The Effects of Postpartum Depressi on

on Child Development:
A Meta-anal ysi s
Cheryl Tatano Beck
The adverse, shor t - t er m ef f ect s of pos t par t um depr essi on on mat ernal -
infant i nt eract i on have been r epeat edl y document ed. Are t here l ong-t erm
sequel ae for children whose mot her s had exper i enced pos t par t um depres-
si on? The pur pose of this met a- anal ysi s was t o det ermi ne t he magni t ude of
t he ef f ect of pos t par t um depr essi on on t he cognitive and emot i onal
devel opment of children older t han t he age of 1 year. Nine st udi es which
met t he sampl e criteria were included in this met a-anal ysi s. Res ul t s
i ndi cat ed t hat pos t par t um depr essi on had a small but significant effect on
chi l dren' s cognitive and emot i onal devel opment . The r indicator for effect
s i ze ranged f r om. 18 t o . 22 wher eas t he d indicator ranged from . 36 t o . 45.
Implications for fut ure r esear ch are addr essed.
Copyri ght 1998 by W..B. Saunders Company
A META-ANALYSIS OF 9 studies revealed
that postpartum depression has a moderate to
large adverse effect on maternal-infant interaction
during the first year after delivery (Beck, 1995).
Effects using the d index ranged from .68 to .78 for
maternal interactive behavior, .75 to .83 for infant
interactive behavior, and 1.07 to 1.15 for dyadic
interactive behavior. The short-term effects of post-
partum depression on maternal-infant interaction
have been repeatedly documented. Are there long-
term sequelae for children of mothers who have
experienced postpartum depression?
Research is revealing that children older than 1
year of age whose mothers had been postpartatly
depressed, displayed problems including insecure
attachment, antisocial behavior, and cognitive defi-
cits. Uddenberg and Englesson (1978) reported that
4-year-old children of mothers who had suffered
from postpartum depression experienced more fre-
quent temper tantrums and were described as more
uncontrollable than children whose mothers had
From the School of Nursing, University of Connecticut,
Storrs, CT.
Address reprint requests to Cheryl Tatano Beck, DNSc,
CNM, FAAN, School of Nursing, University of Connecti-
cut, 231 Glenbrook Road, U-26, Storrs, CT06269-2026.
Copyright 1998 by W.B. Saunders Company
0883-9417/98/1201-000353.00/0
not experienced postpartum depression. Margolies
(1989) reported that children of postpartum de-
pressed mothers were more neurotic and exhibited
more antisocial behavior than other children. Rot-
nem (1989) supported her hypothesis that children,
whose mothers had been significantly depressed
during the early months of their lives, were more
likely to exhibit behavioral difficulties between the
ages of 4 to 8 when compared with children whose
mothers had not been depressed. Nineteen-month-
old toddlers whose mothers had postpartum depres-
sion showed significantly less affective sharing and
less initial sociability with strangers and were more
likely to display marked distress during a bri ef
separation from their mothers than toddlers of
nondepressed mothers (Stein et al., 1991). Eighteen-
month-old toddlers whose mothers had been de-
pressed in the postpartum period were significantly
more likely to be insecurely attached to their
mothers than toddlers of nonpostpartum depressed
mothers (Murray, 1992).
To summarize the research to date and determine
whether there are cumulative adverse effects of
living with and being socialized by postpartum
depressed mothers during the first year of life on
children' s development, a meta-analysis was con-
ducted. The following two research questions were
investigated:
12 Archi ves of Psychiatric Nursing, Vol. XII, No. 1 (February), 1998: pp 12-20
POSTPARTUM DEPRESSION AND CHILD DEVELOPMENT t3
1. What is the magnitude of the effect of postpar-
tum depression on the cognitive and emo-
tional development of children over the age
of 1 year?
2. To what extent does the effect size vary as a
function of the following variables: publica-
tion date, publication source, sample size,
research design, postpartum depression mea-
surement, outcome measurement, and quality
index?
DATA COLLECTION
Cooper' s (1982) five approaches were used to
retrieve the individual studies included in this
meta-analysis: ancestry approach, descendency ap-
proach, informal networking, abstracting services,
and on-line computer search. Citations from refer-
ence lists of previously located articles were used
to track additional references. Dissertation ab-
stracts, psychological abstracts, and sociological
abstracts were searched. Informal networking at
research conferences was used to identify pub-
lished and nonpublished research on the review
topic. The Social Science Citation Indexes, one
example of the descendency approach, was used to
retrieve studies that cited articles central to this
meta-analytic topic. On-line computer searches
yielded the most studies that were included in this
meta-analysis. Examples of some of the on-line
databases searched from 1974 to 1995 were PsycLit,
Cumulative Index to Nursing and Allied Health
Literature, Medline, and ERIC. Key words such as
postpartum depression, maternal mood, postnatal
depression, and child development were used in
these searches.
