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Depression is a frequent disorder that affects more than 300 million people worldwide (WHO, 2023). As a mental disorder called Major Depressive Disorder, its central aspects are depressed mood and loss of pleasure and/or interest in previously satisfying activities, significantly damaging important spheres of an individual’s life, such as relationships and work (DSM-5-TR, 2022).
Depression can be classified according to levels of severity, considering the intensity and duration of symptoms and functional impairment. Severe depression presents more symptoms than necessary to reach a diagnosis, causing much suffering and seriously impacting an individual’s social and work life. Moderate depression shows enough symptoms to get a diagnosis and causes significant distress, impairing important spheres of life. Mild depression, on the other hand, presents fewer symptoms than necessary to reach a diagnosis. Additionally, the intensity of symptoms is milder and causes little impact on an individual’s functionality. Depression can also be characterized as current when symptoms are present in the last two weeks or chronic when symptoms persist for at least two years (DSM-5-TR, 2022).
Its prevalence is higher among women, with rates almost twice as high as in men, especially between menarche and menopause (DSM-5-TR, 2022). In Brazil, data from the 2019 National Health Survey (PNS) show that the prevalence of self-reported depression in the adult population was 10.2%, while among women, it was 14.7% (Brito; Bello-Corassa; Stopa; Sardine; Dahl & Vianna, 2022).
The higher prevalence in women and the fact that it affects women during childbearing age highlight the relevant role of depression among women who are mothers. Women are the primary caregivers of children in most cultures, and maternal depression is associated with the quality of parenting practices and children’s adaptation (Goodman, Simon, Shamblaw & Kim (2020).
In Brazil, childcare practices can be referred to as “parentalidade,” which is a term adapted from the English word “parenting,” which, albeit not a word that formally exists in Portuguese, has been widely used (Barroso and Machado, 2015). Parentalidade refers to the role of raising children and practices that promote and facilitate child development, learning, and socialization (Wei, Swan, Makover, & Kendall, 2017).
Childhood adaptation is assessed according to developmental indicators based on age. For instance, behavior problems are the most frequent challenge among schoolchildren. They can be defined as externalizing problems, characterized by impulsivity, aggressiveness, and hyperactivity, or internalizing problems, characterized by personality disturbances, withdrawal, low self-esteem, feelings of inferiority, sadness, somatic complaints, and fear (Achenbach et al., 2008).
The positive association between maternal depression and children’s behavior problems is well established, as well as the association between depression and multiple contextual variables (Goodman et al., 2011), among which parenting and the severity of the depressive disorder.
The meta-analysis by Goodman et al. (2020) identified that depression was significantly associated with impairments in several domains of child functioning, more expressively affecting schoolchildren than younger children. Multiple contextual variables were considered in the analysis, including parenting. They found that parenting plays a moderating role in the relationship between maternal depression and child functioning.
Some studies address the impact of the severity and chronicity of depressive symptoms on children’s behavior. Conners-Burrow et al. (2016) found that children of mothers with mild and severe depression were twice as likely to present behavioral problems than children of mothers without depression. However, no significant differences were identified regarding mild and severe symptoms. On the other hand, based on a longitudinal study, Cerniglia (2020) reported that chronic depression of mild severity significantly predicted internalizing and externalizing behavior problems among children.
O’Connor, Langer, and Tompson (2017) performed a longitudinal study among school-aged children to address current and past maternal depressive symptoms, considering different levels of severity. Regardless of the condition’s severity, chronicity predicted more frequent externalizing problems, highlighting an important residual effect of previous depressive symptoms. They found that fewer current symptoms impacted children’s behavior when in the presence of a history of severe depression.
Interactions between the severity and chronicity of maternal depression for children’s cognitive, behavioral, and emotional problems were addressed in the recent meta-analysis by Sutherland et al. (2021), where children who lived with highly severe and chronic maternal depression were found to present more frequent behavior problems than children who lived exclusively with chronic or severe depression.
