSCAW, a fixed-panel design with four waves of data collection, had a stratified two-stage sample.

The primary sampling units (PSUs) were county child welfare agencies; the secondary sampling units were children (and their families) chosen from a list of completed investigations at the sampled agencies.

The sample was selected from 92 PSUs located in 36 states (NSCAW Research Group, 2002). The random sample of families within each agency was drawn from those who underwent a complete investigation for child maltreatment.The targeted population was all children and families investi- gated for child maltreatment in the United States; however, four states that required child welfare agency personnel to make first contact with the family instead of the NSCAW field representative were excluded from the study.

For statistical rea- sons, infants, sexual abuse cases, and cases receiving ongoing services after the investigation were over- sampled (Dowd et al., 2003).

Weighting was then performed to adjust for the unequal probability Social Work Research VOLUME 35, NUMBER 4 DECEMBER 2011 216 of selection from oversampling and nonresponse.

Cases with both substantiated and unsubstantiated maltreatment were included in NSCAW.

The ra- tionale for inclusion of both types of cases in the proposed project was the significant evidence that the ultimate substantiation of a particular report is not a good indicator of the seriousness of the report or the likelihood of continued and serious problems in parenting (Drake, Jonson-Reid, Way, & Chung, 2003; Hussey et al., 2005;Jonson-Reid, Drake, Kim, Porterfield, & Han, 2004; Kohl & Barth, 2007; Kohl, Jonson-Reid, & Drake, 2009).

Furthermore, many states now use a differential response system and offer voluntary services to at-risk families whose cases were not substantiated.

Hence, substantiation status cannot be used as a proxy for service receipt.

The NSCAW data were collected from caregiv- ers and child welfare workers at four time points:

baseline (between October 1999 and December 2000), approximately 12 months after baseline (wave 2), approximately 18 months after baseline (wave 3), and approximately 36 months after baseline (wave 4).

At baseline, wave 3, and wave 4, an NSCAW field representative conducted face-to-face interviews with the permanent caregiver of children remaining in the home; for wave 2, the field representative con- ducted a telephone interview with the permanent caregiver.

Child welfare workers also participated in face-to-face interviews at baseline.

If a case remained open to child welfare services, additional worker face-to-face interviews were completed at wave 2, wave 3, and wave 4.

Wave 1, wave 3, and wave 4 included comparable measures of maternal and child functioning and mental health that were not included in wave 2. Data regarding service receipt was collected from caregivers and child welfare workers at wave 2.

Sample The entire NSCAW sample included 5,501 children (ages 0 to 16 years) and their families investigated for child maltreatment. The following cases, rep- resenting a subset of NSCAW, were included in this study:

• The child remained in home after the index investigation and spent no more than 5% of the study duration in out-of-home placements.

• The child was between the ages of 3 and 10 years at baseline.

The child's primary caregiver was identified as his or her mother (biological, adoptive, or step).

The child age inclusion criterion was selected because of the potent influence of parenting duriiig the preschool and elementary school years.

NSCAW did not capture parenting behaviors that are par- ticularly influential during infancy and toddlerhood; therefore, the youngest children were excluded. In addition, parenting influences may be less powerful during adolescence due to adaptational and matu- rational processes (Sim &Vuchinich, 1996). ¡ With these inclusion criteria, the final sample size was 1,536 cases. Only one child per family was included in the NSCAW; therefore, children were not nested within mothers. The sample was composed of 1,536 mother—child dyads. i Measures Following is an overview of the manner in which variables were measured. ¡ The dependent variables were three parenting practices: harsh parenting, neglect, and emotional maltreatment. These were measured with three subscales of the Conflict Tactics Scale-Parent to Child version (CTS-PC) (Straus, Hamby, Moore; & Runyan, 1998) at baseline, wave 3, and wave 4.The Physical Assault subscale assessed harsh parenting with the following nine items:

(1) spanked child on bottom with bare hand; (2) .slapped on the hand, arhi, or leg; (3) hit on bottom with a belt, hairbrush, stick, or another hard object; (4) hit some other part ¡of the body besides the bottom with a belt, hairbrush, or stick; (5) pinched the child; (6) slapped on the face, head, or ears; (7) hit with a fist or kicked hatd; (8) threw or knocked down; and (9) beat up (that is, kicked or hit the child over and over as hard as possible) .The Neglect subscale assessed neglect with the following five items: (1) had to leave your child home alone, even when you thought some adult should be with him or her; (2) were not able ¡to make sure your child got the food he or she needed; (3) were so drunk or high that you had a problem taking care of your child; (4) were not able to make sure your child got to a doctor or hospital when he or she needed it; and (5) were so caught up with your problems that you were not able to show br tell your child that you loved him or her.

