**Parent-Child Attachment, Parental Depression, and Perception of Child Behavioural/Emotional Problems**

Lawrence T. Lam

[24] Marmar, C. R, & Gaston, L. Manual for the California Psychotherapy Alliance Scale-CALPAS. Unpublished Manuscript, S.Francisco: Department of Psychiatry, University

[25] Marmar, C. R, Weiss, D. S, & Gaston, L. Towards the validation of the California

[26] Martin, D. J, Garske, J, Davis, P, & Katherine, M. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol.

[27] Newman, D. L, et al. Psychiatric disorder in a birth cohort of young adult: prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21. J Counsult

[28] Pani, R, Biolcati, R, & Sagliaschi, S. Psicologia clinica e psicopatologia per l'educazione

[29] Piper, W. E, et al. Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome. Journal of Nervous and

[30] Ryan, V. L, & Cicchetti, D. V. Predicting quality of alliance in the initial psychotherapy

[31] Startup, M, Jackson, M. C, & Bendix, S. The current validity of the Global Assesment of Functioning (GAF). British Journal of Clinical Psychology (2002). , 46(1), 126-142.

[32] Wilson, P. A View of intervention in Adolescence. In: Adolescence (1976). Monograph

[33] WHOICD 10, International Classification of Diseases, Geneva: World Health Organi‐

interview. Journal of Nervous and Mental Disease (1985). , 173, 171-125.

Therapeutic Alliance Rating System. Cons Clin Psychol (1989). , 1, 46-52.

of California; (1988).

254 Mental Disorders - Theoretical and Empirical Perspectives

(2000). , 68(3), 438-50.

Clin Psycol (1996). , 64(3), 552-562.

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zation; (1994).

e la formazione,. Bologna Italy: Il Mulino; (2009).

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51170

### **1. Introduction**

The issue of whether parents who have experienced symptoms of psychopathology, particu‐ larly depression, would be able to provide an accurate report on the behavioural/emotional problems of their children has long been raised. [1] It has been suggested that parental de‐ pression plays an important role in their perception of their children's behavioural. [2-7] The early review by Breslau (1988) on the available studies in 1988 found that there was no evi‐ dence for any distortion of child behavioural problems using depressed mothers as inform‐ ants. [1] However, more recent studies have found a positive relationship between parental depression, particularly maternal depression, and report of increased behavioural/emotional problems of their children. For example, in the study by Fergussen et al. on the effect of ma‐ ternal depression on their ratings of children behaviour found a significant association be‐ tween their depression and children's conduct disorder and attention deficit behaviour. [3] A recent study by Hall et al. also found that depressive symptoms in mothers contributed significantly to the perception of both internalising and externalising problems of their chil‐ dren when they were asked to report on their children's behaviour [7].

Parent-child relationships, particularly attachment or connectedness between the parent and child, have been reported to have an effect on the behavioural and emotional health of chil‐ dren and adolescents. [8-9] In terms of the parent-child relationship and parental perception of their children's behavioural and emotional problems, it has been noted that few studies have been conducted. [5] The study by Kolko et al. found that low parental acceptance of the child was significantly associated with the difference between parents' and teachers' percep‐ tion of children's externalising but not internalising behaviour. [10] Another study by Mos‐ ley et al. also found that better parent-child relationships in terms of increased involvement also related to a decrease of parental perception on both internalising and externalising be‐

© 2013 Lam; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

havioural problems. [11] A more recent study by Treulter & Epkins also found that the pa‐ rent-child relationship, measured as parental involvement and time spent with children, was significantly related to both parents' rating of externalising behaviour. [5] In sum, these studies suggested an overall negative association between parent-child relationships and their perception on children's behavioural/emotional problems such that the better the pa‐ rent-child relationship, the less the degree of parental perception of children's behavioural/ emotional problems.

The sample was generated from the total student population of grade 4 primary school chil‐ dren within the study district. All students were registered with the Guangzhou city pri‐ mary school registry. According the latest information from the registry, there were about 8400 grade 4 primary school children enrolled within the study district in 2008. A stratified random sampling method with stratification according to proportions of students in differ‐ ent type of schools: schools run by provincial government, local government, or private

Parent-Child Attachment, Parental Depression, and Perception of Child Behavioural/Emotional Problems

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257

The base-line survey was conducted at different schools within the same week. Parents of the selected students from different schools were invited to participate in the longitudinal study via school principals and their teachers, and were encouraged to fill in the baseline self-reported questionnaire designed specifically for the study. Informed consent was sought from each parent by signing a consent form indicating willing participation in the

The outcome of the study, namely parental perception of child behavioural problems, was assessed using the Child Behavioural Checklist for Ages 6-18 (CBCL/6-18), which was a vali‐ dated, standardised, and a widely used scale for assessing behavioural problems amongst children and adolescents internationally. [13] Parents were asked to respond to 113 items that described specific behavioural and emotional problems that might occur in children and adolescents. These items were rated by parents on their perception of how true each item described their children now or within the past 6 months using a scale ranging from 0 to 2 (0=not true; 1=somewhat true or sometimes true; 2=very true or often true). The main content of the CBCL/6-18 covers 8 different domains including aggressive behaviour, anx‐ ious/depressed, attention problems, rule-breaking behaviour, social problems, somatic com‐ plaints, thought problems, and withdrawal. These eight domains are then further summarised into two main clusters of behavioural or emotive problems: internalisation (CBCL-inter) and externalisation (CBCL-exter) problems. A total score was also calculated for each child as an overall summary of the individual's behavioural problems (CBCL-total). Examples of these items included: "Can't concentrate, can't pay attention for long" for atten‐ tion problems; "Cruel to animals" for aggressive behaviour; and "Unhappy, sad, or de‐ pressed" for anxious/depressed emotions. Higher total scores, internalisation, and externalisation scores, indicate a greater severity of behavioural or emotive problems. Am‐ ple studies have been conducted on the validity and reliability of the CBCL/6-18 with full information available on the Achenbach System of Empirically Based Assessment (ASEBA)

