Prevention and Coping in Child and Family Care: Mothers in adversity coping with child care

Toxic Stress
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http://avmhrs.heptotechnologies.org/database/secret/139.php This will remain significant in terms of policy and practice, because it is difficult to imagine the circumstances in which Policy, Prevention and Practice 37 resources are not rationed, and hence some families fall below the needs threshold to receive a service. The other is a conceptual one. The concept of need is one which is focused on providing resources for those with problems. That much is clear from the theoretical analysis of Sheppard and Woodcock The key issue with need is, what is it that is needed to deal with the particular problem which is confronted?

However, this, in essence, concerns what others will do or provide in order to help families or parents. These are the family support services, as well as other services. The concept of need, as a result, tends not to conceptualise the individual as an active agent. Even the attempt to elicit support involves decision making on the part of parents, acting as active agents seeking to direct their own lives. However, we can go further than this. From the point of view of the parent, the key issue when faced with problems or challenges in child care is one of coping: how will they cope with the challenges with which child care presents them, particularly if they are in some ways disadvantaged?

So while the concept of need, to put things a little simplistically, tends to represent the parent, child or family in a passive way as recipient of services, the concept of coping treats them as active agents seeking to manage and control the challenges, difficulties and disadvantage with which they are confronted. Likewise, the issue of coping comes into the realm of prevention.

All levels of prevention, like need, are concerned with the provision of help or resources. Coping, on the other hand, is about the manner in which parents themselves seek to negotiate the challenges and difficulties with which they are confronted, and this can involve their eliciting services for whichever level of prevention required, or involving themselves in decisions made. Coping can be linked with the operation of partnership, and a focus on different coping strategies can throw light on the different ways in which partnership works. Coping, then, has significant policy, practice and conceptual relevance for families in adversity.

This is the basis on which this study was conducted. Where we know that families can be in adversity, defined both in terms of the child care challenges with which they are presented, and the social disadvantage they suffer, then the issue of coping is important. We also know that this adversity can be extreme, and yet, because of resource rationing and high thresholds, parents are still unable to have access to social work services.

This raises the deceptively simple question in view of the complex answer : how do they cope? What is the range of coping strategies adopted to deal with child care problems? Clearly, this emphasis on coping requires further elucidation, and it is to this that we shall now turn.

CHAPTER 2 Dimensions of Coping Coping theory generally approaches humans as active agents, that is conscious beings who bestow meaning on situations, and act in a motivated and self-directed way. The coping process is generally about two key concepts. The first is that of threat, which derives primarily from the stressor which is confronted, but may also arise because of the response that is made by the individual; the stressor presents the individual with some threat, with which they seek to cope.

The second is that of control. Faced with the threat of the stressor, the individual seeks, through coping processes, to gain some measure of control over the situation, or themselves, including their feelings. Lazarus p. Lazarus and Folkman p. Cohen comments p. Stress and the primary appraisal of threat The start point for understanding coping is, therefore, stress. Stress can be seen as a response to particular, difficult circumstances confronted by individuals. It is 39 40 Prevention and Coping in Child and Family Care a state of tension — anxiety, frustration, etc.

Stress is also seen as a process as, indeed, is coping. Where the stress itself is seen as a process, it is contextualised within the relationship between the person and their environment of which more later. Coping occurs in the face of some stressor. According to Sarafino p. A stressor is generally considered to be circumstances, or particular facets of a circumstance, which are threatening or harmful or perceived to be such to the individual. Examples of this include catastrophic events, such as tornadoes, major life events for example, the break up of a significant relationship , or chronic circumstances, such as living with severe pain from arthritis Baum Although there are some variations in approaches to stress Elliot and Eisdorfer ; Vingerhoets and Marcelissen if an event typically leads to psychological distress, behavioural disruption, or deterioration in performance, then it is characterised as a stressor.

Meaning and appraisal A stressor is not a simple objective thing, but achieves its definition of threat through a process of appraisal by the individual concerned, which is dependent on the meaning of that event for that individual in terms of their wishes, feelings, concerns or interests. Coping theorists generally distinguish between the primary appraisal of threat and the secondary appraisal of controllability. Primary appraisal relates to the appraisal the individual makes of the stressor: it is the process of perceiving a threat to oneself Carver, Weintraub and Schieir At a personal level — and this is the level which interests us when we interview the women, in the first instance — meaning is subjective, and yet affected by the norms and expectations of the social group, and the history and experiences of individuals.

The ways in which, for example, a mother makes sense of an argument with her teenage son depends on her perceptions of his motivation, on her interpretation of the content of what he says and his motivation for saying it.

Coping skills (resilience)

If she sees, for example, his argumentative behaviour as a response to some stress which has occurred in his life for example, that he has been bullied at school, and the stress of the situation is getting to him , she will interpret, or appraise, this behaviour very differently from an argument based, in her view, on an unwarranted and stubborn attempt to get his own way.

New and different information can also change the way a situation is appraised. Suppose, for example, this woman does not know about the bullying at school. She may then see him as argumentative and stubborn. She may subsequently learn of the bullying, and change her view not just of his behaviour, but also of herself at least in relation to that incident.

She may feel guilty, and even criticise herself for failing to realise that his behaviour was a response to external pressure. The same event can have quite different meanings for different people and in different contexts. Take, for example, the case of a woman who finds she is pregnant. We can quite easily understand the uninhibited joy of this woman when we realise that she has been trying and failing to have a child for a number of years.

Another woman, however, may feel desperate in finding that she is pregnant. She may be a woman who is very career-minded, and the prospect of having children will represent a major disruption, or even barrier — or a threat — to her life plans. Apparently straightforward tasks can be imbued with negative meanings and become stressful in the face of a problematic past. Many of the women whose children are subject to social work intervention have themselves been abused in their childhood.

Women subjected to sexual abuse in childhood have described their own inhibitions when having to deal with the physical care of their own children, such as bathing, which they trace directly to their own childhood experiences Sheppard b. Their view is that an event or difficulty becomes more important — more stressful — when it has particular significance for the individual. It then has considerable, and negative, meaning for them, and, according to Brown et al. They identified three ways in which negative events would develop particular significance for women.

The first concerned marked difficulties which were already being experienced. If, for example, women were already worried because of financial difficulties, an additional burden of unexpected debt was likely to be perceived as far more problematic than if long-term financial difficulties were not already being experienced. A second area where stress was likely to gain particular significance or meaning concerned areas of life which had particular value because of the extent of commitment which the woman experienced. This generally concerned a role or activity.