An analysis of the literature showed evidence of comprehensive and consolidated production addressing the negative impact of maternal depression on parenting and child behavior problems. However, even the most recent meta-analyses (Sutherland et al., 2021; Goodman et al., 2020) did not address the severity of manifestations of maternal depressive disorder as a focus of analysis together with parenting and behavior problems.
This systematic review fits into this gap and aims to analyze recent empirical studies that jointly address the impact of the severity of maternal depression on parenting and the behavior of schoolchildren. The guiding hypothesis is that greater severity and/or chronicity of maternal depression directly impacts behavior problems and parenting practices. The objective is to identify the potential mediating effects between such variables in the studies included in the analysis.
Method
This systematic review was guided by the research question: Does the severity of maternal depression have a different impact on parenting and behavior? This review was registered in the protocol established in the international prospective registry of systematic reviews (PROSPERO, CRD42021246049) and conducted according to all procedures recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses -PRISMA (Liberati, Tetzlaff & Altman, 2009).
Criteria for including studies in this review
A search was conducted in the PubMed, PsycINFO, Web of Science, LILACS, and Scielo electronic library databases to identify empirical articles published from 2016 to August 2022 addressing the severity of maternal depression, mothers’ parenting practices, and schoolchildren’s behavior problems.
Filters were used in the databases for the year of publication. The following combination of keywords was used in Pubmed, PsycINFO, and Web of Science: parenting AND (current OR past OR recurrent depression OR severity OR chronicity) AND (maternal depression* OR depress* mother) AND (behavior problem OR behavioral problems OR internalizing OR externalizing problems). Four keywords were searched in the LILACS and SciELO sources: maternal depress* AND parenting; maternal depress* AND behavior problems; maternal depress* AND chronicity; parenting AND behavior. Additionally, the bibliographic references of the articles, the full texts of which were analyzed, were verified to identify other studies that met the inclusion criteria and addressed the same topic.
The following inclusion criteria were adopted: (1) articles published in the last six years (2016 to August 2022); (2) written in English, Portuguese, or Spanish; (3) addressing a human population; (4) quantitative empirical studies; (5) addressing school-aged children between 6 and 11 (in longitudinal studies, we considered those in which the outcome measure addressed this specific age group at least one point in time); (6) adopting systematic measures of maternal depression, maternal parenting, and child behavior problems.
Exclusion criteria were: (1) reviews, meta-analyses, comments, recommendations, letters, editorials, psychometric, qualitative or mixed studies; (2) objectives or main focus being biological variables, other mental disorders presented by the mothers or children, general medical conditions; exposure to violence and/or abuse; psychosocial or intercultural variables; (3) describing the application and assessment of intervention programs.
Procedures used to collect data from the studies
The studies identified in the databases were extracted using the free software Rayyan® (Ouzzani et al., 2016). Next, two judges consensually selected the studies by reading the titles and abstracts and applying the pre-established inclusion and exclusion criteria. In some cases, the full texts were read to determine whether an article met the criteria.
See the trajectory of studies selection in Figure 1.
Source: PRISMA Statement. http://www.prisma-statement.org/PRISMAStatement/FlowDiagram
Figure 1 Articles selection
Procedures used to analyze the studies’ data
Two judges read the full texts of the studies included, and their data were included in a table, such as objectives, design, participants, instruments, data collection and analysis procedures, primary results related to parenting and behavior, limitations, and recommendations described in the studies.
The methodological quality of the empirical studies was assessed using three tools from the Joanna Brigs Institute (JBI, 2020). The JBI Checklist for Analytical Cross-Sectional Studies, composed of eight items, was used to assess six cross-sectional articles; the JBI Checklist for Cohort Studies, with 11 items, was adopted determine five cohort articles; and the JBI Checklist for Case-Control Studies, consisting of 10 items, was used to assess the case-control study included in this review. Two independent evaluators performed the coding and obtained agreement rates of 95%. Disagreements were discussed, and a consensus score was considered for the articles to be included in the final analysis.