Criteria for inclusion of studies in this meta-
analysis included: (1) the study involved examin-
ing the effect of postpartum depression on the
emotional and/or cognitive development of chil-
dren over 1 year of age, (2) adequate statistics were
included in the findings of the research to permit
meta-analytic calculations, (3) i f the study used an
F or X a statistic to analyze the effect of postpartum
depression on children' s development, a df = 1 was
necessary. Mullen (1989) explained that an F test
with more than 1 degree of freedom in the numera-
tor can represent an unfocused, general comparison
between several means. Similarly, a chi squared
test with more than 1 degree of freedom can
represent varying patterns of results for different
analyses.
A potential sample of 13 studies was retrieved.
Nine of these studies met all the sample criteria.
The reason for excluding three studies (Ghodsian,
Zajecek, & Wolkind, 1984; Whiffen, 1990; Wrate,
Rooney, Thomas, & Cox, 1985) was that inad-
equate statistics were reported in the articles prevent-
ing meta-analysis calculations. The fourth study
(Carro, Grant, Gotlib, & Compas, 1993) was ex-
cluded because more than 1 degree of freedom was
used in the F statistic.
The studies by Cogill, Caplan, Alexandra, Rob-
son, & Kumar (1986) and Caplan et al. (1989) used
the same sample of mothers and children but
different data collection instruments. The focus of
these two studies differed. Cogill et al. (1986)
investigated the impact of postpartum depression
on 4-year-olds' cognitive development using the
McCarthy Scales (McCarthy, 1972). Caplan and
colleagues examined the emotional development of
these children which was assessed by the Behav-
iour Screening Questionnaire (Richman & Gra-
ham, 1971).
CODING PROCEDURE
Substantive, methodological, and miscellaneous
variables were extracted from each of the nine
studies that met the sample criteria and were coded
in a meta-analysis codebook. The substantive char-
acteristics included ages of mother and child,
parity, marital status, ethnicity, educational level,
socioeconomic status, and employment status. The
following methodological variables were extracted
and coded: sample size, sampling, research design,
statistics, type of postpartum depression measure-
ment and instruments, data collection times, type of
outcome measurement, and instruments. Some mis-
cellaneous variables also were coded: year and type
of publication (journal, book, dissertation); source
derivation (computer search, issue search); number
of authors, funding, and country. For each study
included in the meta-analysis, all three types of
variables were coded independently by both the
researcher and her research assistant. The initial
interrater agreement achieved in coding these char-
acteristics was 89% for the methodological vari-
ables, 95% for substantive variables, and 100% for
miscellaneous variables. All disagreements were
discussed between the two coders and a consensus
was reached.
The quality of each study included in the meta-
analysis was assessed by a scoring system con-
14 CHERYLTATANO BECK
s t r uc t e d b y t he r e s e a r c h e r f o r e v a l u a t i n g p o s t p a r -
t u m d e p r e s s i o n ( Be c k, 1995) . P r e v i o u s l y r e p o r t e d
r e l i a bi l i t y o f t hi s qua l i t y i n d e x i n s t r u me n t ha s
r a n g e d f r o m 87% t o 89% ( Be c k, 1995, 1996) . I n
t hi s c u r r e n t me t a - a n a l y s i s , t hi s qua l i t y i n d e x i ns t r u-
me n t wa s r e v i s e d t o i nc l ude t wo a ddi t i ona l cr i t er i a.