Finally, the Psychological Abuse subscale assessed for emotiorial maltreatment with the following five items: (1) KOHL, KAGOTHO, AND DIXON / Parenting Practices among Depressed Mothers in the ChildWelfare System 217 shouted, yelled, or screamed at child; (2) threatened to spank or hit the child but did not actually do it; (3) swore or cursed at child; (4) called child dumb or lazy (or similar statement);and (5) said you would send child away or kick child out of the house.

As recommended by the scale developers (Straus, 1991), median scoring was used to assess the frequency of each parenting behavior, with one incident scaled as I, two incidents scaled as 2, three to five incidents scaled as 4, six to 10 incidents scaled as 8,11 to 20 incidents scaled as 15, and more than 20 incidents scaled as 25.

The three parenting variables exhibited a high degree of skewness, in large part due to the high occurrence of 0 values (neglect: about 70%; harsh parenting: about 90%; emotional maltreat- ment: about 40%). Data transformations failed to normalize these data.Thus, a natural dichotomiza- tion at 0 versus not 0 was appropriate. Responses on the parenting outcome measures were analyzed as a series of individual time points (for example, baseline, wave 3,and wave 4) in the bivariate analyses and were analyzed as time-varying variables in the multivariate analyses.

The primary independent variable in our analytic models was maternal depression, which was mea- sured as a binomial variable with the Composite International Diagnostic Interview—Short Form (CIDl-SF) at baseline, wave 3, and wave 4. The CIDI-SF is a structured interview designed to screen for common psychiatric disorders with diagnostic criteria established in the DSM—IV (American Psychiatric Association, 1994; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998). Mothers who met the diagnostic criteria for clinical depression were coded as 1 ; mothers who did not meet these criteria were coded as 2.

As with the parenting out- come measures, responses on the depression measure were analyzed as a series of individual time points in the bivariate analyses and as a time-varying variable in the multivariate analyses.

Control variables included in the analysis were child gender, child age at baseline, mother race/ ethnicity, mother age at baseline, mother educa- tional attainment, family income, urban or nonurban status, and most serious maltreatment type of the baseline maltreatment report. Family income was categorized as "poor" versus "nonpoor" on the basis of the federally defined poverty level. This measure was calculated on the basis of procedures followed by the U.S. Census Bureau and includes both the family's income level and the number of adults and children in the household (Dalaker & U.S. Census Bureau, 2001).The poverty measure was used as a dichotomous variable in the analyses (at or below poverty threshold or above poverty threshold).

Urban/nonurban status of the county was defined consistent with U.S. Census definitions.

Urban was defined as greater than 50% of the population liv- ing in the urban area, and twnurban was defined as all other areas that did not meet this description (NSCAW Research Croup, 2002) .The maltreatment type of the official report at basehne investigation was obtained from the child welfare worker. From a list of 10 categories, the worker first indicated all maltreatment types included in the report. When multiple maltreatment types were reported, the most serious maltreatment type was determined by using a slight modification of the Maltreatment Classification System (Manly, Cicchetti, & Barnett, 1994), resulting in five categories of maltreatment:

(1) physical abuse; (2) sexual abuse; (3) neglect:

failure to provide; (4) neglect: failure to supervise; and (5) other. For purposes of our analyses, we col- lapsed the categories into physical abuse, neglect, and other. Physical abuse was the referent category in our analytic models.

Data Analysis Strategy Data were analyzed using Stata 10 data analysis software. All analyses used the NSCAW sampling weights; therefore, findings are nationally repre- sentative and generalizable to child welfare cases in which a child (between the ages of 3 and 10 years) remained in the home with his or her mother for at least 95% of the time in the 36 months after a maltreatment investigation.

The data analysis strategy included univariate, bivariate, and multivariate analysis techniques.

Frequencies were calculated to provide a general description of the data. Chi-square tests, ( tests, and unadjusted odds ratios were used to analyze the bivariate relation between major depression and the outcome and control variables. Finally, cross- sectional and longitudinal logistic regression models were built to analyze associations and interactions between dependent and independent variables.