Brown et al. For example, a woman might describe herself as highly committed to her marriage, or close relationship. An event presenting a threat to her marriage would have particular significance. The third area was role conflict. Role conflict related to roles where good performance in one area was inconsistent with good performance in another.

Where, for example, work and domestic responsibilities collide in trying to get children to school on time, an additional factor, such as an illness or injury, which makes the smooth performance of these tasks even more difficult, is likely to be experienced as stressful. Add to this an insistence by the boss that the woman must arrive at work on time, or else they will have to review her employment, and this is a recipe for considerable stress.

Coping: emotion-focused and problem-focused While threat underlies appraisal of stressors, control, or the need to gain it, underlies coping responses. The way an individual seeks to gain control may be classified in terms of the functions of coping, involving a basic division between Dimensions of Coping 43 problem-focused coping on the one hand and emotion-focused coping on the other. Lazaraus and Folkman cf Carver et al. It involves efforts to change the troubled person—environment relationship. Emotion-focused coping they define as coping that is directed at regulating the emotional response to the problem.

Emotion-focused coping is aimed at reducing or managing the distress that is associated with, or caused by, the situation. Within these two broad domains, there is a wide range of more detailed coping actions which comprise these coping functions. There are two major groupings of problem-focused activities. Those directed at the environment include strategies for altering environmental pressure, barriers, resources, procedures, and so on.

Inward-directed coping, focusing on the person him- or herself, includes strategies that are directed at motivational or cognitive changes, such as shifting the level of aspiration, reducing personal involvement, finding alternative channels of gratification, developing new standards of behaviour or learning new skills and procedures.

Lazarus and Folkman suggest that, while we can identify generic emotion-focused coping actions identifiable in a wide range of situations, there seems to be greater specificity in problem-focused coping, limiting opportunities for generic classification. Others do not agree, and Carver et al. These include, first, active coping, which is the process of taking active steps to remove or circumvent the stressor, or to ameliorate its effects.

Planning, which can occur alongside active coping, is thinking about how to cope with a stressor. Planning involves coming up with action strategies, thinking about what steps to take, and how best to handle the problem. This involves weighing up the resources available to deal with the problem, and considerating alternative approaches. Some forms of problem-focused coping can involve limiting or delaying action, rather than taking it, where this is believed to facilitate problem amelioration or resolution. Another form of problem-focused coping is the exercise of restraint.

Restraint 44 Prevention and Coping in Child and Family Care coping is waiting until an appropriate opportunity to act presents itself, holding oneself back and not acting prematurely. Lazarus and Folkman suggest that emotion-focused coping strategies are more likely to occur when there has been an appraisal that nothing can be done to modify harmful, threatening or challenging environmental conditions.

Emotion-focused coping can be grouped into various domains. One domain involves attempts at lessening emotional distress, and includes strategies such as avoidance, minimising importance , seeking to find positive value in negative events, distancing oneself from the problem, and so on. Another domain involves reframing encounters. This is where the individual seeks to change the way an encounter is construed, without changing the objective situation.

The event can thereby change from a catastrophic event to a challenge with the supportive imagery of the family around them. Another strategy involves selective attention, rather than seeking to change the meaning of an event. The change in meaning occurs because there is a change in what is being attended to, and what is being avoided. Self-deception can also occur. Emotion-focused coping can be used to maintain hope and optimism, to deny both the fact of an event and its implications. By this the individual refuses to acknowledge the worst and acts as if what has happened does not matter.

Of course, the individual may not know this is happening: one cannot simultaneously deceive oneself and be aware of what one is doing. Successful self-deception, therefore, generally occurs unawares Suls Dimensions of Coping 45 The person—environment interface Coping occurs in a context.

Besides these internal feelings and cognitions, Moos and Schaeffer have suggested that the environment acts in two ways in the coping process: in the demands placed on the person, and in the action and resources available to meet those demands. Together, they consider this to be the person—environment interface, which provides the context for the coping responses of individuals. This is the context for considering secondary appraisal, the process of bringing to mind a potential response to a threat: our assessment of the resources we have available for our coping.

Two key aspects of appraisal seem to influence the perception of our capacity to cope. The first relate to the person — these include intellectual, motivational and personality characteristics e.

The second relate to the situation — the stressful context, including barriers which make management of the problem difficult, and the degree of support available to deal with the problem Paterson and Neufield Stress and constraints The instigator for coping actions, as we have seen, is the existence of a stressor. However, the particular stressor which is the subject of coping actions may itself occur within a context of stress and constraints experienced by the individual Williams Constraints can often be cultural, whereby group norms generate expectations which create a context unpropitious for the woman to cope when confronted with a problem.

Feminist literature has emphasised how women who are mothers in traditional roles are often engaged in work which is routine, repetitive, unrewarding and not highly valued Williams Such work includes housework, and even child care, 46 Prevention and Coping in Child and Family Care particularly if a mother bears sole responsibility, and finds herself socially isolated. Linked to this can be reinforcing negative responses from those in the social network if the woman tries to transcend the limitations of her role Sheppard A particular problem, secondly, can be experienced within a wider context of stresses or disadvantage which makes resolution of that problem more difficult.

A range of stressors have been associated with the women who are the subject of this study. These again can link the external context with the internal psychological state, including mental health. One significant area is that of domestic violence Mirlees Black , which has been associated with poorer physical and mental health outcomes for women, and even as an important cause of suicide and attempted suicide Peterson et al. Poverty is another stressful context. The association between poverty and mental health state is an unsurprising and well established research finding Belle Poverty among women, evidence suggests, is associated with being a single parent, divorced, or a member of an ethnic minority group Payne Family life itself can be stressful, with a well established association between psychological distress and motherhood Pound and Abel Indeed, women may find their normally exhibited behaviours defined as indicators of mental health problems, as feminine attributes have been found to be considered inconsistent with those of mental health Becwith ; Broverman et al.

Social support One of the key dimensions of the person—environment interface is the presence or absence of social support. Social support has been the subject of various definitions Henderson , but it generally refers to help or aid provided by one or more persons for another. Pierce, Sarason and Sarason usefully define it as social transactions which facilitate coping in everyday life and are Dimensions of Coping 47 perceived as such by the recipients. As such, in general, its relevance for coping is fairly obvious.