T h e cr i t er i on, " i n s t r u me n t ( s ) ' r e l i a bi l i t y a nd va l i d-
i t y, " f r o m t he or i gi na l qua l i t y i nde x, wa s d i v i d e d
i nt o t wo cr i t er i a: p o s t p a r t u m d e p r e s s i o n i ns t r u-
me n t ( s ) ' r e l i a bi l i t y a nd v a l i d i t y a nd o u t c o me i ns t r u-
me n t ( s ) ' r e l i a bi l i t y a nd val i di t y. Th e s e c o n d n e w
c r i t e r i on f o c u s e d on wh e t h e r o r not t he w o ma n ' s
c u r r e n t l e v e l o f d e p r e s s i o n wa s c o n t r o l l e d f o r i n t he
s t at i s t i cal a na l ys i s . T h e s e 12 c r i t e r i a i ncl uded: f i r st
a ut hor e xpe r t i s e , f undi ng, s a mp l e si ze, s a mp l i n g ,
p o s t p a r t u m d e p r e s s i o n i n s t r u me n t ( s ) ' r e l i a bi l i t y a nd
val i di t y, o u t c o me i n s t r u me n t ( s ) ' r e l i a bi l i t y a nd v a -
l i di t y, p o s t p a r t u m d e p r e s s i o n me a s u r e me n t s , out -
c o me me a s u r e me n t s , da t a c ol l e c t i on, r e s e a r c h de-
si gn, da t a a na l ys i s , a nd c ont r ol o f c ur r e nt de pr e s s i on
l evel . T h e h i g h e s t p o s s i b l e s c o r e wa s 33 poi nt s .
T h e c r i t e r i on o f f i r st a ut hor e x p e r t i s e wa s s c o r e d
as a 1 i f a ma s t e r ' s d e g r e e wa s t he h i g h e s t d e g r e e
hel d, a 2 i f a P h D or MD wa s t he h i g h e s t d e g r e e
hel d, a nd a 3 i f not o n l y a P h D or MD b u t a l s o t he
f i r st a u t h o r h a d p u b l i s h e d mu l t i p l e s t udi es . I f t he
s t udy h a d r e c e i v e d f undi ng, a s c or e o f 1 wa s g i v e n
b u t i f t he r e s e a r c h h a d not r e c e i v e d f undi ng, a z e r o
wa s a s s i gne d. S a mp l i n g wa s s c o r e d as f o l l o ws : 1 =
c o n v e n i e n c e , 2 = ma t c h e d , a nd 3 = r a n d o m. T h e
s c or i ng f o r t he c r i t e r i on o f s a mp l e s i ze r a n g e d f r o m
1 = 1 t o 50 mo t h e r - c h i l d pai r s , 2 = 51 t o 100
mo t h e r - c h i l d pai r s , t o 3 = mo r e t ha n 100 mo t h e r -
c hi l d pai r s . I n r e g a r d t o b o t h p o s t p a r t u m d e p r e s s i o n
i n s t r u me n t ( s ) ' r e l i a bi l i t y a nd v a l i d i t y a nd o u t c o me
i n s t r u me n t ( s ) ' r e l i a bi l i t y a nd val i di t y, t h e s e c r i t e r i a
we r e s c o r e d as 0 = no me n t i o n o f r e l i a bi l i t y a nd
val i di t y, 1 = me n t i o n o f o n l y p r e v i o u s r e l i a bi l i t y
a n d / o r val i di t y, 2 = a d d r e s s e d r e l i a bi l i t y or v a l i d i t y
i n c u r r e n t st udy, a nd 3 = a d d r e s s e d r e l i a bi l i t y a nd
v a l i d i t y i n c u r r e n t st udy. P o s t p a r t u m d e p r e s s i o n
me a s u r e me n t wa s s c o r e d as 1 i f s e l f - r e p o r t or
u n s t r u c t u r e d i n t e r v i e w wa s us e d, 2 i f t he di a gnos i s
wa s b a s e d on t he Re s e a r c h Di a g n o s t i c Cr i t e r i a
( RDC) , a nd 3 i f t r i a ngul a t i on o f b o t h s e l f - r e p o r t
a nd R D C oc c ur r e d. Ou t c o me me a s u r e me n t s c or i ng
c o n s i s t e d o f 1 = s e l f - r e p o r t i ns t r ume nt s , 2 =
i n t e r v i e w a n d / o r o b s e r v a t i o n , a nd 3 -= t r i a ngul a t i on
o f s e l f - r e p o r t i nt e r vi e w, a nd/ or o b s e r v a t i o n . Re -
s e a r c h d e s i g n wa s s c o r e d as f ol l ows : 1 = c r os s
s ect i onal , a nd 2 = l ongi t udi na l . T h e s c or i ng f o r
da t a c o l l e c t i o n r a n g e d f r o m 1 = unt r a i ne d da t a
c ol l e c t or s / s e l f - r e por t , 2 - - t r a i n e d da t a c ol l e c t or s ,
a nd 3 = t r a i ne d da t a c ol l e c t or s pl us b l i n d t o
mo t h e r ' s di a gnos i s . F o r t he c r i t e r i on o f da t a a n a l y -
sis a s c or e o f 1 wa s a s s i g n e d i f o n l y d e s c r i p t i v e
s t at i s t i cs we r e us e d, a s c o r e o f 2 i f n o n p a r a me t r i c
s t at i s t i cs we r e us ed, a s c o r e o f 3 i f b i v a r i a t e
s t at i s t i cs we r e us ed, a nd a s c or e o f 4 wh e n mu l t i v a r -
i at e s t at i s t i cs we r e us ed. F o r t he f i nal cr i t er i on, a
s c or e o f 0 wa s a s s i g n e d i f mo t h e r ' s c u r r e n t l e v e l o f
d e p r e s s i o n wa s not c o n t r o l l e d f o r a nd a s c o r e o f 1 i f
i t wa s c o n t r o l l e d f o r i n t he s t at i s t i cal a na l ys i s .