Generalized estimating equations (GEEs) were used (Diggle, Heagerty, Liang, & Zeger, 2002).The GEE methodology provides a method of analyzing cor- related data that arise from longitudinal studies in which subjects are measured at different points in time.

GEEs are most effective when the focus is on 218 Social Work Research VOLUME 35, NUMBER 4 DECEMBER 2011 estimating the average response over the population (population-averaged effects),also referred to as the "marginal mean model." The resulting model re- gression coefficients have interpretations that apply to the population of individuals defined by fixing the values of the other covariates in the model.The correlated binary nature of our longitudinal inde- pendent variable (maternal depression—yes/no) lent itself to the GEE methodology as hkelihood-based inference was less applicable.

The xtgee command in Stata was used for GEEs, with the binomial specification for family to indicate the binary dependent variables represented by the three dichotomized parenting practice outcomes.

In addition, compound symmetry was obtained by using exchatigeable for the correlation specification among the binary outcomes.

To conduct the longitudinal multivariate analy- ses, we transformed the data from a wide to a long file. The time-varying dependent variables were coded as follows: If wave = baseline, then the base- line score was used; if wave = 3, then the wave 3 score was used; and if wave = 4, then the wave 4 score was used. Wave was then controlled for in all our analytic models.Three parenting measures were analyzed as dependent variables in separate models.

In each model, the other two parenting measures were included as independent variables (for ex- ample, when neglect was the dependent variable, harsh parenting and emotional maltreatment were included). Neglect and emotional maltreatment were moderately correlated (a = .29, p < .001).

Although this correlation is low enough to indicate that they are distinct constructs, the correlation is high enough that the relationship should be ac- counted for in the models.

Both main effect and interaction models were analyzed with this approach.The interaction model included a dummy-coded interaction term of de- pression by wave.The resulting interaction term was a three-level categorical variable (no depression at baseline, no depression at wave 3, no depression at wave 4), with no depression at baseline held as the reference group across all models.

To correct for missing values in the dependent variables, independent variables, and other control variables, we performed multiple imputation by chained equations. The missing values were im- puted in 10 iterations to create a simulated data set.

All analyses were conducted on the simulated data set.

Table 1: Description of Sample (Unweighted N = 1,536) Child gender Male Female Child age at baseline (years) 3-5 6-10 Mother's race/ethnicity Black, non-Hispanic White, non-Hispanic Hispanic Other Mother's educational attainment Less than high school High school graduate Some post-high school education Family's income At or below poverty threshold Above poverty threshold Primary maltreatment type Physical abuse Sexual abuse Neglect: Failure to provide Neglect: Failure to supervise Other Prior maltreatment reports Yes No Urbanicity of community Nonurban Urban Child age Mother's age Number of people living in home 53.6 46.4 35.4 64.6 22,9 50,8 19.2 7.1 29.0 45.5 25.5 49.8 50.2 28,8 13,3 20,1 26,2 117 48,3 517 24,1 75.9 6.5 32.0 4,3 Note:

We conducted chi-square and í tests to test for differences between cases with depressed mothers at baseline and cases with nondepressed mothers at baseline for each variable reported in this table. No significant differences were found.

RESULTS A description of the cases included in the sample is presented in Table 1, Slightly more than half of the children were male (53.6%).The racial and ethhic composite of the sample of mothers was 22.9% black, 50.8% white, and 19.2% Hispanic. Faniily income was evenly distributed between at or belpw the poverty threshold (49.8%>) and above the pQv- KoHL, KAGOTHO, AND DIXON / Parenting Practices among Depressed Mothers in the Child Welfare System 219 erty threshold (50.2%).The majority of the sample (75.9%) lived in urban areas.The mean age for the children was 6.5 years, with 64.6% between the ages of 6 and 10 years.The mean age of the mothers was 32.0 years. Overall, the mothers had low levels of educational attainment; 29.0%) of the mothers re- ported less than a high school education. Regarding child welfare case characteristics, a slight majority (51.7%) of the sample had no previous referrals to CPS agencies. Neglect was most frequently identi- fied as the most serious child maltreatment type by child welfare workers (failure to provide: 20.2%; failure to supervise; 26.2%).