The presence of social support provides a potential avenue for coping whereby the individual facing a stressor mobilises the help of others to deal with the problem problem-focused coping , or the emotional consequences of the problem emotion-focused coping. In the latter case, social support is something which is given or provided by others.

In coping theory, while this of course can be the case, social support may be actively solicited by the individual. Of course, the first issue for coping is whether or not social support is available. The absence of social support, therefore, closes off a potential avenue for help in coping. The issue of appraisal is relevant here. In this case, social support is a key element of secondary appraisal — appraisal of resources with which to cope with a problem. It may, for example, be the case that an individual does have support available for example, her mother may be prepared to help , but she is either not aware of this, or does not see it that way.

Thus the perception or secondary appraisal of support is crucial in the coping process. A differentiated concept of support is widely accepted as necessary for the understanding of the link between social support and coping processes Thoits , Where support is available, its functional properties are most significant Henderson ; Thoits These functional properties relate to that which is on offer, or provided, through social support. Here, there is an important distinction between availability and adequacy.

Henderson, Byrne and Duncan Jones found that the availability of social support that is, potential avenues for support was much less significant for mental health outcomes than its adequacy i. It is not enough, in other words, for support to be available, it must be enacted and 48 Prevention and Coping in Child and Family Care presumably, from the point of view of the person seeking to cope, solicited — cf Brown et al.

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The difference between crisis and everyday support is the difference between support directed at a particular stressor that is creating a time of particular or discrete difficulty, and routine support derived from everyday interactions with friends, relatives and acquaintances. Thoits gives a variety of ways in which social support may be engaged as part of the coping process. One obvious way is by direct intervention. Others can, alternatively, provide advice or information, like students who recommend study strategies, and books containing useful overviews, to each other.

Others can help the individual to reinterpret situations so they seem less threatening, and reinforce less threatening perceptions by repetition and selective attention to cues. Locus of control An obvious alternative to soliciting help from others is to try and deal with the problem yourself. In this respect the issue of locus of control has some significance. Locus of control relates to an internal state that explains why some people actively, willingly and resiliently try to deal with difficult circumstances, while others succumb to a range of negative emotions Lefcourt It develops as a general sense as a result of accumulated experiences in which individuals perceive a trend of relationships between their actions and the outcomes of their actions.

Perceived controllability affects appraisal of threat. People tend to appraise an uncontrollable event as being more stressful than a controllable one, even if they do not do anything to affect it Sarafino A distinction is made between internal locus of control and external locus of control.

Those with an internal locus of control believe that events are a consequence of their own actions and thereby under their personal control. Those with an external locus of control believe that events are unrelated to their actions, and are thereby determined by factors beyond their personal control. In principle, an internal or external locus of control may be a generalised attribute i. These basic differences can have profound implications for the conduct of individuals.

Furthermore, they are more likely to attempt to resolve the problems themselves.

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Indeed, this can lead to the perception of a direct relationship between effort expended and good outcome the more effort I put into something, the more likely that I am to succeed. Furthermore, the more difficult the problem confronted, the more likely is the individual to redouble their efforts. This gives a clear indication of likely task persistence.

Internals are likely to show greater task persistence than externals, and the more difficult the problem faced by the individual, the more marked this difference is likely to be. To the extent that task persistence is likely to lead to a successful outcome, internals are likely to develop a greater general sense of task competence: i. This, in effect, is likely to create a sense of confidence in themselves as individuals, and to contribute to a higher level of self-esteem. The opposite is likely to be the case with externals.

While locus of control relates to an internal psychological state, the environment itself may be such that this reflects the real circumstances of their lives. For example, where individuals live in less responsive environments, they may, rightly, fail to see connections between their efforts and outcomes. Here 50 Prevention and Coping in Child and Family Care again the issue of systematic disadvantage can have an impact on perceptions of locus of control. Individuals in disadvantaged, discriminated-against groups would, by definition, feel they have a more limited capacity, by their own efforts, to achieve successful outcomes.

Young black males in deprived areas are likely to be fully aware of the higher rates of unemployment compared with similar white populations, and of the link between this and discrimination. Research and conceptual development in relation to locus of control has been most marked in relation to health. The initial position was that those with an internal locus of control would be most likely to engage in healthy behaviours, because they would see themselves liable to determine health outcome through their own efforts.

Thus, in theory, there should be a strong association between health internal locus of control and health-promoting behaviours. However, matters are not that straight forward Norman ; Steptoe et al. An individual might be expected to devote energy and effort to achieving a particular outcome if they place value on the achievement of that outcome, but not to do so if it is not highly valued Abella and Helsin ; Weiss and Larson So an internal locus of control involves a sense that the individual is able to bring a difficult situation under control by their own actions, and is liable to be associated with direct action by the person themselves, and with task persistence and competence, provided it is in an area considered valuable by the individual.

Those with an external locus of control might be expected not to seek actively to cope themselves with a problem, or not to be persistent in doing so, or to seek help from others who might be considered more effective at bringing the problem under control. The belief in powerful others can be a strong factor in engendering a sense that a problem can be brought under control, though not by the individual him- or herself.

This is not an internal locus of control construct, but is rather linked to the use and effectiveness of social support. This Dimensions of Coping 51 would be the case, for example, with professionals who are seen as being able to create change in a positive direction. Such is the case with medical professionals in relation to illness states Wallston Thoits has suggested a further factor in the effective use of social support for coping, which may be used by externals. She believes that socio-cultural and situational similarity between the individual and their supporter are key factors in the acceptability and likely success of the support.

Both, she thinks, are likely to enhance a sense of empathic understanding, a condition under which she thinks coping assistance is likely to be most effective.

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Socio-cultural similarity increases the probability that a significant other will suggest coping techniques, or attempt to influence circumstances in ways that individuals view as acceptable. Individuals, furthermore, are more likely to compare themselves with, and affiliate with, others who have faced similar stressful circumstances.

Distressed individuals tend to feel that others who have experienced similar situations are most likely to understand their position Gottlieb Trait and process, stability and change Coping has been presented in terms of a particular trait or style characteristic of individuals. The assumption underlying this approach is that coping styles are more or less stable, with individuals learning to cope in particular ways.

People do not approach each coping context anew, but rather employ a preferred set of coping strategies that remains relatively fixed across time and circumstances Carver et al. More recently, there has been a growing emphasis on process. Coping is not static, but is a function of continuous appraisals and reappraisals of the shifting person—environment relationship. Any shift in the person—environment relationship may lead to a reappraisal of what is happening, its significance and what is to be done.