Parental depression was measured using the depression subscale of the Hospital Anxiety and Depression Scale (HADS) which was designed as a self-reported screening instrument for depression. [15] The instrument has been used in many studies and its validity is well proven. [16] The depression subscale consists of 7 items assessing depressive affects. Exam‐ ples of these items include: "I look forward with enjoyment to things" and "I have lost inter‐ est in my appearance". Respondents were asked to respond to questions of how often they had experienced these emotional states in the month prior to the survey. On a Likert scale, responses were rated from 0 to 3 for not at all to all of the time or some equivalent responses

schools, were used for sample generation.

longitudinal study.

official website [14].

The above-mentioned studies have suggested both parental depressive symptoms and pa‐ rent-child relationships are associated with parent's perception of children's behavioural/ emotional problems. However, the foci of all these studies are on individual variables, either parental depressive symptoms or parent-child relationships, and their associations with pa‐ rental perception. All of the above-mentioned studies considered only one of the two factors with the exception of the study by Treulter & Epkins. [5] It has been known that parental depression, particularly maternal depression, exerts a significant influence on the parentchild relationship. [12] Therefore, it is logical to consider that there could be an interaction effect of parental depression and parent-child relationship on parent's perception of chil‐ dren's behavioural/emotional problems. A search of the current literature has revealed no related studies on this topic.

The aim of this study is to further examine the relationships between parental depression, parent-child relationship and parental perception of children's behavioural/emotional prob‐ lems. Of particular interest of the study is the possible interaction effect between parental depression and parent-child relationship, specifically parent-child attachment or connected‐ ness, on the perception of children's behavioural/emotional problems. It is hypothesised that the parent-child relationship acts as an effect modifier in the relationship between parental depression and the perception of children's behavioural/emotional problems in a manner that depressed parents who also have inadequate attachment or connectedness with their children would have a significantly increased rating on their children's behavioural/ emotional problems.

### **2. Methods**

This cross-sectional survey is part of the Guangzhou city primary school students' behav‐ ioural problems intervention longitudinal cohort study. The survey serves as the base-line pre-intervention data collected on participating school children and their parents as well as a screening for behavioural problems among children. The cohort study is an on-going study conducted in the YueXiu district, the biggest district of the Guangzhou city in Guang‐ dong Province, since December 2008. Guangdong Province is located in Southern China, and is the most populous province in China of which Guangzhou city is the capital. It is the biggest and most populated city of the Province with an estimated population of nearly 10 million in 2006. Institute ethics approval for the study was granted by the Human Ethics Committee of the Sun Yat-Sen University, GuangZhou, PR China.

The sample was generated from the total student population of grade 4 primary school chil‐ dren within the study district. All students were registered with the Guangzhou city pri‐ mary school registry. According the latest information from the registry, there were about 8400 grade 4 primary school children enrolled within the study district in 2008. A stratified random sampling method with stratification according to proportions of students in differ‐ ent type of schools: schools run by provincial government, local government, or private schools, were used for sample generation.

havioural problems. [11] A more recent study by Treulter & Epkins also found that the pa‐ rent-child relationship, measured as parental involvement and time spent with children, was significantly related to both parents' rating of externalising behaviour. [5] In sum, these studies suggested an overall negative association between parent-child relationships and their perception on children's behavioural/emotional problems such that the better the pa‐ rent-child relationship, the less the degree of parental perception of children's behavioural/

The above-mentioned studies have suggested both parental depressive symptoms and pa‐ rent-child relationships are associated with parent's perception of children's behavioural/ emotional problems. However, the foci of all these studies are on individual variables, either parental depressive symptoms or parent-child relationships, and their associations with pa‐ rental perception. All of the above-mentioned studies considered only one of the two factors with the exception of the study by Treulter & Epkins. [5] It has been known that parental depression, particularly maternal depression, exerts a significant influence on the parentchild relationship. [12] Therefore, it is logical to consider that there could be an interaction effect of parental depression and parent-child relationship on parent's perception of chil‐ dren's behavioural/emotional problems. A search of the current literature has revealed no

The aim of this study is to further examine the relationships between parental depression, parent-child relationship and parental perception of children's behavioural/emotional prob‐ lems. Of particular interest of the study is the possible interaction effect between parental depression and parent-child relationship, specifically parent-child attachment or connected‐ ness, on the perception of children's behavioural/emotional problems. It is hypothesised that the parent-child relationship acts as an effect modifier in the relationship between parental depression and the perception of children's behavioural/emotional problems in a manner that depressed parents who also have inadequate attachment or connectedness with their children would have a significantly increased rating on their children's behavioural/

This cross-sectional survey is part of the Guangzhou city primary school students' behav‐ ioural problems intervention longitudinal cohort study. The survey serves as the base-line pre-intervention data collected on participating school children and their parents as well as a screening for behavioural problems among children. The cohort study is an on-going study conducted in the YueXiu district, the biggest district of the Guangzhou city in Guang‐ dong Province, since December 2008. Guangdong Province is located in Southern China, and is the most populous province in China of which Guangzhou city is the capital. It is the biggest and most populated city of the Province with an estimated population of nearly 10 million in 2006. Institute ethics approval for the study was granted by the Human Ethics

Committee of the Sun Yat-Sen University, GuangZhou, PR China.

emotional problems.

256 Mental Disorders - Theoretical and Empirical Perspectives

related studies on this topic.

emotional problems.