Mothers' self-reports of maternal depression and parenting practices at each of the three waves are reported in Table 2. Approximately one in five mothers (21.1%) met the diagnostic criteria for major depressive episode at baseline, and this percentage was fairly stable across waves (15.5% at wave 2, 21.5% at wave 4). More than half (59.4%) of mothers did not report depression at any wave, and 5.7% of mothers reported depression at all waves; for 34.9%, the results were mixed across waves (not shown in table). As shown in Table 2, harsh parenting practices were highly skewed in the direction of the absence of these behaviors across all three waves. Nearly one out of every 10 mothers (9.6%) reported harsh parenting practices at baseline, whereas approximately 14% of mothers reported harsh parenting at waves 3 and 4. Approximately one-third (35.0%) of mothers reported neglectful parenting behavior at baseline, whereas 30.8% and 35.2% ofmothers, respectively,reported the same at waves 3 and 4.

Finally, a higher percentage ofmothers reported emotional maltreatment at all three time points; 61.5%, 55.4%, and 56.1% at baseline, wave 3, and wave 4, respectively.

The association between maternal depression and parenting behaviors reported at baseline are reported in Table 3.

The unadjusted odds of self-reporting neglect for depressed mothers were approximately three times those of nondepressed mothers at base- line (odds ratio [OR] = 2.7, p < .001) and wave 3 (OR = 3.5, p < .001). In addition, the unadjusted odds of emotional maltreatment for depressed moth- ers were approximately twice those of nondepressed mothers at baseline (OR = 2.0, p < .001), wave 3 (OR = 2.3,p < .001), and wave 4 (OR = 2.6,;; < .001).The odds ofself-reported harsh parenting were not statistically significantly different for depressed and nondepressed mothers.

Results of the main effects multivariate models assessing the relation between parenting and depres- sion are reported in Table 4. Consistent with the bivariate analysis, depression status and self-reported harsh parenting were unrelated.The overall model fit, however, was significant fWald)(^(17) = 145.6,/) < .001].

For this and the other models, the average Wald chi-squares for the 10 produced completed data sets are reported because Stata output did not include Wald chi-squares for analyses of the simu- lated data set. As demonstrated by the statistically significant wave variables, harsh parenting signifi- candy changed over time.The odds ofself-reported harsh parenting were significantly higher at wave 3 than at baseline (OR = 1.8, p < .05) and at wave 4 than at baseline (OR = 1.7, p < .05), with the other variables in the model controlled for. Racial and ethnic differences were found. Black and His- panic mothers were about two times more likely to self-report the use of harsh parenting practices over the 36-month study window than were white mothers (OR = 2.3,p < .001, and OR = 2.0,;J < .05, respectively). FinaUy, self-reported emotional Table 2: Frequencies of Maternal Depression and Parenting Practices Measured at Multiple Time Points (Unweighted N = 1,536) msMïus Dependent variable Maternal depression Parenting practices Harsh parenting Neglect Emotional maltreatment S5t3S 21.1 9,6 35.0 61,5 cs® 78,9 90,4 65,0 38,5 S33S 15.5 13.9 30.8 55.4 Ws 84.5 86.1 69,2 44.6 21.5 13,9 35,2 56,1 C3® 78.5 86.1 64.8 43.9 Note:

All values represent weighted percentages.

220 Social Work Research VOLUME 35, NUMBER 4 DECEMBER 2011 Table 3: Odds Ratios for Maternal Depression and Parenting Practices (Unweighted N = 1,536) Harsh parenting Neglect Emotional maltreatment 1.4 2 T*** 2.0*** 1.3 3.5*** 2.3*** 1.1 1.5 2.6' maltreatment and self-reported neglect frequently co-occurred with harsh parenting. Mothers report- ing emotional maltreatment (OR = 3.8, p < .001) and neglect (OR = 2.2,p < .001) had much higher odds of also self-reporting harsh parenting than did mothers not reporting emotional maltreatment and neglect, respectively.

Depression was statistically significant in the ne- glect model [overall model fit: Wald x^(17) = 104.8, p < .001].