I n t hi s me t a - a n a l y s i s on p o s t p a r t u m d e p r e s s i o n
a nd c hi l d d e v e l o p me n t t he r a n g e o f qua l i t y s c or e s
a c h i e v e d b y t he ni ne s t udi e s wa s 18 t o 25 wi t h a
me a n o f 22. 5. T h e r e s e a r c h e r a nd r e s e a r c h a s s i s t a nt
e a c h i n d e p e n d e n t l y e v a l u a t e d t he qua l i t y o f e a c h
s t udy i n c l u d e d i n t he me t a - a n a l y s i s . An i nt e r r a t e r
a g r e e me n t o f 87% wa s i ni t i al l y a c hi e ve d. Af t e r
di s c us s i ng t he i r r a t i ona l e f o r c odi ng, c o n s e n s u s
wa s r e a c h e d on t he qua l i t y s c or e f o r e a c h st udy.
MEASURES
Mu l t i p l e o p e r a t i o n i s m wa s u s e d i n t hi s me t a -
a na l ys i s . I n mu l t i p l e o p e r a t i o n i s m, v a r i o u s me a -
s ur es t ha t ar e s u p p o s e d t o me a s u r e t he s a me
t he or e t i c a l c o n s t r u c t b u t h a v e di f f e r e nt pa t t e r ns o f
e r r or v a r i a n c e ar e i n c l u d e d i n a me t a - a n a l y s i s
( We bb, Ca mp b e l l , Sc hwa r t z , Sechr i s t , & Gr o v e ,
1981) . Co o p e r ( 1984) ha s s t r e s s e d t ha t a me t a -
a na l ys i s i s s t r e n g t h e n e d wh e n mu l t i p l e o p e r a t i o n -
i s m i s u s e d b e c a u s e t he f i ndi ngs o f t he me t a -
a na l yt i c r e v i e w wi l l not b e c o n t a mi n a t e d b y one
s peci f i c pa t t e r n o f e r r or va r i a nc e .
Postpartum Depression
A v a r i e t y o f i n s t r u me n t s we r e u s e d t o me a s u r e
p o s t p a r t u m de pr e s s i on. Th e Be c k De p r e s s i o n I n v e n -
t o r y ( BDI ) ( Be c k, War d, Me n d e l s o n , Mo c k , &
Er b a u g h , 1961) wa s u s e d i n t wo st udi es. I n one
s t udy t ha t us e d t he BDI , t hi s t ool wa s t he s ol e
me a s u r e me n t o f p o s t p a r t u m d e p r e s s i o n a nd i n t he
ot he r s t udy i t wa s us e d i n c o mb i n a t i o n wi t h t he
Sc h e d u l e o f Af f e c t i v e Di s o r d e r s a nd Sc h i z o p h r e n i a
( SADS) ( Endi c ot t & Spi t zer , 1978). T h e Ge n e r a l
He a l t h Qu e s t i o n n a i r e ( GHQ) ( Go l d b e r g , 1972) wa s
u s e d i n t h r e e s t udi es . I n e a c h o f t he s e t hr e e s t udi es
a s e c o n d me a s u r e o f p o s t p a r t u m d e p r e s s i o n wa s
u s e d a l o n g wi t h t he GHQ. T h e o n l y o t h e r me a s u r e
o f p o s t p a r t u m d e p r e s s i o n t ha t wa s u s e d mo r e t ha n
o n c e i n t hi s me t a - a n a l y s i s wa s t he S ADS ( Endi c ot t
POSTPARTUM DEPRESSION AND CHILD DEVELOPMENT 15
& Spitzer). Examples of some of the instruments
used just once in this meta-analysis were the
Edinburgh Postnatal Depression Scale (Cox,
Holden, & Sagovsky, 1987), the Montgomery and
Asberg Depression Rating Scale (Montgomery &
Asberg, 1979), and Clinical Interview Schedule
(Goldberg, Cooper, Eastwood, Kedward, & Shep-
herd, 1970).
