Parenting Practices among DepressedMothers in the Child Welf.docx

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 ômen 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.
likely to demonstrate neglectful parenting over
a 36-month period than would nondepressed
mothers.
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
2011216
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)
K O H L , K A G O T H O , A N D D I X O N / 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
N o
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
1 1 7
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 w i t h
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 O R = 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.

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 x7) = 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 . i l
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 O R 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
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
K O H L , K A G O T H O , A N D D I X O N / 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.
For instance, do they work with both depressed and
nondepressed mothers? In addition, our findings
highlight the importance of providing culturally
relevant services to the diverse population referred
to CPS agencies, and efforts are needed to determine
what, if any, cultural adaptations should be made to
address their unique needs. KlVlil
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Patricia L. 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
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