Depressed mothers were 1.8 times more likely to self-report neglectful parenting behaviors than were nondepressed mothers. Mothers engaging in self-reported emotional maltreatment had a higher odds (OR = 2.4, p < .001) of also self-reporting neglect than did mothers without self-reported emotional maltreatment. In addition, mothers with self-reported harsh parenting were two times more likely to self-report neglect than were mothers without self-reported emotional maltreatment (QR = 2.0,p<.01). ' The odds of emotional maltreatment were greater among depressed mothers than nondepressed mothers (OR = 1.8, p < .001).The overall motfel fit was good [Wald x\\7) = 142.2,;; < .001], and additional variables were associated with emotional maltreatment across the study window. Emotional maltreatment was associated with self-reported harsh parenting and neglect. For mothers reporting harsh Table 4: Multivariate Models Assessing the Relationship between Self-reported Parenting Practices and Depression (Main Effect Models) Major depression (No depression) Wave 2 ( 18-month follow-up) (Baseline) Wave 3 (36-month follow-up) (Baseline) Child gender (Male) Parent age Mother race: Non-Hispanic black (Non-Hispanic white) Mother ethnicity: Hispanic (Non-Hispanic white) Mother race: Other (Non-Hispanic white) No high school education (More than high school) High school education (More than high school) Urban/rural status (Urban) Prior reports (No prior reports) Poverty (At or below poverty threshold) Official report: Neglect (Physical abuse) Official report: Other (Physical abuse) Self-reporr: Emotional maltreatment Self-report: Harsh parenting Self-report: Neglect 1.0 1.8* 1.7* 1.1 1.0 2.3*** 2.0* 1.4 0.9 1.3 0.9 0.7 1.4 0.8 0.7 3.8*** 0.6, 1.7 1.1,2.9 1.1,2.6 0.7, 1.3 1.0, 1.0 1.3,3.3 1.2,3.3 0.7, 2.9 0.3, 1.7 0.8,2.1 0.6, 1.4 0.3, 1.1 0.9, 2.2 0.3 1.3 0.4, 1.2 2.2,6.3 1.8** 0.9 1.0 1.1 1.0 1.1 1.2 1.0 1.1 1.0 1.3 1.2 1.0 1.4 1.2 2.4*** 2.0** 1.3,2.3 0.7, 1.1 0.8, 1.3 0.8, 1.4 1.0, 1.0 0.7, 1.6 0.7, 1.6 0.6, 1.8 0.7, 1.6 0.7, 1.4 0.9, 1.7 0.9, 1.6 0.7, 1.3 1.0,2.1 0.8, 1.9 1.8,3.2 1.3,2.9 1.8*** 0.8 0.7 0.9 1.0 1.5* 0.7 0.9 0.7 0.7 0.9 1.1 1.0 0.8 0.8 3.0*** 1.3,2.

0.6, 1.

4 0 0.6, 1.0 0.8, 1.4 1.0, 1.0 1.1,2.2 0.3, 1.1 0.3, 1.7 0.4, l.il 0.3, 1.1 0.7, l.j 0.7, 1.3 0.7, 1.3 0.6, 1.2 0.5, 1.2 1.8.5.0 2.2* 1.4,3.3 Note:

Reference groups are given in parentheses, OR = odds ratio; CI = 95% confidence interval.

'p s ,05, •*p s ,01, ***p Ä ,001, KOHL, KAGOTHO, AND DIXON / Parenting Practices among Depressed Mothers in the ChiU We/fare System 221 parenting, the odds of emotional maltreatment were three times greater than for riiothers not reporting harsh parenting (OR = 3.0,p< .001).Likewise,for mothers reporting neglect, the OR of self-reported emotional maltreatment was 2.3 (p < .001). Black mothers were more likely to self-report emotional maltreatment than were white mothers (OR = 1.5,p< .05).

To assess whether changes in maternal depres- sion between baseline and wave 4 affected changes in parenting behaviors, we analyzed additional multivariate models that included a Depression x Wave term. Results from the harsh parenting and neglect model are not reported because inclusion of the interaction term did not contribute to the models.

The overall fit of the emotional maltreat- ment model was good [Wald x^(19) = 151.7, p < .001], and the Depression x Wave interaction was significant (not shown in table).

Depressed mothers at wave 3 were two times more likely to self-report emotional maltreatment than were nondepressed mothers at baseline (OR = 2.2; confidence interval = 1.1,4.3;/) < .05)—an indication that risk of emo- tional maltreatment varied over time by mother's depression status.

The significance and strength of association of the other variables in the model were similar to the main effects model and are therefore not reported again.