**2. Methods**

The base-line survey was conducted at different schools within the same week. Parents of the selected students from different schools were invited to participate in the longitudinal study via school principals and their teachers, and were encouraged to fill in the baseline self-reported questionnaire designed specifically for the study. Informed consent was sought from each parent by signing a consent form indicating willing participation in the longitudinal study.

The outcome of the study, namely parental perception of child behavioural problems, was assessed using the Child Behavioural Checklist for Ages 6-18 (CBCL/6-18), which was a vali‐ dated, standardised, and a widely used scale for assessing behavioural problems amongst children and adolescents internationally. [13] Parents were asked to respond to 113 items that described specific behavioural and emotional problems that might occur in children and adolescents. These items were rated by parents on their perception of how true each item described their children now or within the past 6 months using a scale ranging from 0 to 2 (0=not true; 1=somewhat true or sometimes true; 2=very true or often true). The main content of the CBCL/6-18 covers 8 different domains including aggressive behaviour, anx‐ ious/depressed, attention problems, rule-breaking behaviour, social problems, somatic com‐ plaints, thought problems, and withdrawal. These eight domains are then further summarised into two main clusters of behavioural or emotive problems: internalisation (CBCL-inter) and externalisation (CBCL-exter) problems. A total score was also calculated for each child as an overall summary of the individual's behavioural problems (CBCL-total). Examples of these items included: "Can't concentrate, can't pay attention for long" for atten‐ tion problems; "Cruel to animals" for aggressive behaviour; and "Unhappy, sad, or de‐ pressed" for anxious/depressed emotions. Higher total scores, internalisation, and externalisation scores, indicate a greater severity of behavioural or emotive problems. Am‐ ple studies have been conducted on the validity and reliability of the CBCL/6-18 with full information available on the Achenbach System of Empirically Based Assessment (ASEBA) official website [14].

Parental depression was measured using the depression subscale of the Hospital Anxiety and Depression Scale (HADS) which was designed as a self-reported screening instrument for depression. [15] The instrument has been used in many studies and its validity is well proven. [16] The depression subscale consists of 7 items assessing depressive affects. Exam‐ ples of these items include: "I look forward with enjoyment to things" and "I have lost inter‐ est in my appearance". Respondents were asked to respond to questions of how often they had experienced these emotional states in the month prior to the survey. On a Likert scale, responses were rated from 0 to 3 for not at all to all of the time or some equivalent responses with total scores ranging from 0 to 21. Responses were graded in a negative direction in a manner that higher scores represent greater depressive affects. Attachment or connected‐ ness between parent and child was assessed using the Attachment Problems subscale of the Parental Stress Index (PSI). [17] The PSI was designed specifically to evaluate and to diag‐ nose individual parent-child dyads under stress. Of different domains included in the in‐ strument, attachment between parent and child is one "designed to measure the intrinsic investment the parent in the role of parent". [17] It was used to assess the degree of willing‐ ness parents would commit and attach in the relationship with their children. Parents were asked to rate how much they agree to a series of statements regarding their relationship with their children on a Likert scale ranging from 0 to 4. Responses were graded in a direc‐ tion with higher scores indicating greater attachment problems. An example item is "I ex‐ pected to have closer and warmer feelings for my child than I do and this bothers me". The reliability and validity of the PSI have been demonstrated in many studies [17-19].

were not parents of the targeted child. The characteristics of children and their parents in‐ cluding parental depression, attachment problems, and parental perception of behavioural problems were summarised in Table 1. In terms of the outcome variables, the mean values of all CBCL scores were larger than their corresponding median values with large standard deviations suggesting all three scores were skewed and had problems of over dispersion.

Parent-Child Attachment, Parental Depression, and Perception of Child Behavioural/Emotional Problems

**Variables Frequency (%) or mean (s.d.), median**

958 (52.2) 876 (47.8)

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259

767 (42.7) 1031 (57.3)

1624 (89.8) 184 (10.2)

920 (51.1) 418 (23.2) 462 (25.7)

232 (13.1) 465 (26.4) 425 (24.1) 201 (11.4)

601 (35.2) 522 (30.5) 586 (34.3)

292 (15.9) 1547 (84.1)

Age of the child (years) Mean=9.5 (0.61), median=9.5

Age of parent (years) Mean=38.7 (4.11), median=38.1

**Demographics**

Sex of child Male Female

Father Mother

Others

Business

Low Middle High

Yes No

Family structure

Parent's education level High school or lower Post secondary University or higher

Parent's occupation Unemployed /retired Farmer/labourer Government official Professional/technical

Monthly income (RMB\$)\*

Parent having chronic disease or hospitalised

Relation of parent to child

Living with both biological parents

Other information collected in the survey included age and sex of the child, respondents' age and sex, parental education levels, occupation, family structure whether intact or di‐ vorced, family monthly incomes, and whether the parent suffered any chronic illnesses or hospitalisation. Included in the study were only parents of target children. Other respond‐ ing relatives, such as grandparents, were excluded.

Data were analysed using the Stata V10.0 statistical software program. [20] Descriptive sta‐ tistics on the sample including frequencies, percentages, means, standard deviations, and median were presented according to the nature of variables. All CBCL scores were treated as continuous variables. Bivariate analyses were conducted to examine unadjusted relation‐ ships between parental depression, attachment problems, demographics, and parental per‐ ception of child behavioural problems including the total, internalisation, and externalisation scores. Owing to the fact that CBCL-total, CBCL-inter, and CBCL-exter scores were highly skewed and exhibited problems of over dispersion, it was considered more appropriate to analyse these data with negative binomial regression models. Hence, this analytical technique was applied to all unadjusted and adjusted analyses. Bivariate as‐ sociations between all variables of interest and parental perception of child behavioural problems were analysed with simple negative binominal regression models and were tested using the Likelihood Ratio Chi-squared tests. All significant variables identified from the bi‐ variate analyses were included in further analyses for the adjusted relationship between pa‐ rental depression, attachment problems and their perception of their children's behavioural problems. Of particular interest to the study was the interaction effect of parental depression and attachment problems between parent and child, on parental perception of children be‐ havioural problems. Hence, the significance of interaction terms was tested in the final mod‐ els for CBCL-total, CBCL-inter, and CBCL-exter scores.