The coping actions, like the circumstances in which the coping takes place, are considered to have a high degree of specificity, always directed towards particular conditions. It follows that coping 52 Prevention and Coping in Child and Family Care is a shifting process in which a person may rely on different coping strategies at different times. One example of changes in the coping process may be found in loss and bereavement, and in the frequently long duration of grief work, beginning with the moment of loss.

Initially there may be frantic activity, tearfulness or brave struggles to carry on socially or at work. Later stages often involve temporary disengagement and depression, followed ultimately by acceptance of the loss, re-engagement and even attachment to other persons Littlewood This process can last some time, even years, and be characterised by many emotional difficulties and ways of coping.

To an observer according to those who consider coping to be a process these may well appear quite different at different times. There is, indeed, evidence that different modes of coping are used in dealing with different aspects of a stressful situation, and at different stages in a stressful encounter Cohen et al.

However, there may be dispositions evident where coping strategies are consistent over time, or across different types of stress Carver et al. Where a consistent pattern of this sort is shown, this would indicate coping patterns characteristic of the individual. Nevertheless, the degree of variance over time, as observed in the process approach, can depend on the time period over which observations are made. What may be identifiable as a process over a lengthy period may appear to be stable when focusing on a shorter period of time; even a process such as adjusting to loss may involve shorter periods of stability.

Denial, for example, may occur over some time. However, one can take this further. There may be relatively stable elements in the key individual and situational factors relating to particular stressors which lead to stability in coping response. Particular behaviours may elicit particular responses. For example, aggressive behaviour by a teenager may elicit argumentative responses in the parent. There is a case to be made, therefore, that while process is a very important aspect of coping, elements of continuity should not be lost in pursuit of elements of change.

Where we are concerned with practical implications and responses, elements of continuity, and the time period concerned, may assume greater significance than change. For example, where a particular coping response leads to danger to children, it may matter little whether the parent would have adjusted their coping behaviour one year down the line. By that Dimensions of Coping 53 time a child might be injured or even dead. A crucial variable in the focus on elements of continuity and change, therefore, is the relevant time period concerned.

Under some circumstances it is the issue of stability of coping behaviour which assumes greatest importance. Conclusion and summary It is evident that there is a need for clarity about a wide range of factors which serve to situate the coping process. Obviously, the stressor itself has to be identified, but so, too, do background stresses.

The context, both in terms of internal psychological factors and the external environment, provides the setting through which coping strategies can develop, including the persistence and perceived competence of the individual to respond. Broadly, we can summarise the key factors as follows: 1. Coping theory generally approaches humans as active agents, that is, conscious beings who bestow meaning on situations, and act in a motivated and self-directed way. This allows them to initiate actions and respond to problems with which they are confronted. Coping is a response to some stressor.

There are two key dimensions to coping, which underlie the perspectives taken by the individual and their need to respond. These are: the threat posed by the stressor, and the need for some control, which is the main purpose of the coping attempts. Appraisal is key to understanding both stressor and coping strategy, defining and bestowing meaning upon both. Neither stress, nor coping, therefore, is straightforwardly and unproblematically defined.

Events and difficulties are likely to be more stressful when endowed with particular value or significance by the individual. The way individuals seek to gain control of a stressful situation is through their coping strategy. Coping is generally divided into two basic functions: problem-focused and emotion-focused. Another plausible explanation for the inconsistencies is comorbid alcohol or substance use during pregnancy. Researchers have found high rates of antenatal depression co-occurring with cigarette smoking, alcohol consumption, and abuse of such substances as cocaine, often in combination with each other e.

For example, depression is especially prevalent 35—56 percent in samples of drug-dependent pregnant women Burns et al. Several researchers have found that infants of depressed mothers, relative to controls, have more difficult temperament. Whiffen and Gotlib found that infants of depressed mothers were perceived as more difficult to care for and more bothersome. A meta-analysis found a significant, moderate correlation between postpartum depression and infant temperament, with a 95 percent confidence interval that ranged from 0.

Among the potential moderators or correlated risk factors that have been studied, co-occurring anxiety in mothers has been found to play a role in associations between maternal depression and infant temperament, but the precise role is not clear. It may be that the anxiety, known to be highly correlated with depression, matters more. In one study, maternal trait anxiety predicted difficult infant temperament independent of antenatal and postnatal depression scores Austin et al. Another study found that both anxiety and depression in mothers matter. One study, which measured temperament not only with maternal reports but also with observations, found that mild parental dysphoria and mild parental anxiety were associ ated with two dimensions of child temperament: attention and emotion regulatory difficulties West and Newman, Some of the findings are informative of the developmental perspective, especially of the role of transactional processes.

Positive infant emotionality was not a predictor. Others have found that children with more difficult temperament are more vulnerable to the effects of inadequate parenting, such as that found to be associated with depression in mothers Goldsmith, Buss, and Lemery, Mothers of more difficult infants also perceive their parenting to be less efficacious, which in turn is linked to depression in mothers Cutrona and Troutman, ; Porter and Hsu, Antidepressant medication treatment during pregnancy, at least in one study, did not predict temperament Nulman et al.

However, other prenatal or fetal processes may matter. One study found that elevated maternal cortisol at 30—32 weeks of gestation, but not earlier in pregnancy, was significantly associated with greater maternal report of infant negative reactivity, with additive predictions from prenatal maternal anxiety and depression, even after controlling for postnatal maternal psychological state Davis et al. Genetics is likely to be another mediator. Temperament itself is highly heritable Hwang and Rothbart, Furthermore, genetics may explain associations between maternal depression and infant temperament and the later development of depression or other disorders Gonda et al.

That is, the same set of genes may predict both temperament qualities, such as negative affectivity and depression. More broadly, current temperament questionnaire measures have been developed to minimize the contribution of reporter bias Rothbart and Hwang, One longitudinal study, which followed children of depressed parents over a period of 20 years, showed the expected association between depression in one or both parents and having a difficult temperament Bruder-Costello et al.

Second, they found that difficult temperament in the children increased their likelihood of major depressive disorder. There is sufficient literature that it has been subject to some meta-analyses. One meta-analysis reviewed effects of maternal mental illness including both depression and psychosis on quality of attachment in clinical samples van Ijzendoorn et al. They found that maternal mental illness increased the likelihood of insecure attachment relative to norms and relative to samples of children with a range of problems.