DISCUSSION By using a national probability sample, we were able to demonstrate that maternal depression impedes the achievement of the primary objective of child welfare services: child safety. Maternal depression, which is prevalent among this population, was found to place children at risk for both self-reported ne- glect and emotional maltreatment. On entry into the child welfare system, 21% of mothers met the diagnostic criteria for major depression—well above the national average of 7% in the general population (Kessler et al., 2005).

Furthermore, the percentage of mothers reporting depression remained fairly stable across the study window.

That only 5.7% of mothers reported depression at all three time points means that different women experienced depression at dif- ferent time points after entry into the child welfare system.

Although, at first glance, the percentage of mothers reporting depression at all three time points appears low, this represents a substantial number of mothers.

This rate is a concern given the harmful effects of persistence of maternal depression on chil- dren.The investigators of the Sequenced Treatment Alternatives to Relieve Depression trial found that, although children improved when their mothers' depression subsided after a medication intervention, symptoms worsened when their mothers' depression continued (Weissman et al., 2006).

Harsh Parenting We hypothesized that, on average, depressed mothers would be more likely to demonstrate harsh parenting over a 36-month period than would nondepressed mothers.This hypothesis was not supported; among the child welfare population, depressed and nonde- pressed mothers had similar rates of self-reported harsh parenting.This unanticipated finding is con- trary to the published literature.

Among community populations, maternal depression has been found to increase the risk of harsh parenting (Chung et al., 2004; Lovejoy et al., 2000; Lyons-Ruth et al., 2002).

However, this relation was not upheld among this national probability sample of mothers in the child welfare population whose children remained in the home after the index maltreatment investiga- tion.

This finding may be a result of differences in measurement of harsh parenting across studies or of differences between the community population and the child welfare population. Families enter- ing the child welfare system are often faced with a complex web of problems, and it may be the cumu- lative nature of those problems that places children at risk for harsh parenting practices, not maternal depression alone.

Harsh parenting was a fairly rare event, but the percentage of mothers self-reporting harsh parent- ing increased from baseline (9%) to wave 4 (14%); the increase remained statistically significant in the multivariate models.

It is alarming that harsh parent- ing increased over the course of the study window.

This finding highlights the need to effectively as- sess discipline strategies used by mothers receiving voluntary or mandatory services following entry into the child welfare system and, when warranted, provide effective interventions aimed at reducing the use of harsh parenting behaviors.

Consistent with the findings of others, we found an increased risk of harsh parenting toward black children (for example, Deater-Deckard, Dodge, Bates, & Pettit, 1996; Pinderhughes, Dodge, Bates, Pettit, & Zelh, 2000). These results need to be discussed within their cultural context. Culture influences parental beliefs about child development 222 Social Work Research VOLUME 35, NUMBER 4 DECEMBER 2on promotion and appropriate socialization strategies (Caughy & Franzini, 2005; Murry, Smith, & Hill 2001).

Hence, harsh parenting may serve different functions and have different meanings for black and white families. Among black famihes, harsh (physical) parenting appears to have a socialization role, the purpose being to prepare youths for adult competence (Deater-Deckard & Dodge, 1997).

Furthermore, although harsh parenting increases the risk for externalizing behavior problems among white children, this same relation does not hold true for black children (Deater-Deckard & Dodge, 1997).

Parenting interventions aimed at changing parenting behaviors must therefore be culturally relevant.

Neglectful Parenting Hypothesis 2 was supported. On average, depressed mothers were more likely to engage in neglect- ful parenting over a 36-month period than were nondepressed mothers. Bivariate findings revealed some variation in self-reported neglect from baseline (34%) to wave 3 (24%) to wave 4 (33%); however, these differences were not statistically significant when other variables in the multivariate model were controlled for. Surprisingly, we did not find a significant Depression x Wave interaction term in the neglectful parenting model. This indicates that the risk of neglect did not vary by changes in depression over time, which is likely related to the relatively stable percentage of depressed mothers (although different mothers) across time points.

Emotional Maltreatment Hypothesis 3 was also supported. Depressed moth- ers were more likely to demonstrate emotional maltreatment over a 36-month period than were nondepressed mothers, and emotional maltreatment improved more for nondepressed mothers than for depressed mothers.

Overall, rates of self-reported emotional mal- treatment were high across waves. In fact, over half of mothers reported emotional maltreatment at each of the time points.These high rates of ongoing emotional maltreatment after a CPS referral are a concern, given the long-term adverse consequences of experiencing this type of maltreatment in child- hood. Emotional maltreatment has been found to be an important contributor of psychological adjustment in young adulthood, with higher levels of emotional maltreatment being associated with poorer outcomes (Miller-Perrin, Perrin, & Kociir, 2009).