#### **3. Results**

A total of 1839 parent-child dyads were recruited and provided usable information. This represented 97.1% of the total participants of the longitudinal study. Fifty-six respondents were not parents of the targeted child. The characteristics of children and their parents in‐ cluding parental depression, attachment problems, and parental perception of behavioural problems were summarised in Table 1. In terms of the outcome variables, the mean values of all CBCL scores were larger than their corresponding median values with large standard deviations suggesting all three scores were skewed and had problems of over dispersion.

with total scores ranging from 0 to 21. Responses were graded in a negative direction in a manner that higher scores represent greater depressive affects. Attachment or connected‐ ness between parent and child was assessed using the Attachment Problems subscale of the Parental Stress Index (PSI). [17] The PSI was designed specifically to evaluate and to diag‐ nose individual parent-child dyads under stress. Of different domains included in the in‐ strument, attachment between parent and child is one "designed to measure the intrinsic investment the parent in the role of parent". [17] It was used to assess the degree of willing‐ ness parents would commit and attach in the relationship with their children. Parents were asked to rate how much they agree to a series of statements regarding their relationship with their children on a Likert scale ranging from 0 to 4. Responses were graded in a direc‐ tion with higher scores indicating greater attachment problems. An example item is "I ex‐ pected to have closer and warmer feelings for my child than I do and this bothers me". The

reliability and validity of the PSI have been demonstrated in many studies [17-19].

ing relatives, such as grandparents, were excluded.

258 Mental Disorders - Theoretical and Empirical Perspectives

els for CBCL-total, CBCL-inter, and CBCL-exter scores.

**3. Results**

Other information collected in the survey included age and sex of the child, respondents' age and sex, parental education levels, occupation, family structure whether intact or di‐ vorced, family monthly incomes, and whether the parent suffered any chronic illnesses or hospitalisation. Included in the study were only parents of target children. Other respond‐

Data were analysed using the Stata V10.0 statistical software program. [20] Descriptive sta‐ tistics on the sample including frequencies, percentages, means, standard deviations, and median were presented according to the nature of variables. All CBCL scores were treated as continuous variables. Bivariate analyses were conducted to examine unadjusted relation‐ ships between parental depression, attachment problems, demographics, and parental per‐ ception of child behavioural problems including the total, internalisation, and externalisation scores. Owing to the fact that CBCL-total, CBCL-inter, and CBCL-exter scores were highly skewed and exhibited problems of over dispersion, it was considered more appropriate to analyse these data with negative binomial regression models. Hence, this analytical technique was applied to all unadjusted and adjusted analyses. Bivariate as‐ sociations between all variables of interest and parental perception of child behavioural problems were analysed with simple negative binominal regression models and were tested using the Likelihood Ratio Chi-squared tests. All significant variables identified from the bi‐ variate analyses were included in further analyses for the adjusted relationship between pa‐ rental depression, attachment problems and their perception of their children's behavioural problems. Of particular interest to the study was the interaction effect of parental depression and attachment problems between parent and child, on parental perception of children be‐ havioural problems. Hence, the significance of interaction terms was tested in the final mod‐

A total of 1839 parent-child dyads were recruited and provided usable information. This represented 97.1% of the total participants of the longitudinal study. Fifty-six respondents



CBCL scores. Results also suggested the unadjusted association between parental depres‐ sion and the perception of their children's behavioural problems was highly significant for

Parent-Child Attachment, Parental Depression, and Perception of Child Behavioural/Emotional Problems

1=42.52, p<0.001; CBCL-inter: χ<sup>2</sup>

1=28.83, p<0.001). This also applied to attachment problems (CBCL-total: χ<sup>2</sup>

**Variables in the final model** β SE(β) Z-value p-value

Female -0.21 0.047 -4.45 <0.001 Parent's age -0.02 0.006 -3.66 <0.001 Parent having chronic disease or hospitalised 0.25 0.062 3.94 <0.001 Attachment problems 0.03 0.007 3.32 0.001 Parental depression 0.05 0.008 5.71 <0.001

Parent's age -0.02 0.007 -2.49 0.013 Parent having chronic disease or hospitalised 0.31 0.070 4.50 <0.001 Attachment problems 0.03 0.008 3.97 <0.001 Parental depression 0.06 0.001 5.96 <0.001

Female -0.31 0.047 -6.605 <0.001 Parent's age -0.03 0.006 -4.72 <0.001 Parent having chronic disease or hospitalised 0.24 0.063 3.79 <0.001 Attachment problems 0.03 0.008 3.37 0.001 Parental depression 0.04 0.008 4.25 <0.001

The results obtained from the multiple negative binomial regression analyses were also pre‐ sented in Table 3 and Table 4. Table 3 presented results on final regression models of CBCL scores, including the total, internalisation, and externalisation, regressing on various study variables with terms of interaction between parental depression and attachment problems included. Results indicated the interaction term in the final model for CBCL-exter was sig‐ nificant (Z=2.19, p=0.029), suggesting that there was a significant interaction effect of paren‐ tal depression and attachment problems between parent and child on the perception of their

**Table 3.** Results obtained from the multiple negative binomial regression analyses on CBCL Total, CBCL-

Internalisation, and CBCL-Externalisation without interaction terms.

children's behavioural problems.

1=19.22, p<0.001; CBCL-exter: χ<sup>2</sup>

1=50.62, p<0.001; CBCL-exter:

http://dx.doi.org/10.5772/51170

1=12.38, p<0.001).