Another meta-analysis of 16 studies found that maternal depression was not associated with significantly higher rates of disorganized attachment in children relative to middle-class samples or to poverty samples van IJzendoorn, Schuengel, and Bakersmans-Kranenburg, This was true even taking into account so cioeconomic status, type of depression assessment, and clinical versus community samples.

However, severely and chronically depressed parents were not targeted in this particular study population. Another meta-analysis, restricted to studies of clinically diagnosed depression in mothers, found that infants of depressed mothers showed significantly reduced likelihood of secure attachment and marginally raised the likelihood of avoidant and disorganized attachment Martins and Gaffan, For example, clinically significant depression in mothers increased the likelihood of disorganized attachment from 17 to 28 percent on average.

The reviewed studies predominantly sampled middle-income families with minimal risk factors other than the depression in the mothers. Thus, poverty and other risk factors do not explain this finding. Infants of depressed mothers show more negative affect crying and fussing and more self-directed regulatory behaviors e. Toddlers show more dysregulated aggression and heightened emotionality Zahn-Waxler et al.

These studies predominantly, but not exclusively, sampled middle-class populations. Various indices of cognitive-intellectual or academic performance have reliably been found to be associated with depression in mothers. Children with depressed mothers, compared with children whose mothers are medically ill or have other psychiatric disorders, have poorer academic performance and other behavioral problems in school Anderson and Hammen, Children of depressed mothers or mothers high in depressive symptom levels have been found to score lower on measures of intelligence in several studies Anderson and Hammen, ; Hammen and Brennan, ; Hay and Kumar, ; Hay et al.

This literature has been qualitatively reviewed from a developmental perspective, including the role of timing of the depression in the mothers Sohr-Preston and Scaramella, Among the strongest evidence for moderators of the association between maternal depression and academic functioning is exposure to violence Silverstein et al. Essentially, in a large nationally representative sample of kindergarten-aged children, Silverstein et al. They also had more behavior problems compared with children who had been exposed to either maternal depression or violence alone.

This pattern of findings was stronger for boys than for girls. In a longitudinal study of offspring of depressed and nondepressed mothers followed annually from 6th through 12th grade, higher IQ was found to be protective of dropping out among offspring of never- or moderately depressed mothers but not for adolescents whose mothers had been chronically or severely depressed Bohon, Garber, and Horomtz, One of the strongest predictors of depression in adults and also in children is the presence of cognitive vulnerabilities. Thus, this has been of interest to researchers who study the children of depressed parents.

Across multiple studies, depression in mothers and high levels of depressive symptoms in mothers are associated with children, as young as age 5, showing early signs of cognitive vulnerability to depression, including being more likely than controls to blame themselves for negative outcomes, having a more negative attributional style, hopelessness, pessimism, being less likely to recall positive self-descriptive adjectives, and having lower self-worth Anderson and Hammen, ; Garber and Robinson, ; Hammen and Brennan, ; Hay and Kumar, ; Jaenicke et al. Adolescents with depressed mothers show early signs of cognitive vulnerability to depression, such as being more likely than other adolescents to blame themselves for negative outcomes and less likely to recall positive self-descriptive adjectives Hammen and Brennan, ; Jaenicke et al.

Of particular concern is a pattern of children of depressed mothers current or past depression being more reactive cognitively e. Specifically, increased levels of parent-child stress due to parental withdrawal and parental intrusiveness were associated with higher levels of stress reactivity in children e. These findings suggest that teaching children of depressed parents to use more effective coping strategies may be an important target for preventive interventions Compas et al.

They have found, essentially, that children of depressed mothers vary in their adaptive functioning, and those with more adaptive functioning function better. For example, more flexible approaches to coping and more situationally appropriate strategies are associated with better outcomes a moderator relationship Beardslee, Schultz, and Selman, ; Carbonell, Reinherz, and Beardslee, Results from other studies by Beardslee and colleagues suggest that children may be protected by how they perceive and respond to depression in their parents Beardslee and Podorefsky, ; Solantaus-Simula, Punamaki, and Beardslee, a, b.

Specifically, youth who were resilient in the face of parental depression understood that their parents were ill and that they were not to blame for the illness. Thus, it was possible to increase understanding through preventive intervention. Beginning with studies of infants, researchers have identified problems in interpersonal functioning associated with depression in mothers. She has also found that infants of depressed mothers whose interaction style is characterized as withdrawn have poorer interactive qualities than those whose style is characterized as intrusive Jones et al.

Murray has studied infants, toddlers, and preschool-age children interacting with their depressed mothers. Studies of young children interacting with their depressed mothers, best illustrated by the work of Radke-Yarrow and colleagues, revealed that children whose mothers have been depressed engage in excessive compliance, excessive anxiety, and disruptive behavior that, when the children were followed into adolescence, were found to persist over time Radke-Yarrow, Among the few studies of peer interactions, sons but not daughters of depressed mothers were found to display more aggressive behavior during interactions with friends Hipwell et al.

Kindergarten-age children whose mothers were depressed were more often excluded by peers Cummings, Keller, and Davies, Adolescent children of depressed mothers have poorer peer relationships and less adequate social skills than teens of nondepressed control mothers Beardslee, Schultz, and Selman, ; Billings and Moos, ; Forehand and McCombs, ; Hammen and Brennan, Researchers have found significant associations between maternal depression and two psychobiological systems in children that have been found to play a role in emotion regulation and expression.

The first is stress responses measured in either a autonomic activity higher heart rate and lower vagal tone or b stress hormonal levels higher cortisol as an index of HPA axis activity. Field found that infants of depressed mothers have higher cortisol levels, especially following interaction with their depressed mothers Field, Harsh parenting, which is sometimes associated with maternal depression, has also been linked to higher cortisol levels in children Hertsgaard et al. The second significant association with maternal depression is cortical activity in the prefrontal cortex and particularly the pattern of greater relative right frontal EEG asymmetries.

This pattern is associated with the experience of withdrawal emotions in children and with depression in adults and adolescents Davidson et al. Even 1-week-old infants of depressed mothers, as well as 1-month-old infants, showed greater relative right frontal EEG asymmetry compared with infants of nondepressed mothers, and these early EEGs are correlated with EEGs at 3 months and 3 years Jones et al. Dawson and colleagues saw similar patterns in month-olds Dawson et al.