Results
The variables’ characteristics will be compared to those in the studies analyzed; the numbers are presented in the tables. The results are grouped in three tables presenting the studies’ characterization, such as sample, design, informants, and bias indicators (Table 1), the main instruments and procedures used (Table 2), and the studies’ objectives and primary results (Table 3).
Table 1 Studies’ characterization concerning samples, designs, informants, and bias indicators* (n=12)
| Studies | Sample | Design | Informants | JBI Score* |
|---|---|---|---|---|
| 1- Ahun, et al. (2017) | 1218 Cohort |
Longitudinal predictive |
Mothers and teachers | 10/11** |
| 2- Bolsoni-Silva & Loureiro (2020) | 70 Community |
Cross-sectional predictive |
Mothers | 9/10*** |
| 3- Bolsoni-Silva & Loureiro (2019) | 151 pairs -74 community schoolchildren | Cross-sectional Comparison groups |
Mothers | 8/8* |
| 4- Burlaka, et al. (2017) | 251 Community |
Cross-sectional predictive |
Mothers and children | 6/8* |
| 5- Cilino, et al. (2018) | 100 Community |
Cross-sectional Correlational |
Mothers | 8/8* |
| 6- Gajos & Beaver (2017) | 6691 Cohort |
Longitudinal predictive |
Mothers | 9/11** |
| 7- Gruhn, et al. (2016) | 180 Community |
Cross-sectional predictive |
Mothers | 8/8* |
| 8- Kuckertz, Mitchell & Wiggins (2018) | 5581 Cohort |
Longitudinal predictive-mediation |
Mothers | 8/11** |
| 9- Rodrigues-Palucci, Pizeta & Loureiro. (2020) | 60 Community |
Cross-sectional predictivemediation |
Mothers and children | 8/8* |
| 10- Swetlitz, et al. (2021) | 206 Cohort |
Longitudinal predictivemediation |
Mothers and teachers | 10/11** |
| 11- Watson, et al. (2022) | 116 Community |
Cross-sectional predictive |
Mothers and children | 8/8* |
| 12- Wolford, Cooper & McWey (2019) | 325 Community -specificity-Cohort |
Longitudinal predictivemediation |
Mothers and children | 11/11** |
Legend:
*JBI Checklist for Analytical Cross Sectional Studies,
**JBI Checklist for Cohort Studies, and
***JBI Checklist for Case Control Studies.
Table 2 Characterization of the instruments and procedures used to measure maternal depression and qualify its severity, parenting practices, and children’s behaviors (n=12)
| Study | Maternal depression | Parenting practices | Behavior |
|---|---|---|---|
| 1- Ahun, et al. (2017 | CES-D MD: chronic |
Home Observation Measurement of the Environment PP: parental self-efficacy, Parental impact, coercion, affection, super protection, perception of children’s characteristics |
Preschool Behavior Questionnaire PB: internalizing |
| 2- Bolsoni-Silva, et al. (2020) | PHQ-9 MD: current mild (subclinical) and moderate/severe (clinical) |
RE-HSE-P PP: Set of practices grouped into negative or positive |
CBCL QRSH-Parents PB: internalizing, externalizing, and total score |
| 3- Bolsoni-Silva, et al. (2019) | PHQ-9 MD: current moderate/severe |
RE-HSE-P PP: Set of practices grouped into negative or positive |
CBCL PB: total score |
| 4- Burlaka, et al. (2017) |
CES-D MD: current moderate/severe. |
Alabama Parenting Questionnaire PP: involvement, PPP, poor monitoring, inconsistent discipline, physical punishment. |
YRS PB: internalizing. |
| 5- Cilino, et al. (2018) | SCID-IV SDQ MD: chronic |
Semi-structure interview PP: positive patterns of family organization (flexibility, parental involvement, support) |
SDQ PB: total score |
| 6- Gajos, et al. (2017) | CES-D- 12 items MD: current moderate/severe and chronic |
Index developed to measure: poor parenting; parental supervision; display of affection, compliments; quality of interaction | Child Antisocial Behavioral Index PB: total score |
| 7- Gruhn, et al. (2016) |
BDI-II / SCID-IV MD: current moderate/severe and history of previous depression |
Iowa Family Interaction Rating Scales PP: Withdrawn and intrusive parenting. |
CBCL PB: internalizing/ externalizing |
| 8- Kuckertz, et al. (2018) | CIDI-SF MD: diagnosis |
The Parent Child Conflict Tactics Scales PP: psychological aggression, Non-violent discipline, Physical abuse and negligence |
CBCL PB: internalizing |
| 9- Rodrigues-Palucci, et al. (2020) | PHQ-9 MD: current moderate/severe |
EQIF PP: Set of practices grouped into positive and negative practices. |
SDQ PB: total. |