**Results**

**CBCL-Total**

**CBCL-Internalisation**

**CBCL-Externalisation**

1=12.13,

261

all CBCL scores (CBCL-total: χ<sup>2</sup>

p<0.001; CBCL-inter: χ<sup>2</sup>

χ2

**Table 1.** Description information on the characteristics of children, their parents, parent-child attachment problems, parental depression, and parental perception of child behavioural problems (N=1839)


**Table 2.** Unadjusted associations between child and parent characteristics and parental perception on child behavioural problems: CBCL Total; CBCL-Internalisation: and CBCL-Externalisation

The bivariate relationships between demographics, parental depression, attachment prob‐ lems and parental perception of child behavioural problems were examined. The results were summarised in Table 2. As shown, among the demographic variables, child's sex, pa‐ rents' age, monthly income, and parental illness were significantly associated with all three CBCL scores. Results also suggested the unadjusted association between parental depres‐ sion and the perception of their children's behavioural problems was highly significant for all CBCL scores (CBCL-total: χ<sup>2</sup> 1=42.52, p<0.001; CBCL-inter: χ<sup>2</sup> 1=50.62, p<0.001; CBCL-exter: χ2 1=28.83, p<0.001). This also applied to attachment problems (CBCL-total: χ<sup>2</sup> 1=12.13, p<0.001; CBCL-inter: χ<sup>2</sup> 1=19.22, p<0.001; CBCL-exter: χ<sup>2</sup> 1=12.38, p<0.001).

**Variables Frequency (%) or mean (s.d.), median**

**Parental Stress Index -Attachment Problems scores** Mean=18.4 (3.35), median=18.0

Parental depression HADS depression scores Mean=4.7 (3.04), median=4.0

**CBCL-Total scores** Mean=21.1 (17.66), median=18.0

**CBCL Internalisation scores** Mean=5.8 (5.79), median=4.0

**CBCL Externalisation scores** Mean=7.9 (7.06), median 6.0

parental depression, and parental perception of child behavioural problems (N=1839)

**Table 1.** Description information on the characteristics of children, their parents, parent-child attachment problems,

**Variables CBCL total Internalisation Externalisation**

Age of the child χ<sup>2</sup> 1=2.52, p=0.112 χ<sup>2</sup> 1=0.49, p=0.485 χ<sup>2</sup> 1=3.81, p=0.051 Sex of child χ<sup>2</sup> 1=23.77, p<0.001 χ<sup>2</sup> 1=4.50, p=0.034 χ<sup>2</sup> 1=50.18, p<0.001 Age of parent χ<sup>2</sup> 1=16.01, p<0.001 χ<sup>2</sup> 1=8.09, p=0.0042 χ<sup>2</sup> 1=23.69, p<0.001 Relation of parent to child χ<sup>2</sup> 1=1.13, p=0.288 χ<sup>2</sup> 1=0.62, p=0.432 χ<sup>2</sup> 1=1.14, p=0.216 Family structure χ<sup>2</sup> 1=2.16, p=0.141 χ<sup>2</sup> 1=2.50 p=0.114 χ<sup>2</sup> 1=1.85, p=0.174 Parent's education level χ<sup>2</sup> 2=5.90, p=0.052 χ<sup>2</sup> 2=4.32, p=0.115 χ<sup>2</sup> 2=3.95, p=0.139 Parent's occupation χ<sup>2</sup> 4=5.34, p=0.254 χ<sup>2</sup> 4=7.21, p=0.125 χ<sup>2</sup> 4=3.70, p=0.449 Monthly income χ<sup>2</sup> 2=5.32, p=0.007 χ<sup>2</sup> 2=2.67, p=0.263 χ<sup>2</sup> 2=7.55, p=0.023

**Table 2.** Unadjusted associations between child and parent characteristics and parental perception on child

The bivariate relationships between demographics, parental depression, attachment prob‐ lems and parental perception of child behavioural problems were examined. The results were summarised in Table 2. As shown, among the demographic variables, child's sex, pa‐ rents' age, monthly income, and parental illness were significantly associated with all three

behavioural problems: CBCL Total; CBCL-Internalisation: and CBCL-Externalisation

**Results on association**

χ<sup>2</sup> 1=22.65, p<0.001 χ<sup>2</sup> 1=27.31, p<0.001 χ<sup>2</sup> 1=25.36, p<0.001

χ<sup>2</sup> 1=12.13, p<0.001 χ<sup>2</sup> 1=19.22, p<0.001 χ<sup>2</sup> 1=12.38, p<0.001

χ<sup>2</sup> 1=42.52, p<0.001 χ<sup>2</sup> 1=50.62, p<0.001 χ<sup>2</sup> 1=28.83, p<0.001

\*Low <RMB\$3000; middle 3000-4900; high>5000

260 Mental Disorders - Theoretical and Empirical Perspectives

**Demographics**

Parent having chronic disease or

**Parental depression HADS depression scores**

**Parental Stress Index -Attachment**

hospitalised

**Problems scores**


**Table 3.** Results obtained from the multiple negative binomial regression analyses on CBCL Total, CBCL-Internalisation, and CBCL-Externalisation without interaction terms.

The results obtained from the multiple negative binomial regression analyses were also pre‐ sented in Table 3 and Table 4. Table 3 presented results on final regression models of CBCL scores, including the total, internalisation, and externalisation, regressing on various study variables with terms of interaction between parental depression and attachment problems included. Results indicated the interaction term in the final model for CBCL-exter was sig‐ nificant (Z=2.19, p=0.029), suggesting that there was a significant interaction effect of paren‐ tal depression and attachment problems between parent and child on the perception of their children's behavioural problems.