These patterns show remarkable stability from as early as age 1 week to age 3 years, suggesting that the early measures are reliably detecting a pattern of individual differences Dawson et al. For example, the number of prenatal months of exposure to maternal depression marginally predicted left frontal lobe activation from EEG Ashman and Dawson, ; Dawson et al. However, depression during pregnancy was measured retrospectively when the mothers were 13—15 months postpartum, and depression was defined to include women who were in partial remission or subthreshold.

If this finding is replicated, it suggests the need to examine such mechanisms as genetics and intrauterine factors for the association between maternal depression and frontal brain activity in prenatally exposed infants. Other potential moderators yield mixed findings. For example, abnormalities in neurobiological or neuroendocrine functioning in infants are sometimes specifically found to be associated with face-to-face interaction with their depressed mothers Field, and with harsh parenting in particular Hertsgaard et al.

The ultimate outcome of concern among children of depressed parents is the emergence of elevated levels of behavior problems or diagnosable psychopathology. Many studies show that rates of depression are higher in children with depressed mothers, whether the maternal depression is determined by meeting diagnostic criteria or clinically significant levels of depressive symptom scale scores, relative to a variety of controls Beardslee et al.

Studies with adolescents show the same. Adolescents with depressed parents have been found to have higher rates of depression Beardslee et al. Overall, rates of depression in the school-age and adolescent children of depressed mothers have been reported to be between 20 and 41 percent, in contrast to general population rates of about 2 percent in children ages 12 and younger and 15 to 20 percent in adolescents Lewinsohn et al.

Not only are rates of depression higher, but depression in children of depressed parents, relative to depression in same-age children of non-depressed parents, has an earlier age of onset and longer duration and is associated with greater functional impairment and a higher likelihood of recurrence Hammen and Brennan, ; Hammen et al.

For example, maternal depression was associated with higher rates of internalizing problems e. In middle childhood and adolescence, daughters of depressed mothers may be more likely than sons to show depression Davies and Windle, ; Fergusson, Horwood, and Lynskey, ; Hops, , although others have not found sex differences Fowler, In terms of clinical characteristics, mothers who reported high levels of depressive symptoms reported higher levels of behavior problems in their 5-year-old children, with even stronger associations when those symptoms were severe, chronic, and recent Brennan et al.

A few of the studies of psychopathology as an outcome for children or adolescents have tested the bidirectional or transactional role—to what extent do problems in the children contribute to the depression in the parents? In two seminal studies on this topic, based on two distinct samples Gross et al. At the same time, a few findings, specific to particular ages, supported child effects on parental depression. For example, higher levels of aggressive behavior in 5-year-old boys predicted higher levels of maternal depression when the boys were 6 years old Gross, Shaw, and Moilanen, These researchers also found that child noncompliance was more strongly associated with depression in mothers than in fathers Gross et al.

Across multiple studies, depression in mothers has been found to be more strongly associated with internalizing and externalizing problems in children relative to depression in fathers, as revealed in a meta-analysis Connell and Goodman, Nonetheless, depression in fathers is of concern.

For example, in a large cohort study, depression in fathers during the postnatal period predicted a greater likelihood of preschool-age boys and girls having emotional and behavioral problems and boys having conduct problems Ramchandani et al. These findings were maintained even after accounting for postnatal depression in the mothers and later depression in the fathers.

A more recent study found that the problems in the children persist until age 7 Ramchandani et al. Sons of depressed fathers also had higher levels of suicidal ideation and higher rates of attempts, whereas that association with depression in mothers was not significant. And recurrent depression in fathers but not mothers was associated with depression recurrence in daughters, but not sons.

These studies suggest direct and specific associations between depression in fathers and the development of psychological problems in their children. In order to further examine the relationship of paternal depression to psychopathology in the child, the committee undertook an independent analysis of public use data from the National Comorbidity Survey-Replication NCS-R 1 study. The NCS-R offered the opportunity to analyze a data set generalizable to the population in the United States in which the elements of a comprehensive theoretical framework consistent with the goals of our committee could be examined.

We conducted our analysis separately among male and 1, female respondents, ages 18—35 at the time of the NCS-R interview. These analyses were conducted incorporating the weighting and design effects from the NCS-R. We statistically tested the mediational effects of these factors and found that an alternate model in which these potential mediating variables were treated as covariates provided a better fit.

Hence, we evaluated the independent and potential moderating effects of these variables in multiple logistic regression analyses. In these logistic regression models, we retained independent variables that had p-values less than 0. Interaction terms with p-values less than 0. In contrast, those whose fathers experienced 2 or more weeks of sadness alone and those whose fathers had drug or alcohol problems alone had elevated rates of major depression compared to those with neither risk factor, with odds ratios of 3.

Also, males who reported having experienced trauma before the age of 18 were approximately 3. These findings underscore the importance of examining the effects of paternal risk factors as well as maternal risk factors for psychopathology in children and that comprehensive models are required to properly quantify the effects of these risk factors, many of which are intercorrelated and may show effect moderation. Further studies of this type are needed, especially those in which more detailed information on personal trauma and neglect history can be included in public use data sets to be further analyzed, e.

The timing of exposure has received quite a bit of attention as a potential moderator, addressing the question: Is there a sensitive period for exposure to maternal depression?

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Two prospective studies conducted in Great Britain came to somewhat different conclusions regarding the role of postpartum depression alone in predicting adverse outcomes for children, regardless of subsequent episodes. Hay and colleagues studied youth from low-income homes. In the other British study, which sampled from a more middle-income population, postnatal depression exposure was associated with subsequent behavior problems at age 5 and symptoms of hyperactivity and conduct disorder at age 8 Morrell and Murray, However, later follow-ups revealed that both postnatal depression and later episodes of depression in mothers predicted depression in the children at age 13, although anxiety was best predicted by postpartum exposure alone Halligan et al.

Others concluded that postpartum depression does not predict later functioning in children, but that it is later exposures that matter. Typical of these studies are two that focused on children of preschool age through adolescence. Most of the longitudinal studies of infants and toddlers have drawn similar conclusions, that is, children of the recovered mothers showed fewer disturbances than the children of unrecovered mothers but greater disturbances than the children of control mothers who had never been depressed Cox et al.

Similarly, in a follow-up of low-income children ages 18 months to 4—6 years, Alpern and Lyons-Ruth showed that both the group of children whose mothers exceeded the clinical cutoff score on a depression rating scale at both times and the group whose mothers were previously but not currently depressed had more behavior problems than the children with never-depressed mothers. Stein et al. There are some exceptions to this finding, and these are intriguing. For example, Field reported that 75 percent of mothers who had been depressed early in the postpartum period continued to have symptoms at 6 months postpartum.