| 10- Swetlitz, et al. (2021) | BSI-18 MD: current moderate/severe |
Observation of free play (Sensitive and aggressive-intrusive parenting) | CBCL PB: internalizing/externalizing |
| 11- Watson, et al. (2022) |
BDI-II MD: current moderate/severe |
Observation of discussions between mother and child (primary, secondary and disengaged coping messages). | CBCL PB: internalizing |
| 12- Wolford et al. (2019) |
CES-D MD: current moderate/severe |
Parent to Child Conflict Tactics Scale PP: Psychological and physical aggression. |
CBCL PB: internalizing/externalizing |
Legend: MD (maternal depression); PB (Problem behavior); PP (parental practices) BDI-II (Beck Depression Inventory-II); BSI-18 (Brief Symptom Inventory-18); CBLC (Child Behavior Checklist); CES-D (Center for Epidemiologic Studies Depression Scale); CIDI-SF (Composite International Diagnostic Interview-Short Form); MD (depressão materna); EQIF (Escala de qualidade nas interações familiares); PB (Problem behavior); EPB (Externalizing problem behaviors); IPB (Internalizing problem behavior); PHQ-9 (Patient Health Questionnaire-9); PP (parental practices); NPP (Negative parenting practices); PPP (Positive parenting practices); QRSH-Pais (Questionário de Respostas Socialmente Habilidosas para Pais); RE-HSE-P (Roteiro de Entrevista de Habilidades Sociais Educativas Parentais); SCID-IV (Structured Clinical Interview for DSM-IV); SDQ (Strengths and Difficulties Questionnaire); TRF (Child Behavior Checklist Teacher’s Report Form); YRF (Internalizing Problems Scale of the Youth Self-Report); YRS (Internalizing Problems Scale of the Youth Self-Report).
Table 3 Objectives and primary results concerning the associations between maternal depression, parenting, and schoolchildren behavior.
| Study/Objective | Primary results |
|---|---|
| 1- Ahun, et al. (2017)
To verify associations between the history of MD during the children’s early childhood and the developmental trajectory of IPB in children before and after controlling for family factors associated with MD. |
Chronic MD predicted IPB MD during early childhood associated with IPB: Group: high rates of IPB (evaluators: mothers) and higher levels (evaluators: teachers) Group: Low levels of IPB (evaluators: mothers) and moderate levels (evaluators: teachers) Group: High levels of IPB (evaluators: mothers and evaluators: teachers) Low parental self-efficacy associated with groups with high levels of IPB There are no associations between MD and IPB with the remaining practices |
| 2- Bolsoni-Silva, et al. (2020) To identify the predictive effect of positive and negative parental practices and MD on PB of children from bi-parental families. |
Current moderate/ severe MD predicted EPB MD (subclinical indicators) associated with more frequent PB (total score) Associations of total sample: NPP associated with more frequent PB (general score) No significant associations between current moderate/severe MD and PPP and NPP with IPB |
| 3- Bolsoni-Silva, et al. (2019) To compare the parental practices of mothers of preschoolers and schoolchildren considering MD and children’s PB |
Current moderate/severe MD associated with less frequent PPP for schoolchildren, not identified for preschoolers Less frequent PPP associated with more frequent PB among schoolchildren |
| 4- Burlaka, et al. (2017)
To examine the association between IPB with variables from the child’s environment, i.e., parenting and MD |
Current moderate/severe MD and poor monitoring predictors of IPB Current moderate/severe MD associated with poor monitoring, inconsistent discipline, and physical punishment Physical punishment associated with more frequent IPB PPP associated with less frequent IPB |
| 5- Cilino, et al. (2018)
To compare associations between family organization patterns and the PB of children of mothers with recurrent depression and mothers without psychiatric disorders |
Chronic MD is associated with less frequent positive family organization patterns and more frequent PB Positive family organization patterns associated with less frequent PB |
| 6- Gajos, et al. (2017) To examine differences between depressive and non-depressive mothers regarding the children’s antisocial PB, considering various covariates, including parenting. |