Child Development
The Child Behavior Checklist (CBCL) (Achen-
bach & Edelbrock, 1983) was used in three studies
whereas the remaining instruments were each used
only one time in the studies included in this
meta-analysis. Examples of these tools were: Rey-
nell Scales of Language Development (Huntley,
1985), the McCarthy Scales (McCarthy, 1972),
Behavior Screening Questionnaire (Richman &
Graham, 1971), and the Junior Eysenck Personality
Questionnaire (Eysenck & Eysenck, 1975). Murray
(1992) and Cogill et al. (1986), for example,
focused on the cognitive development of children.
Cogill and colleagues used the McCarthy Scales
which consist of standardized tests of verbal,
perceptual, and quantitative skills and are com-
bined to give a general cognitive index. Murray
used Piaget's object concept tasks (Stages V and
VI). Children's emotional and behavioral develop-
ment was examined by Philipps and O'Hara (1991)
using the CBCL. The CBCL consists of a list of
behavioral items that assess difficulties a child may
exhibit reflecting phenomena such as depression,
withdrawal, hyperactivity, and aggression. Margo-
lies (1989) used the Junior Eysenck Personality
Questionnaire which consists of three scales which
measured children's introversion/extraversion, neu-
roticism, and psychoticism.
Data were collected on postpartum depression
and the dependent variables of cognitive and emo-
tional development of the children of mothers who
had experienced postpartum depression at various
times in the studies included in the meta-analysis.
The age range of the children when data collection
occurred was 1 years (Murray, 1992) to 14 years
(Margolies, 1989) (Table 1).
RESULTS
Sample
Sample characteristics. Nine studies com-
prised the sample for this meta-analysis. The total
number of subjects in the combined nine studies
was 1,473. One study (11%) was published in the
1970s, four studies were published in the 1980s
(44.5%), and four studies in the 1990s (44.5%).
Seven studies (78%) were journal articles whereas
two studies (22%) were unpublished dissertations.
Six of the studies (67%) received funding whereas
three (33%) did not. One study (11%) occurred in
Sweden, three studies (33%) were conducted in the
United States, and five studies were performed in
Great Britain (56%). A longitudinal design was
used in all but one study. Convenience sampling
was used in six studies (67%), random sampling
occurred in two studies (22%), and matching was
used in one study (11%).
Sample s&e. In recta-analysis the "file drawer
problem" refers to the possibility that unknown,
Tabl e 1. Da t a Col l ect i on Ti mes
3 6 2 9 3 4 6 1 18 19 4 4~ 4-8 10 12-14
Study WK WK MO WK MO MO MO YR MO MO YR YR YR YR YR
X X Uddenberg & Englesson, 1978
Cogill, Caplan, Al exandr a,
Robson, & Kumar, 1986
Caplan, Cogill, Al exandr a,
Robson, Katz, & Kumar, 1989
Margol i es, 1989"
Rotnem, 1989"
Philipps & O' Hara, 1991
Stei n, Gath, Bucher, Bond, Day,
& Cooper, 1991
Murray, 1992
Sharp, Hay, Pawl by, Schnucker,
Al l en, & Kumar, 1995
X X X X
X X X X
X X X X X
X X X X
X X X X
X X X
X X
ABBREVIATIONS: WK, weeks; MO, mont hs; YR, years.
*Ret rospect i ve design.
16 CHERYL TATANO BECK
unpublished research might exist whose results fail
to confirm the pattern revealed by the published
findings (Rosenthal, 1979). I f the retrieval of
studies in a meta-analysis focuses exclusively on
published research where a publication bias in
favor of significant findings was operating, the
results of the meta-analysis can be distorted. Rosen-
thai developed a method for determining the magni-
tude of the file drawer problem by calculating the
minimum number of unpublished studies reporting
nonsignificant findings that would be necessary to
overturn the conclusion reached in a particular
meta-analysis. This number has been termed the
fail-safe number (Cooper, 1979). Rosenthal and
Hall (1981) have proposed that a reasonable toler-
ance level of the file drawer problem has been
achieved if the fail safe number exceeds 5K + 10
where K = number of studies included in the
meta-analysis. Using Mullen' s (1989) database
management system for meta-analysis, the fail safe
number computed for this recta-analysis on the
long-term effect of postpartum depression on chil-
dren' s cognitive and emotional development was
139 unpublished studies. This fail safe number
exceeded the 55 unpublished studies that would
need to be retrieved to overturn the conclusions of
this meta-analysis.