The infants of the remaining 25 percent did not display a depressed style of interaction or have lower Bayley mental and motor scale scores at 1 year of age Field, Another intriguing question that has been addressed by some of the longitudinal studies is: If parenting quality improves with remission of depression, do children benefit?

A few studies help to answer that question. Campbell, Cohen, and Meyers , for example, found that mothers who were depressed 2 months postpartum but whose depression remitted by 6 months were significantly more positive and more competent in feeding their infants relative to mothers whose depression was chronic through 6 months postpartum Campbell, Cohn, and Meyers, Furthermore, the infants in the depression remission group were significantly more positive in face-to-face interactions with their mothers than were those whose mothers remained depressed, although they did not differ significantly in terms of negative interaction or in the quality of engagement with their mothers in toy play.

Treatment studies are reviewed in Chapter 6 , but we focus here on the small subset of treatment studies that allow us to address this issue. More recent studies continue to show that despite improvement in depression with interpersonal psychotherapy, mother-infant relationships were not improved Forman et al. Similarly, Cooper and Murray , with a community sample screened for depression, found that treated mothers randomly assigned to either nondirective counseling, cognitive-behavioral therapy, or dynamic psychotherapy , despite significant improvement in mood, were not ob served to differ from untreated mothers or early remission mothers either on sensitive-insensitive or intrusive-withdrawn dimensions in face-to-face interactions with their infants Cooper and Murray, It should be noted that these studies may have been restricted in their ability to find an impact of treatment on parenting in that the initial level of disturbance in parenting in these community samples may have been relatively minor.

System Under Maintenance

How do mothers cope with child care and associated problems when, in adversity, they do not gain access to social service support? This book considers the. No results for Prevention and Coping in Child and Family Care: Mothers in Adversity Coping With Child Care Michael Sheppard, Mirka Grohn in Books.

In a third study, Fleming, Klein, and Corter investigated a community sample of women with self-reported depression who were treated with group therapy. Despite limited changes in ratings of depression, the treated mothers made more noninstrumental approaches to their infants, and the infants decreased in amounts of crying and increased in noncry vocalizations.

In a recent small sample study, in contrast to these three studies of psychotherapy, the intervention for postpartum depression was antidepressant medication treatment Goodman et al. Others, such as Weissman et al. Those studies are reviewed in Chapter 7. Although strong evidence now supports the breadth and extent of associations between depression in parents and adverse outcomes in children, there remain many unanswered questions.

Coping with child violencein primary care: how do professionals perceive it?

In particular, many questions remain regarding mediation and moderation of those associations. In terms of mediation, more studies are needed to test specific aspects of parenting and other potential mediators of associations between depression in parents and child functioning. In this regard, the committee noted the strong potential of studies designed to test the effectiveness of interventions aimed at reducing the level of constructs that have been found to mediate associations between depression in parents and outcomes in children, for example, particular aspects of parenting.

Such experimental designs can be strong tests of mediation. In terms of moderation, more studies are needed to reveal which children of depressed parents are more or less likely to develop problems and which parents with depression are more or less likely to have problems with parenting. Moderators might include parent characteristics, including severity, duration, and impairing qualities of their depression, social context variables, and child characteristics, among others. More broadly, more studies are needed to quantify percentages of children who are affected with specific outcomes and those who are not and what distinguishes them.

The committee notes the potential knowledge to be gained by further studies that target interventions to subsets of children with greater or lesser risk degree of presence of moderators to determine whether interventions need to be addressed to children at all levels of risk do they benefit equally? The committee also notes several gaps in the literature related to the physical health of children of depressed parents. More tracking is needed of health care utilization, missed school days, and other aspects of daily functioning in association with depression in parents.

In particular, we conclude that more research is needed to understand the role of maternal depression in the health outcomes of children. Furthermore, both psychological and physical health outcomes need to be addressed in longitudinal studies of healthy and chronically ill children in order to know how physical health outcomes relate to psychological outcomes.

Finally, tracking of avoidable and desirable health care utilization is needed to understand the impact on health services. In addition to the research gaps in terms of unanswered questions, the committee also found gaps in relation to study design. First, tests of mediation are most informative when conducted on data from longitudinal designs, with measures of depression, parenting, and child functioning at multiple time points in order to capture the pathways. A second methodological issue concerns the measurement of depression in parents. The committee recognizes the staffing and time constraints that often prohibit the use of diagnostic interviews yet encourages their use whenever possible.

Among groups who exceed clinical cutoffs will be those who would also meet diagnostic criteria and those who do not, despite their high symptom levels. Differences in parenting and child outcomes between those two groups need to be understood. Third, more studies from a developmental perspective are needed. Such studies need not be longitudinal but require an understanding of child development in their theoretical model, hypotheses, design especially in terms of the ages of the children studied , and the selection and psychometric properties of the measures.

Fourth, the research literature would benefit from improving on the measurement of depression in population-based surveys to enhance their potential value to address these research gaps. Fifth, more research studies are needed to test hypotheses derived from transactional models. Depression interferes with parenting. Depression in mothers of young children is significantly associated with more hostile, negative, and disengaged withdrawn parenting. Maternal depression is significantly associated with less positive parenting warmth. Parenting quality may not improve with recovery from depression.

Although depression and parenting of older children are less often studied, findings are clear that depression also interferes with the qualities of parenting needed by children in middle school and in adolescence. Although less is known about parenting in depressed fathers, the accumulating evidence suggests that depression also interferes with healthy parenting in fathers. Families with one or more depressed parents often have additional factors that generally impose risk for children, such as substance use disorders, poverty, exposure to violence, minority status, cultural and linguistic isolation, and marital conflict, which interfere with good parenting qualities and healthy child rearing environments.

These additional risk factors are sometimes found to work independently and at other times found to be additive or interactive with the effects of depression in parents. A child with a depressed parent is more likely than other children to evidence other psychological impairment e. Turn recording back on. National Center for Biotechnology Information , U. Search term. SUMMARY Parenting Practices Depression is significantly associated with more hostile, negative parenting, and with more disengaged withdrawn parenting, both with a moderate effect size.

Findings are primarily related to mothers rather than to fathers. Depression in mothers is significantly associated with less positive parenting warmth , with a small effect size. The poorer parenting qualities may not improve to levels comparable to those of never-depressed parents, despite remission or recovery from episodes of depression.