**Figure 1.** Plot of mean externalisation scores of parental depression status by attachment problems,\*Depression sta‐ tus was classified using a cut-off suggested by the HADS author (>7=depressed); Attachment problems was clssified

Parent-Child Attachment, Parental Depression, and Perception of Child Behavioural/Emotional Problems

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263

This study aims to examine the relationship between parental depression, parent-child rela‐ tionship and parental perception of children's behavioural/emotional problems. Particular‐ ly, it aims to test the hypothesis of the interaction effect of parental depression and parentchild attachment on parental perception of children's behavioural/emotional problems. The results provided evidence of a significant interaction effect between parental depression and parent-child attachment problems on parental perception on the externalising of children's problems, but no effects on internalising problems and total problems. The main effects of parental depression and parent-child attachment problems on parental perception of chil‐

Due to the lack of a similar study on the interaction between parental depression and attach‐ ment problem and parental perception on children's behavioural/emotional problems, a comparison of results obtained from this study with others reported in literature would be difficult. However, other results obtained from the study are consistent with those obtained in the general literature of parental depression, parent-child relationships and the distortion of parental perception of children's behavioural/emotional problems as highlighted in the introduction section. For example, in the study by Treutler et al, it was found that parental depression and parent-child relationship were both associated with their ratings on internal‐ ising behaviours. [5] The results of the current study have rendered further support to this finding. Furthermore, it has shown that parental perception of children's externalising be‐

using a cut-off of >15 as suggested by the PSI author.

dren behavioural/emotional problems were found significant.

**4. Discussion and conclusion**

**Table 4.** Results obtained from the multiple negative binomial regression analyses on CBCL Total, CBCL-Internalisation, and CBCL-Externalisation with interaction terms.

Figure 1 depicted the unadjusted mean scores of externalisation behaviour for different pa‐ rental depression status by different levels of attachment problems. The figure exhibited a lack of parallelism suggesting an interaction effect between parental depression and parentchild attachment on the CBCL-exter scores. The interaction terms in models for CBCL-total and CBCL-inter were not significant. Table 4 presented results on the final models of CBCLtotal and CBCL-inter after removal of the interaction terms. As shown, parental depression and attachment problems between parent and child were significantly related to parental perception of their children's behavioural problems for both the total (depression: Z=5.71, p<0.001: attachment: Z=3.32, p=0.001) and internalisation (depression: Z=5.96, p<0.001: at‐ tachment: Z=3.97, p<0.001) scores after adjusting for sex, parental age, and parental illness.

**Figure 1.** Plot of mean externalisation scores of parental depression status by attachment problems,\*Depression sta‐ tus was classified using a cut-off suggested by the HADS author (>7=depressed); Attachment problems was clssified using a cut-off of >15 as suggested by the PSI author.

### **4. Discussion and conclusion**

**Results**

**CBCL-Total**

**CBCL-Internalisation**

**CBCL-Externalisation**

**Variables in the final model with interaction term** β SE(β) Z-value p-value

Female -0.21 0.047 -4.45 <0.001 Parent's age -0.02 0.006 -3.61 <0.001 Parent having chronic disease or hospitalised 0.25 0.062 3.99 <0.001 Attachment problems 0.04 0.012 3.18 0.001 Parental depression 0.11 0.046 2.41 0.016 Interaction: Attachment\*Parental depression 0.01 0.002 1.42 0.155

Parent's age -0.02 0.007 -2.45 0.014 Parent having chronic disease or hospitalised 0.32 0.070 4.51 <0.001 Attachment problems 0.04 0.014 2.84 0.004 Parental depression 0.08 0.053 1.54 0.124 Interaction: Attachment\*Parental depression 0.01 0.003 0.51 0.611

Female -0.34 0.048 -7.01 <0.001 Parent's age -0.03 0.006 -4.09 <0.001 Parent having chronic disease or hospitalised 0.25 0.063 4.00 <0.001 Attachment problems 0.05 0.013 4.02 <0.001 Parental depression 0.13 0.046 2.90 0.004 Interaction: Attachment\*Parental depression 0.01 0.002 2.19 **0.029**

**Table 4.** Results obtained from the multiple negative binomial regression analyses on CBCL Total, CBCL-

Figure 1 depicted the unadjusted mean scores of externalisation behaviour for different pa‐ rental depression status by different levels of attachment problems. The figure exhibited a lack of parallelism suggesting an interaction effect between parental depression and parentchild attachment on the CBCL-exter scores. The interaction terms in models for CBCL-total and CBCL-inter were not significant. Table 4 presented results on the final models of CBCLtotal and CBCL-inter after removal of the interaction terms. As shown, parental depression and attachment problems between parent and child were significantly related to parental perception of their children's behavioural problems for both the total (depression: Z=5.71, p<0.001: attachment: Z=3.32, p=0.001) and internalisation (depression: Z=5.96, p<0.001: at‐ tachment: Z=3.97, p<0.001) scores after adjusting for sex, parental age, and parental illness.

Internalisation, and CBCL-Externalisation with interaction terms.

262 Mental Disorders - Theoretical and Empirical Perspectives

This study aims to examine the relationship between parental depression, parent-child rela‐ tionship and parental perception of children's behavioural/emotional problems. Particular‐ ly, it aims to test the hypothesis of the interaction effect of parental depression and parentchild attachment on parental perception of children's behavioural/emotional problems. The results provided evidence of a significant interaction effect between parental depression and parent-child attachment problems on parental perception on the externalising of children's problems, but no effects on internalising problems and total problems. The main effects of parental depression and parent-child attachment problems on parental perception of chil‐ dren behavioural/emotional problems were found significant.