Moderate/severe MD measured at 6 and 11 years old predicted PB at the age of 11 Current moderate/severe MD at 9 years old did not predict PB at the age of 11 Chronic MD (measured at 6, 9 and 11 years old) did not predict PB at 11 years old. There are no significant associations between MD and PB with parental practices |
| 7- Gruhn, et al. (2016)
To examine the specificity of the relationship between intrusive and withdrawn parenting with IPB and EPB among boys and girls in the context of parental depression history. |
History/current MD associated with intrusive parenting (boys), withdrawn parenting (both sexes), IPB and EPB (both sexes). History/current MD predicted IPB (girls) and withdrawn parenting (girls). Intrusive parenting predicted IPB (both sexes) Withdrawal parenting predicted more frequent EPB (girls) |
| 8- Kuckertz, et al. (2018)
To verify the predictive effects of MD on children’s IPB and investigate potential mediators, such as psychological aggression, non-violent discipline, and physical abuse. |
MD diagnosed at the age of 3 predicted IPB at the age of 9, mediated by psychological aggression at the age of 5 Non-violent discipline at the age of 5 predicted more frequent IPB at the age of 9. No significant associations between MD and PB with physical aggression. |
| 9- Rodrigues-Palucci, et al. (2020)
To identify associations between MD, children’s PB and perceptions of the quality of family interactions, focusing on predicting and mediating variables. |
PPP mediated the predictive relationship between MD and PB. Current moderate/severe MD associated with less frequent PPP (Evaluators: mothers Evaluators: children), more frequent negative practices (Evaluators: mothers Evaluators: children) and more frequent PB. NPP associated with more frequent PB (Evaluators: mothers) PPP associated with less frequent PB (Evaluators: children) |
| 10- Swetlitz, et al. (2021)
To verify the predictive effects of MD at six months of age with IPB and EPB at 7 years old reported by teachers. To investigate the moderating effect of maternal involvement with conversations with the child about experiences shared by both and sensitive and intrusive parenting at the age of 5. |
More maternal involvement when talking to the child about experiences shared by both mediated the predictive relationship between current moderate/severe MD at 6 months of age and EPB at 7 years old Less frequent maternal involvement in conversations with the children about experiences shared by both at the age of 5, predicted EPB (Evaluators: teachers) at the age of 7. Fewer symptoms of current moderate/severe MD at 6 months old predicted more frequent maternal involvement in conversations with the child about shared experiences at the age of 5 |
| 11- Watson, et al. (2022)
To verify MD as a potential moderator of the association between maternal coping messages and children’s adjustment |
Current/moderate MD predictive of IPB (Evaluators: mothers and Evaluators: children). Fewer coping messages secondary adaptation to a stressor- (Evaluators: mothers) were predictors of IPB (Evaluators: children) Children experienced less stress among peers (Evaluators: children) and more disengaged messages - escape from a stressor - fewer IPB predictors More frequent indicators of current depression and fewer primary coping messages - encouragement to cope with a stressor - predicted more IPB |
| 12- Wolford et al. (2019)
To verify the mediating effects of rude parenting in the relationship of MD and the children’s PB to identify factors associated with decreased risk transmission. |
Current moderate/severe MD predicted IPB and EPB -Relationship partially mediated by physical and psychological aggression Current moderate/severe MD (6 and 12 years old) associated with more frequent psychological aggression, more physical aggression (6 years old), more IPB and more EPB (6 and 12 years old) More physical and psychological aggression (6 years old) associated with more PPI and PPE (6 and 12 years old) |
Legend: MD (maternal depression); PB (problem behavior); EPB (externalizing problem behavior); IPB (internalizing problem behavior); PP (parental practices); NPP (Negative parental practices); PPP (positive parental practices).