Sample homogeneity. To quantitatively com-
bine individual studies in one meta-analysis, an
assumption that should be met is that each study
provides a sample estimate of the effect size that is
representative of the population effect size (Wolf,
1986). If a group of individual studies provide a
homogeneous estimate of the population effect
size, it is more likely that these different studies are
testing the same hypothesis. A homogeneity test
was conducted to identify any outlier studies in this
meta-analysis. Heterogeneity is indicated when a
homogeneity test is significant. I f this occurs, the
outliers are identified by removing them one at a
time, recalculating the homogeneity test on the
studies that remain, until a nonsignificant homoge-
neity statistic is obtained. Once a nonsignificant
homogenei t y statistic is reached, the effect sizes
from the remaining studies can then be combined to
calculate a mean effect size. In this recta-analysis
no outliers were identified. The homogeneity tests
for significance levels (X 2 = 3.38, p = .91) and for
effect sizes (X 2 = 5.15, p = .74) were both nonsig-
nificant.
Research Question 1
In this first research question the magnitude of
the effect of postpartum depression on the cognitive
and emotional development of children was exam-
ined. The nine hypothesis tests included in the
meta-analysis are located in Table 2. The general
combinations and comparisons of significance lev-
els and effect sizes are found in Table 3. A database
management system for meta-analysis (Mullen,
1989) was used to analyze these hypothesis tests
and it provided results for r and d indicators of
effect size in three different ways: unweighted,
weighted by sample size, and weighted by the
quality index score. Cohen' s (1988) conventional
operational definitions of small, medium, and large
effects sizes for r (.10, .30, and .50) and for d (.2, .5,
and .8), respectively, were used to interpret the
findings.
As indicated in Table 3, postpartum depression
had a small but significant effect on children' s
cognitive and emotional development. Children
whose mothers had suffered from postpartum de-
pression displayed more behavior problems and
lower cognitive functioning compared with chil-
dren whose mothers had not been depressed.
A 95% confidence interval around the average
effect size was constructed using Cooper' s (1989)
formula to help interpret the meaning of the
calculated effect size. I f this interval does not
contain r = 0, the null hypothesis that no relation-
ship exists between postpartum depression and
children' s cognitive and emotional development
Table 2. Studi es Included in Met a- anal ysi s Database
Sample r d Quality
Study Si ze Indicator Indicator Index
Uddenberg & Eng-
lesson, 1978 69 .27 .56 19
Cogill, Caplan, Al ex-
andra, Robson, &
Kurnar, 1986 94 .25 .51 22
Caplan, Cogill, Al ex-
andra, Robson, Katz,
& Kumar, 1989 92 .17 .35 22
Margol i es, 1989 206 .17 .35 24
Rotnem, 1989 618 .13 .27 18
Phiiipps & O' Hara, 1991 70 .12 .24 22
Stei n, Gath, Bucher,
Bond, Day, & Cooper,
1991 98 .24 ,50 24
Murray, 1992 56 .27 .57 23
Sharp et al., 1995 60 .34 .72 24
POSTPARTUM DEPRESSION AND CHILD DEVELOPMENT 17
Table 3. General Combi nat i ons and Compari sons of Significance Levels and Effect Sizes f or t he Effect of Post part um Depression
on Child Devel opment Ol der Than 1 Year of Age
Combinations of
Significance Level Combinations of Effect Sizes
Zf or Associated Mean Mean Mean Mean
Combination 1-tailed P ZFisher r r 2 d
Al l st udi es ( N = 9)
Unwei ght ed 6.67
Wei ght ed by sampl e size 5.35
Wei ght ed by qual i t y 6.51
Cont r ol l ed f or cur r ent depressi on ( N = 4)
U nwei ght ed 4.10
Wei ght ed by sampl e size 3.92
Wei ght ed by qual i t y 3,90
Lack of cont r ol f or cur r ent depressi on ( N = 5)
Unwei ght ed 5.29
Wei ght ed by sampl e size 4.63
Wei ght ed by qual i t y 5.29
2.13E-11 .22 .22 .05 .45
4.86E-08 .18 .18 .03 .36
5.85E-11 .22 .22 .05 .45
2.06E-05 .16 .16 .03 .33
4.38E-05 .15 .15 .02 .30
4.84E-05 .17 .17 .03 .34
6.77E-08 .27 .26 .07 .54
1.84E-06 .24 .23 .05 .48
6.60E-08 ,27 .26 .07 .54
can be rejected (Wolf, 1986). The 95% confidence
interval ranged from .125 to .230 and did not
contain zero thus indicating that post part um depres-
sion was significantly related to child development.