Due to the lack of a similar study on the interaction between parental depression and attach‐ ment problem and parental perception on children's behavioural/emotional problems, a comparison of results obtained from this study with others reported in literature would be difficult. However, other results obtained from the study are consistent with those obtained in the general literature of parental depression, parent-child relationships and the distortion of parental perception of children's behavioural/emotional problems as highlighted in the introduction section. For example, in the study by Treutler et al, it was found that parental depression and parent-child relationship were both associated with their ratings on internal‐ ising behaviours. [5] The results of the current study have rendered further support to this finding. Furthermore, it has shown that parental perception of children's externalising be‐ havioural problems is a function of their own depressive symptomatologies and the attach‐ ment to their children.

tween parents and their children may provide an inroad to, not only the change of perception of child behavioural problems but also, the actual developmental problems dur‐ ing early childhood and behavioural problems throughout the entire child and adolescence period. A recent study has identified that the quality of interaction between mother and child, particularly in the area of emotion availability of the mother, has a direct bearing on the functioning, behavioural problems, and depressive symptomatologies of the child. [24] In this longitudinal study, it has been found that dysfunctional mother-child relationship and poor attachment at infancy is predictive of developmental and behavioural problems at later years of childhood. [24] However, early intervention program in enhancing attachment between parent and child could have a positive effect in improving the quality of parentchild relationship and reinforcing a secure attachment. [25] This could, in turn, have a direct impact on the on-going development of the child. Furthermore, it could also be possible that the problematic parent-child relationship may have contributed to the depression of the pa‐ rent. An improvement in parent-child attachment could have an alleviating effect of the pa‐ rent's depression and, in turn, reinforcing a better relationship with the child and resulting

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265

As in all studies, there are strengths and weaknesses in this study. This is a populationbased study that includes a random sample of students. The use of a standardised and vali‐ dated assessment instrument for the outcome measure minimised some measurement biases. The assessments on parental depression, parent-child relationship, and parental per‐ ception of children's behavioural problems were concurrent and captured the current status on all these variables, hence minimising biases due to the lapse of time. A potential limita‐ tion has been identified in this study. Information on the exposure variables, namely paren‐ tal depression and attachment problems is obtained via a self-reported questionnaire. Hence this will constitute a report bias in the exposure variables and it would likely present as a differential bias due to depressive parents reporting more severe symptomatologies as well as parent-child relationship problems. To improve the quality of the study, parental depres‐ sion and parent-child relationships are best to be assessed by multiple informants as well as

in a better behavioural outcome.

by observers as suggested by [23].

Address all correspondence to: lawrence.lam@nd.edu.au

1 The School of Medicine Sydney, The University of Notre Dame, Sydney, Australia

2 Discipline of Paediatrics and Child Health, Sydney Medical School, The University of Syd‐

**Author details**

Lawrence T. Lam1,2

ney, Australia

The results indicated that attachment between parent and child acts as an effect modifier in the relationship between parental depression and their perception of children's externalising behavioural problems. For parents who have a close relationship with their children, it could be considered natural that depression would influence their perception of children's behavioural problems. However, for parents who have experienced attachment problems with their children as well as depression, the alienated relationship with their children tends to enhance their perception of children's behavioural problems to such a degree that is much more than the usual effect brought on by depression alone. In other words, the alien‐ ated relationship enhances the effect of depression on parental perception of children's be‐ havioural problems. It is interesting to note that such an interactive effect is observed for externalising behavioural problems, but not for internalising problems. One possible explan‐ ation for this phenomenon is that externalising behavioural problems, including aggressive behaviour, rule-breaking, and attention problems, are observable manifestations of child‐ hood problems. Parents can identify these behaviours and perceive them as problematic easily for both depressive and non-depressive parents, with depressive parents labelling them with a greater degree of severity. However, if the parent-child dyad has been experi‐ encing a detrimental relationship, it is likely that the parent would have a heightened sensi‐ tivity to the child's observable behavioural problems. This heightening of awareness or sensitivity is further enhanced in a parent who is also experiencing depression. This height‐ ening of awareness may be absent for those less observable behavioural problems such as withdrawal and depression.

The results obtained from this study have a direct clinical implication on the validity of us‐ ing parents as informants for children's behavioural assessments. As above-mentioned, pa‐ rental distortion in their report on children's behavioural assessments has long been identified and established as a potential source of error. [7] The results of this study further indicate that parents' perception of their children's behaviour is a function of their own in‐ ternal state as well as their relationship with their children. The potential for distortion in reporting of child behaviour is great if a single parent is used as the sole informant. Should this aspect be overlooked, systematic biases would result due to distortion errors. This may occur in research as well as in clinical assessment. In fact, it has been advocated that multi‐ ple informants, especially non-familial informants, should be used for any childhood behav‐ ioural problems in both research and clinical settings. [21-22] If possible, observational tools instead of self-reported instruments should be employed and non-family observers should be used as informants. [23] In the current longitudinal study, children who have been identi‐ fied with scores higher than the recommended cut-off will be assessed by a child psychia‐ trist using another clinical assessment tool.

In terms of prevention and early intervention of developmental psychopathology in chil‐ dren, the results of the study can also shed some lights. Tackling attachment problems be‐ tween parents and their children may provide an inroad to, not only the change of perception of child behavioural problems but also, the actual developmental problems dur‐ ing early childhood and behavioural problems throughout the entire child and adolescence period. A recent study has identified that the quality of interaction between mother and child, particularly in the area of emotion availability of the mother, has a direct bearing on the functioning, behavioural problems, and depressive symptomatologies of the child. [24] In this longitudinal study, it has been found that dysfunctional mother-child relationship and poor attachment at infancy is predictive of developmental and behavioural problems at later years of childhood. [24] However, early intervention program in enhancing attachment between parent and child could have a positive effect in improving the quality of parentchild relationship and reinforcing a secure attachment. [25] This could, in turn, have a direct impact on the on-going development of the child. Furthermore, it could also be possible that the problematic parent-child relationship may have contributed to the depression of the pa‐ rent. An improvement in parent-child attachment could have an alleviating effect of the pa‐ rent's depression and, in turn, reinforcing a better relationship with the child and resulting in a better behavioural outcome.