Table 1 presents the studies’ general characteristics concerning design, samples, and methodological quality.
The number of pairs in the study samples ranged from 50 to 17,067, with six studies addressing 1-200 pairs (2;3;5;7;9;11). Eleven studies addressed community samples; one addressed a community sample of abused mothers (12).
Regarding methodological aspects, seven studies adopted cross-sectional designs (2;3;4;5;7;9;11), and five were longitudinal prospective studies (1;6;8;10;12). Most were cross-sectional studies (7 studies) investigating predictive relationships (10 studies), one exclusively compared groups (3), and one was exclusively correlational (5). Regarding the informants, only mothers were the informants in six studies (2;3;5;6;7;8); the mothers assessed the three variables. Half of the studies addressed multiple informants, mothers, and children, or mothers and teachers, as evaluators.
As for the studies’ methodological quality, it was assessed using the tools of the Joanna Brigs Institute (JBI). The six cross-sectional studies (3;4;5;7;9;11) showed high methodological quality, as only one of them (4) did not obtain the score maximum in the checklist; it did not include the items related to a good definition of the inclusion criteria and did not use a validated instrument to measure the outcome variable. The five cohort studies (1; 8; 6; 10; 12) were also considered high quality, with one obtaining the maximum score. The item less frequently included concerned the analysis of losses from the initial sample. The only article with a case-control design (2) was also classified as high quality; only one checklist item was missing.
Table 2 presents the studies’ main objectives and the instruments used to investigate maternal depression, parenting practices, and behavior problems.
Nine studies exclusively used screening instruments to measure maternal depression. The primary ones included the CES-D, four studies (1;4;6;12), and the PHQ-9 was adopted by three studies (2;3;9). Only two studies used depression diagnostic tools (5-SCID; 8-CIDI-SF) and one article used both a diagnostic and a screening tool (7).
Eight studies (2;3;4;5;6;8;9;12) used self-report instruments to measure parenting practices. Four studies (1;7;10;11) adopted observational tasks, recording the sessions, which were later transcribed and coded by independent evaluators.
Behavior problems were measured using self-report instruments, mainly the CBCL, in seven studies (2;3;7;5;8;9; 10;11), and the SDQ, in two studies (5;9). Four instruments were used only once. All studies used validated instruments with good psychometric properties for the population of interest. As for the outcomes, only one study did not use a validated instrument for the population of interest (4).
Table 3 presents the studies’ objectives, focusing on the aspects addressed in this review, besides the primary results.
The specific aspects of the studies’ objectives concerning the question addressed in this review were inserted in the table. The other associated variables are presented after the table description.
Of the 12 studies included, six (3;4;9;10;11;12) addressed current maternal depression of moderate/severe severity. Two (10;12) of these six studies investigated internalizing and externalizing behavior problems, and depression was found to predict externalizing problems in both studies and internalizing problems in one (12). Two studies exclusively addressed internalizing behavior problems (4;11), and depression predicted more frequent internalizing problems. Two studies (3;9) verified a total score of behavioral issues, and depression predicted more frequent behavior problems in one study (9); the other study (3) did not identify a significant association between these variables.