Because more than hal f of the studies included in
this meta-analysis did not control for mot hers'
current level of depression when determining the
effect of post part um depression on children' s cogni-
tive and emot i onal development, two submeta-
analyses were computed. One recta-analysis com-
bined the four studies that did control for mot hers'
current depression and the other one combi ned the
five studies that did not control for current depres-
sion. As can be seen in Table 3, the results for bot h
of these additional met a-anal yses revealed that
post part um depression had a small, significant
effect on child development. The studies that did
control for current depression, however, had a
slightly smaller effect.
Because the range of children' s ages from the
nine studies in this meta-analysis was from 1 to 14
years, two submet a-anal yses were comput ed to
determine i f the effect sizes differed depending on
the ages of the children. The five studies that
exami ned the effect of post part um depression on
the devel opment of 4-year-olds (Caplan e t a l . ,
1989; Cogill et al . , 1986; Philipps & O' Har a, 1991;
Sharp et al . , 1995; Uddenberg & Englesson, 1978)
were combi ned in one submeta-analysis. The r and
d effect sizes obtained, .23 and .46 p = .000004,
respectively, are considered small and are similar to
the effect sizes obtained when all nine studies were
combined. Another submeta-analysis was corn-
puted for the two studies which had measured the
effect of post part um depression on the develop-
ment of 18- to 19-month olds (Murray, 1992; Stein
et al . , t991). The effect sizes obtained were again
considered in the small range (r = .24, d = .50,
p = .001) and essentially the same as for the 4-year
olds.
Only one study included in the mai n meta-
analysis had collected data on 4- to 8-year olds and
its effect size was .13 for the r indicator and .27 for
the d indicator, both indicating post part um depres-
sion had a small effect on the devel opment of
children in this age group. In Margol i es' (1989)
study the devel opment of the oldest children (10 to
14 years old) was examined. Just as in all the
previous age groups, post part um depression was
found to exert a small effect (r = . 17, d = .36) on
these children' s development.
Research Question 2
In this second research question the effects of the
following seven variables on the outcome of the
recta-analysis were investigated: publication date,
publication source, sampl e size, research design,
postpartum depression measurement, outcome mea-
surement, and quality index. Only one of the
predictor variables was significantly correlated with
the effect size of cognitive and emotional develop-
ment in children of post part um depressed mothers.
Sample size ( - . 51, p = .03) was the predictor
which was significantly correlated with the effect
size. This finding indicates that the studies included
in this recta-analysis which had larger samples
18 CHERYL TATANO BECK
reported that postpartum depression had a smaller
effect on child development than the studies that
used smaller samples. Perhaps the tighter designed
studies are reflecting a more accurate picture of the
size of the impact of postpartum depression.
DISCUSSION
The results of this meta-analysis revealed that
postpartum depression had a small but significant
adverse effect on the development of children older
than 1 year of age. Even in the more methodologi-
cally strong studies that had controlled for mothers'
current depression level, postpartum depression
still maintained a small, significant effect. The
strength of its effect, however, appears to have
weakened as infants grow older. In a previous
meta-analysis (Beck, 1995), postpartum depression
displayed a moderate to large adverse effect on
infants' behavior.
Some methodological issues regarding the re-
search involved in this meta-analysis prevent draw-
ing any firm conclusions regarding long-term
sequelae of postpartum depression on child devel-
opment. Unlike the earlier meta-analysis (Beck,
1995) in which a limited time frame of the first 12
months of an infant' s life was used, this current
meta-analysis included children of a much wider
age range of 1 to 14 years. Although the submeta-
analyses in which the studies were divided up by
age groups did not find any differences in the effect
of postpartum depression, there are a myriad of
factors that can influence child functioning during
such a broad span of time. Until research moves
beyond the linear developmental models the merit
of this quantitative review of the research to date
for clinicians is in alerting them to the importance
of early detection and treatment of women with
postpartum depression. When a mother is treated
for her depression she is not the only person in the
family who may reap the benefits, so may her
children. Clinicians also should start identifying
women during pregnancy who are at risk for
developing depression after delivery. Predictors
such as prenatal depression and lack of social
support have been identified (Beck, 1996). If
interventions targeting specific predictors of post-
partum depression can be initiated during preg-
nancy, perhaps the incidence of this postpartum
mood disorder can be decreased and its adverse
effects on children prevented.