As in all studies, there are strengths and weaknesses in this study. This is a populationbased study that includes a random sample of students. The use of a standardised and vali‐ dated assessment instrument for the outcome measure minimised some measurement biases. The assessments on parental depression, parent-child relationship, and parental per‐ ception of children's behavioural problems were concurrent and captured the current status on all these variables, hence minimising biases due to the lapse of time. A potential limita‐ tion has been identified in this study. Information on the exposure variables, namely paren‐ tal depression and attachment problems is obtained via a self-reported questionnaire. Hence this will constitute a report bias in the exposure variables and it would likely present as a differential bias due to depressive parents reporting more severe symptomatologies as well as parent-child relationship problems. To improve the quality of the study, parental depres‐ sion and parent-child relationships are best to be assessed by multiple informants as well as by observers as suggested by [23].

### **Author details**

havioural problems is a function of their own depressive symptomatologies and the attach‐

The results indicated that attachment between parent and child acts as an effect modifier in the relationship between parental depression and their perception of children's externalising behavioural problems. For parents who have a close relationship with their children, it could be considered natural that depression would influence their perception of children's behavioural problems. However, for parents who have experienced attachment problems with their children as well as depression, the alienated relationship with their children tends to enhance their perception of children's behavioural problems to such a degree that is much more than the usual effect brought on by depression alone. In other words, the alien‐ ated relationship enhances the effect of depression on parental perception of children's be‐ havioural problems. It is interesting to note that such an interactive effect is observed for externalising behavioural problems, but not for internalising problems. One possible explan‐ ation for this phenomenon is that externalising behavioural problems, including aggressive behaviour, rule-breaking, and attention problems, are observable manifestations of child‐ hood problems. Parents can identify these behaviours and perceive them as problematic easily for both depressive and non-depressive parents, with depressive parents labelling them with a greater degree of severity. However, if the parent-child dyad has been experi‐ encing a detrimental relationship, it is likely that the parent would have a heightened sensi‐ tivity to the child's observable behavioural problems. This heightening of awareness or sensitivity is further enhanced in a parent who is also experiencing depression. This height‐ ening of awareness may be absent for those less observable behavioural problems such as

The results obtained from this study have a direct clinical implication on the validity of us‐ ing parents as informants for children's behavioural assessments. As above-mentioned, pa‐ rental distortion in their report on children's behavioural assessments has long been identified and established as a potential source of error. [7] The results of this study further indicate that parents' perception of their children's behaviour is a function of their own in‐ ternal state as well as their relationship with their children. The potential for distortion in reporting of child behaviour is great if a single parent is used as the sole informant. Should this aspect be overlooked, systematic biases would result due to distortion errors. This may occur in research as well as in clinical assessment. In fact, it has been advocated that multi‐ ple informants, especially non-familial informants, should be used for any childhood behav‐ ioural problems in both research and clinical settings. [21-22] If possible, observational tools instead of self-reported instruments should be employed and non-family observers should be used as informants. [23] In the current longitudinal study, children who have been identi‐ fied with scores higher than the recommended cut-off will be assessed by a child psychia‐

In terms of prevention and early intervention of developmental psychopathology in chil‐ dren, the results of the study can also shed some lights. Tackling attachment problems be‐

ment to their children.

264 Mental Disorders - Theoretical and Empirical Perspectives

withdrawal and depression.

trist using another clinical assessment tool.

Lawrence T. Lam1,2

Address all correspondence to: lawrence.lam@nd.edu.au

1 The School of Medicine Sydney, The University of Notre Dame, Sydney, Australia

2 Discipline of Paediatrics and Child Health, Sydney Medical School, The University of Syd‐ ney, Australia

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**Chapter 12**

**Current Advances in the Treatment of Major**

Ashok Kumar Jainer, Rajkumar Kamatchi,

Additional information is available at the end of the chapter

disease (20%-30%) and multiple sclerosis (16%- 30%).

opment of new promising antidepressants.

http://dx.doi.org/10.5772/46217

**1.Introduction**

Marek Marzanski and Bettahalasoor Somashekar

**Depression: Shift Towards Receptor Specific Drugs**

Depression is one of the most common psychiatric disorders with a life time prevalence of 10% - 20% in the general population and women being at twice the risk of developing de‐ pression compared to men (Kessler et al., 2007). Literature suggests that prevalence of de‐ pression is higher in patients with chronic illnesses (Katon 2003). It is estimated that around 11%-15% of patients with diabetes, 15%-23% of patients with coronary artery disease, and 9%-31% of stroke patients suffer from depression. The prevalence of depression has been re‐ ported even higher among patients with chronic neurological illness such as parkinson's

The high prevalence of depression in the general population has an adverse impact on the com‐ munity and depression affects the patients well being and their productivity in life. It is report‐ ed as the third leading cause of disability as measured by disability adjusted life years (DALYs) and is projected to became the second leading cause in 2020 (WHO 2012). Furthermore, the life time risk of suicide in patients diagnosed with depression is as high as 6% (Inskip et al., 1998).Therefore effective treatment of depression is very important to prevent disability.

The management of depressive disorder is challenging for most clinicians. Over the last 50 years, repeated attempts were made to develop a novel antidepressant, with the intention of maximising the efficacy and minimising the side-effect profile. The research has moved from time to time as in the beginning it was focussed on noradrenaline neurotransmission, later on serotonin neurotransmission. In the last decade, it has moved towards dual action and receptor specific agents. In this chapter we review and update the high quality evidence for pharmacotherapies of depressive disorder and highlight the future trends in the devel‐

> © 2013 Jainer et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.