Five of the six studies that addressed current moderate/severe depression identified positive and negative parenting practices and significant associations were found between depression and less frequent positive practices in four studies (3;9;10;11); and between depression and less frequent positive and more frequent negative practices in one study (4). Only one study addressing current moderate/severe depression exclusively investigated negative practices; an association was found between depression and more frequent negative parenting practices (12).
Three studies investigated chronic depression (1;5;6). Two studies investigated chronic depression and a general index of problem behaviors; depression was associated with more frequent behavioral problems in one study (5); no significant association was found in the other (6). Chronic depression predicted more frequent internalizing behavior problems (1) in a study investigating only internalizing problems. A study exclusively addressing parenting practices found that chronic depression was associated with less frequent positive parenting practices (5). Two studies investigated positive and negative practices (1;6), and no significant associations were found with chronic depression.
A single study investigated current mild and current moderate/severe maternal depression (2) and addressed positive and negative practices and the total score of behavioral problems. Mild depression was associated with more frequent problem behaviors, and current moderate/severe depression was found to predict externalizing but not internalizing problems.
One study investigated current moderate/severe maternal depression (7), with its entire sample diagnosed with a history of depression, negative parenting practices, and internalizing and externalizing problems. Depression was reported to be associated with intrusive parenting (boys), withdrawn parenting (both sexes), and internalizing and externalizing problems for both sexes. Additionally, depression predicted more frequent internalizing problems and withdrawn parenting only for girls.
Only one study exclusively addressed diagnosed maternal depression (8), in which positive and negative practices and internalizing behavior problems were investigated. Negative practices mediated the predictive relationship between diagnosed depression and more frequent internalizing problems.
The studies also investigated other variables, and those presenting significant associations with the variables addressed in this review, i.e., depression, parenting, and behavior, were presented here. The children’s sex was addressed by four studies (4;7;10;11); being a girl was found to predict internalizing problems in two studies (4;11) while being a boy predicted externalizing problems in one study (10).
Children’s social skills were addressed by two studies (2;3). In one study (2), positive parenting practices were associated with more frequent social skills; in the other (3), negative parenting practices were associated with less frequent social skills. One study (2) investigated marital relationships, and mild current maternal depression was associated with less frequent positive marital relationships: moderate/severe current depression was associated with more frequent negative marital relationships, and positive parenting practices were associated with more frequent positive marital relationships. One article (4) addressed the mothers’ alcohol consumption, and it was associated with fewer positive parenting practices and more frequent negative parenting practices.
Discussion
This review’s guiding question was: Does the severity of maternal depression have a different impact on parenting and schoolchildren’s behavior? Hence, recent empirical studies jointly addressing the impact of maternal depression severity on parenting and schoolchildren’s behavior were analyzed. The guiding hypothesis was that the greater the severity and/or chronicity of maternal depression, the greater the impact on the problem behaviors and parenting practices.
The analysis intended to answer this question reviewed some limitations when comparing the studies. The reason is that most studies did not compare the intensity of depressive symptoms or between chronic and exclusively current depression. The studies generally report data concerning one specific type of depression compared to individuals without mental disorders. Thus, the findings of specific articles that considered the severity of depression are organized in blocks to facilitate the discussion of results.
Regarding current moderate/severe depression, five of the six studies exclusively investigating this clinical condition found that depression was associated with more frequent varied behavioral problems (total score, internalizing, and externalizing). As for parenting practices, five studies addressed negative and positive practices, all of which found that current moderate/severe depression was associated with fewer positive practices, and only one identified an association with negative practices. A study exclusively addressing negative practices showed an association between current moderate/severe depression and more frequent negative practices. These results point to data from the meta-analysis by Goodman et al., 2020, in which parenting was found to moderate the relationship between maternal depression and difficulties in child functioning.
The second block of analysis concerns chronic depression, which was associated with more frequent and varied behavior problems in two out of three studies that addressed the severity of this condition, corroborating the results of O’Connor, Langer, and Tompson (2017) regarding chronic depression. As for parenting practices, two studies addressed positive and negative practices and did not find significant associations with chronic depression. One study that exclusively investigated positive practices identified that the chronicity of the depressive disorder was associated with fewer positive parenting practices.