These patterns of parenting have been found in depressed mothers of infants and young children as well as in depressed mothers of school-age children and adolescents. Less is known about parenting in depressed fathers relative to mothers, but most of the findings from the smaller number of studies are consistent with the findings about mothers. Infants and young children of mothers with depression are more likely to use a variety of acute health care services. For older children and adolescents, there is limited evidence to suggest that depression plays a role in visits for stress-related health conditions and increased health care utilization.

Adverse health outcomes of accidents, childhood asthma, child maltreatment, and adolescent tobacco and substance use occur more often when a parent is depressed. Maternal depression symptoms and stress levels are high among caregivers of children with chronic conditions. Depression in parents is associated with maladaptive patterns of health care utilization for children. For older children and adolescents, there is limited evidence to suggest impact on health care utilization. Depression in parents has been consistently associated with a number of behavior problems and psychopathology in children, including higher rates of depression, earlier age of onset, longer duration, greater functional impairment, higher likelihood of recurrence, higher rates of anxiety, and higher rates and levels of severity of internalizing and externalizing symptoms and disorders in children and adolescents.

Mediators and Moderators Depression in parents is more likely to be associated with adverse outcomes in children with the presence of additional risk factors e. Parental functioning, prenatal exposure to stress and anxiety, genetic influences, and stressful environments appear to play a role in the development of adverse outcomes in children.

Middle Childhood and Adolescence Although direct observations of parent-child interactions in samples of depressed parents with older children and adolescents have been less common than with infants and younger children, a few studies have tested and found support for the hypothesis that depression is associated with parenting of adolescents and that the affected parent-child interactions may represent a crucial pathway for parental depression to the development of psychological problems in the adolescents e.

Maternal Depression Increases Risk for Punitive Parenting and Child Abuse As much as one needs to be concerned about depression in parents being associated with negative parenting qualities such as rejection, harshness, and intrusiveness, it is of even greater concern that researchers find depression in parents to be associated with maltreatment of children.

Mediators and Moderators of Associations Between Depression and Parenting Given the strong and consistent evidence linking depression and parenting, it is important to ask what factors might mediate the relations between parental depressive symptoms and parenting behaviors. Summary The studies reveal well-replicated findings on the relation between parental depression and impaired parenting for children from infancy and even fetal development through adolescence.

Physical Health and Health Care Utilization Consequences The health-related outcomes for children when a parent is depressed have been studied in several key areas. Newborns Antenatal depression, as well as stressful life events and anxiety, which often co-occur with depression, have been linked to complications of pregnancy or delivery e.

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Infants and Young Children The social-environmental risk factors for child hospitalization in the first two years were examined in a Canadian cohort while controlling for biological risk factors. Child Psychological Problems and Well-Being Particular Aspects of Concern Researchers have studied a range of aspects of child psychological problems and well-being. Newborn Neurobehavioral Outcomes Researchers have reported varying degrees of consistency of support for associations between elevated levels of antenatal depression and poorer newborn neurobehavioral regulation.

Temperament Several researchers have found that infants of depressed mothers, relative to controls, have more difficult temperament. School Dropout and Adolescent Sexual Behavior In a longitudinal study of offspring of depressed and nondepressed mothers followed annually from 6th through 12th grade, higher IQ was found to be protective of dropping out among offspring of never- or moderately depressed mothers but not for adolescents whose mothers had been chronically or severely depressed Bohon, Garber, and Horomtz, Cognitive Vulnerabilities to Depression One of the strongest predictors of depression in adults and also in children is the presence of cognitive vulnerabilities.

Stress and Coping Of particular concern is a pattern of children of depressed mothers current or past depression being more reactive cognitively e. Interpersonal Functioning Beginning with studies of infants, researchers have identified problems in interpersonal functioning associated with depression in mothers. Psychobiological Systems: Stress Responses and Cortical Activity Researchers have found significant associations between maternal depression and two psychobiological systems in children that have been found to play a role in emotion regulation and expression.

Behavior Problems or Psychopathology The ultimate outcome of concern among children of depressed parents is the emergence of elevated levels of behavior problems or diagnosable psychopathology. Timing of Exposure The timing of exposure has received quite a bit of attention as a potential moderator, addressing the question: Is there a sensitive period for exposure to maternal depression?

Stress exposure and stress generation in children of depressed mothers. Journal of Consulting and Clinical Psychology , 61 , — Alpern, L. Preschool children at social risk: Chronicity and timing of maternal depressive symptoms and child behavior problems at school and at home.

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Ashman, S. Maternal depression, infant psychobiological development, and risk for depression. Goodman, editor; and I. Gotlib, editor. Austin, M. Maternal trait anxiety, depression and life event stress in pregnancy: Relationships with infant temperament. Early Human Development , 81 , — Avenevoli, S. Implication of high-risk family studies for prevention of depression. American Journal of Preventive Medicine , 31 , — Bailey, D. Maternal depression and developmental disability: Research critique. Banyard, V.

The impact of complex trauma and depression on parenting: An exploration of mediating risk and protective factors. Child Maltreatment , 8 , — Bartlett, S. Maternal depressive symptoms and emergency department use among inner-city children with asthma. Archives of Pediatric and Adolescent Medicine , , — Maternal depressive symptoms and adherence to therapy in inner-city children with asthma.

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In this sense, the difficulties refer to the following aspects: the lack of instruments to cope with questions related to violence during the qualification of nurses and other heath team professionals, fear of exposure of professionals in areas with great violence and a bureaucratic support network, as these situations take a long time to be resolved. It may be that the anxiety, known to be highly correlated with depression, matters more. Thus, one may question whether rights are being protected, when insufficient investment of public power has been made in human, financial and logistic resources that guarantee the rights of children and adolescents. Classes 2, 3 and 4 mainly include discourses on the local level community health agents, nursing assistants, physicians, nurses, managers and professionals responsible for questions related to violence or the Family Health Support Center , corresponding to 70 ECUs out of the 72 that comprise them. The future of any society depends on its ability to foster the healthy development of the next generation. A more recent study found that the problems in the children persist until age 7 Ramchandani et al.

Abstract The central position of parents, in particular, mothers, in childcare has been the focus of much recent legislation and research in social work. Issue Section:. You do not currently have access to this article. Download all figures. Sign in. You could not be signed in. Sign In Forgot password? Don't have an account? Sign in via your Institution Sign in. Purchase Subscription prices and ordering Short-term Access To purchase short term access, please sign in to your Oxford Academic account above.

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