Emotional maltreatment, which can cause these adverse outcomes, frequently co-occurs with both harsh parenting and neglect. This suggests that physical abuse or neglect should not be the scjle focus of interventions after entry into the child welfare system. Assessments of mothers determined to need voluntary or mandated services following child maltreatment investigations should evaluate a range of parenting behaviors, including emotional maltreatment, physical abuse, and neglect. ' Assessments for maternal depression also appebr to be essential, given the high percentage of mothers in the child welfare system meeting the diagnostic criteria for major depressive episode. Although all mothers determined to need services on entry into this system of care should be provided with inteN ventions to improve positive parenting and parent- child interactions, for some mothers, adaptatioris to'interventions may be necessary to concurrently address the mothers mental health needs. ' !

Limitation and Strengths J An important limitation is that our sample was liinited to mother-child dyads in which the child remained in the home after the index maltreatment investigation.The experiences of children who were removed from the home are likely different froiii those of children who remained in the home after a CPS referral; however, we were unable to analyse these important differences. Self-report measures of major depression and parenting were only obtained at baseline, wave 3, and wave 4 from the permanent caregiver if the child remained in the home. ' Another limitation is the sole reliance of self- report of parenting practices. Mothers may be re- luctant to divulge information about their parenting practices (Knight et al.,2000),so parental self-report of their behaviors could result in lower bound estimates of the actual behavior (Straus, Gelles, & Steinmetz, 1980).

Although NSCAW took steps tp increase the disclosure of sensitive topics through the use of an audio computer-assisted self-interview, harsh, neglectful, and emotionally abusive parenting may be underreported by mothers. ¡ Although it is important to acknowledge these limitations, the strengths outweigh the limitations.

NSCAW provides rich epidemiological data about children and families investigated for child maltreat- ment. Because it is a national probability study, it KOHL, KAGOTHO, AND DIXON / Parenting Practices among Depressed Mothers in the Child Welfare System 223 allows for the generalization of findings to all in- vestigated cases of maltreatment in which children between the ages of 3 and 10 years remained in the home.

IMPLICATIONS Rates of maternal depression were high across the 36-month follow-up period. Yet rates of mental health service receipt among the child welfare population are lower than rates among the general population. For example, 41% of those in the gen- eral population with a mental health need receive treatment (Wang et al., 2005), compared with 14% in the child welfare population (Libby et al, 2006).

To improve long-term outcomes, efforts are needed to improve assessment and identification of mental health needs and access to treatment when deemed necessary.

Although there are a growing number of evi- dence-based parent training programs that aim to promote positive parenting, improve parent-child relationships, and reduce harmful parenting behav- iors, they are rarely provided within the child wel- fare system.

Although the majority of child welfare families have parenting services included as part of their service plan, the services that are typically pro- vided have been harshly criticized for their lack of empirical support and applicability to a child welfare population (Barth et al.,2005;Hurlburt,Barth,Leslie, Landsverk, & McCrae, 2007).Translation efforts of evidence-based programs into this system of care should include research to determine whether they reduce the risk of emotional maltreatment, neglect, harsh parenting, and physical abuse. Furthermore, efforts should be undertaken to examine the sub- populations for which these programs are effective.

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Kohl, PhD, is assistant professor, Centerfor Mental Health Services Research, George Warren Brown School of So- cial Work, Washington University in St. Louis, One Brookings Drive, Campus Box Í196, St. Louis, MO 63130; e-thail:

[email protected] NJeri Kagotho, PhD, is assistant professor.

School of Social Work, Adelphi Uttiversity, Garden City, NY. David Dixon, PhD, is a statistical data analyst, Centerfor Mental Health Services Research, George Warren Brown School of Social Work, Washington University in St. Louis. Support for this project was provided by National Institute of Mental Health Grant R03MH082203.

Patricia Kohl is an investigator with the Centerfor Metttal Health Services Research, George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (5P30 MH068519).

Original manuscript received May 8, 2009 Final revision received April 1, 2010 Accepted April 27, 2010 KOHL, KAGOTHO, AND DIXON / Parenting Practices among Depressed Mothers in the Child Welfare System 225 Copyright of Social Work Research is the property of National Association of Social Workers and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.