Regarding the severity of current mild and moderate/severe depression, only one study (2) addressed this aspect, showing an association between more frequent behavioral problems with mild depression, a relationship also found by Conners-Burrow et al. (2016). These findings show a gap in the literature regarding the impact of subclinical depressive symptoms on parenting and schoolchildren behavior, mainly because those affected by mild depression failed to seek health care to treat the condition.
Only one study addressed the previous history of depression associated with current moderate/severe severity and found associations between depression and more frequent negative parenting practices and more frequent internalizing and externalizing problems. The prediction analysis revealed that depression predicted more frequent internalizing problems and more frequent negative practices only for girls, highlighting the relevance of contextual variables.
The diagnosis of depression was addressed in a study that identified that negative practices mediated the predictive relationship between depression and more frequent internalizing problems. Notably, the diagnosis as a criterion for being included in the sample was a positive differential of three studies, compared to those that predominantly used exclusively screening instruments, contributing to control bias.
The studies analyzed in this review addressed parenting practices and different behavior problems, measured by different instruments and tools, which restrict comparisons. Some studies exclusively addressed positive or negative practices, while others addressed both. Studies addressed behavior problems without specifying which, while others evaluated internalizing or externalizing problems, and others addressed both. Additionally, even though some studies addressed the same variables of interest, e.g., positive practices, some investigated sets of positive practices while others addressed a specific positive parenting practice.
The other variables associated with the variables of interest addressed here (i.e., depression, parenting, behavior) were varied and appeared in a few studies, which hindered any assumptions, except for sex, a variable addressed by one-third of the studies. Nonetheless, these variables showed significant association with maternal depression and/or parenting practices, suggesting that they may play a role in the interaction between depression, parenting, and child behavior, reinforcing the existence of multiple aspects in families living with maternal depression.
As for the characteristics of the samples, all studies adopted community samples, and none of them mentioned whether the mothers were receiving any treatment for depression, nor did they specify the modality. Due to the severity of depression identified in some studies, it is likely that the mothers had undergone or were undergoing treatment; hence, it is relevant to characterize this condition.
Most studies used screening and self-report instruments to measure maternal depression. The combination of diagnostic and screening measures would provide a more accurate assessment of the history of depression.
Finally, although this review did not include the grey literature, it brings relevant information regarding the impact of maternal depression and its severity on parenting and schoolchildren’s behavior within the timeframe adopted. The studies’ good methodological quality confirms that the combined impact of these variables is relevant as it shows that the severity of depression influences parenting practices and behavior, mainly because the studies conducting mediation analyses showed this interrelationship, focusing on the multiple conditions involved. The clinical relevance of the severity of depression, highly valued given its impact on functionality, is seldom addressed together with parenting and children’s behavior, even in recent meta-analyses, to indicate adaptation.
New studies analyzing the impact of different levels of severity of maternal depression as a sample selection variable are important to allow comparisons between parenting practices and behavior variables assessed by the same instruments and in similar temporal contexts. Another point to be noted concerns the specification of conditions in the context of the families’ lives, which some studies have sparsely suggested. The cross-sectional design predominated in the studies addressed here, and longitudinal studies did not align regarding the role of the severity of depression and parenting practices in predicting behavioral outcomes, highlighting the importance of further research, especially longitudinal studies, to allow monitoring the mutual influence of these variables over time.
Considering the analysis of the studies included in this review and the limitations previously noted, the conclusion is that depression at different levels of severity was associated with fewer positive practices and problem behavior among students. Additionally, current depression, considering its chronic nature, better explain the negative effects of depression on parenting practices and children’s behavior. Regarding this study’s applicability, considering that most of the studies addressed community samples, this review’s results can guide health professionals caring for children with problem behaviors, considering the mothers’ mental health conditions. As for research in the field, new studies are needed to address the joint impact of different levels of severity of maternal depression on parenting and behavior.