Prospective, longitudinal designs with more con-
sistent data collection times are needed to disen-
tangle the cansal processes involved in any possible
long-term effects of postpartum depression on
children' s cognitive and emotional development.
Researchers need to follow-up on Phillips and
O' Hara' s (1991) finding that postpartum depres-
sion exerted an indirect effect on 4-year-old
children' s behavior problems. Postpartum depres-
sion significantly increased mothers' risk for devel-
oping later maternal depression which, in turn,
increased the risk for child behavior problems. The
significance of other variables that may have con-
tributed to impairments in child functioning such as
marital conflict, poor social support, and adverse
life events need to be determined. Research needs
to move beyond linear developmental models and
begin to incorporate the complex interactions of
children and their caregiving environment. Caplan
and colleagues (1989) alert researchers that this is a
compl ex reciprocal process with both child and
mother contributing to each other' s current difficul-
ties and to the child' s future problems. Researchers
need to explore more fully the child' s contribution
to this interpersonal system of mother and child.
The studies incorporated in this meta-analysis have
been based on this linear thinking.
The understanding of both the short- and long-
term sequelae of postpartum depression on chil-
dren' s development also can be increased by exam-
ining those factors that may serve a protective
function against the risks associated with postpar-
tum depression. Sources of protection and resil-
ience in children in the face of postpartum depres-
sion are critical to unraveling how some children
successfully adapt (Caplan et al., 1989). The fa-
ther' s role, for example, in decreasing the adverse
effects postpartum depression on children can be
investigated.
Additional limitations of the research combined
in the meta-analysis focus on sample and data
collection techniques. A power analysis had not
been conducted in any of the nine studies included
in this meta-analysis to determine the appropriate
sample size. In the future, researchers investigating
postpartum depression need to use power analysis
before data collection to ensure the study has
adequate statistical power. Another issue concerns
self-report of depressive symptomatology as the
sole measurement of postpartum depression. In
POSTPARTUM DEPRESSION AND CHILD DEVELOPMENT 19
three studies i ncl uded i n this meta-anal ysi s (Carro
et al., 1993; Margol i es, 1989; Whi ffen, 1990) the
BDI was the sol e measurement o f postpartum
depression. Kendal l , Hol l on, Beck, Hammen, and
Ingram ( 1987) warn that onl y whe n consi st ent
agreement occurs i n the assessment of depressi on
across mul ti pl e measurement methods, such as the
BDI and a structured cl i ni cal interview, can one be
safe i n assumi ng nos ol ogi c al cl assi fi cati on and
secure i n appl yi ng the l abel depressed. Kendal l and
c ol l e ague s s t rongl y r e c omme nd that mul t i pl e
met hod assessment be used. The si mpl e i ncl usi on
o f other self-report measures o f depressi on does
not, however, remedy this probl em because this
does not vary the met hod o f assessment. Onl y five
of the studi es (45%) i ncl uded i n this meta-anal ysi s
used mul ti pl e met hod assessment (Capl an et al.,
1989; Cogi l l et al., 1986; Murray, 1992; Philipps &
O'Hara, 1991; Stei n et al., 1991). Al s o, onl y hal f o f
the studi es control l ed for mothers' current l evel o f
depressi on whe n determi ni ng the effect o f postpar-
tum depressi on on the devel opment o f children
older than the age of 1 year.
As evi denced i n Table 1, the myriad of data
col l ect i on ti mes for both postpartum depressi on
and the dependent variables o f chi l d out come
presents another met hodol ogi cal short comi ng that
limits the concl us i ons that can be drawn from this
meta-anal ysi s. For exampl e, does the t i mi ng and
duration o f postpartum depressi on affect chi l d
devel opment ? A research quest i on whi ch deserves
attention i s whether infants and children are espe-
ci al l y vul nerabl e to their mothers' depressi on at
certain poi nt s i n their devel opment . Wrate et al.
( 1985) , for i nstance, f ound that briefer postpartum
depressi on as compared wi t h l engt hy postpartum
depressi on was associ ated wi t h an increase in chi l d
behavi or probl ems at 3 years o f age.
A conservat i ve approach s houl d be used regard-
i ng recommendat i ons for cl i ni cal practice deri ved
from research i ncl uded i n this meta-anal ysi s be-
cause these studi es were based on linear thi nki ng,
that is, the assumpti on that postpartum depressi on
al one wi l l have a cont i nui ng i mpact on chi l d
devel opment unaffected by other i nterveni ng l i f e
experi ences.
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