The five minute speech sample in children with asthma: deconstructing the construct of expressed emotion

OBJECTIVE: To use the Five Minute Speech Sample (FMSS) to assess Expressed Emotion (EE) in various samples of children with asthma in order to clarify (1) developmental and validity issues for the EE construct and (2) the use of the FMSS technique, specifically, in children with chronic medical illness. METHOD: Data were collected on a sample of 84 adolescents with severe, chronic asthma who had failed outpatient management. In addition, a sample of 30 children with asthma, ages 6-9. were recruited from an outpatient pediatric clinic. A comparison sample of 15 children without any chronic illness, ages 6 9, were recruited by notices posted in the community. The primary caregiver of each child was assessed using the FMSS. RESULTS: FMSS interviews were reliability coded in all samples. Rates of high Criticism (FMSS CRIT), Emotional Overinvolvement (FMSS EOI), and EE were comparable to rates previously reported in child and adolescent samples. Although the validity for ratings of FMSS CRIT was well supported, the validity of FMSS EOI ratings and the overall EE construct were more problematic. CONCLUSIONS: The FMSS is a useful and largely valid measure in children with asthma. Ratings of FMSS CRIT were found to have strong validity. There was little problem shifting the context of FMSS administration from chronic mental to chronic medical illness, but a variety of developmental considerations arose, especially regarding FMSS EOI ratings. Although we raise concerns about viewing EE as a valid construct, it may remain a useful predictive index.     

Expressed emotion, parenting stress, and adjustment in mothers of young children with behavior problems

Expressed Emotion (EE), a measure of the emotional climate of the family, predicts subsequent adjustment of adults with mental disorder (Leff & Vaughn, 1985). Despite the acknowledged importance of the family in childhood disorders, there have been relatively few studies of expressed emotion with adolescents and school-aged children and virtually none focused on preschoolers. The present study utilized the Five Minute Speech Sample (FMSS) to examine how Expressed Emotion relates concurrently and longitudinally to child problem status in a community sample of 112 preschool-aged children. At preschool, the proportion of high EE increased significantly across three child groups: Comparison (8.1%), Borderline Problem (15.8%), and High Problem (41.2%); however, preschool EE was not predictive of subsequent child status at 1st grade. Expanded FMSS codes. tapping positive affect and worry about the child, were also related to child problem group at preschool and were predictive of subsequent child status at 1st grade. Because parents' stress and adjustment were also highly related to child problem group status, we examined whether the FMSS codes were essentially a proxy for these or whether they explained unique variance. In two stepwise regressions on preschool child group status (divided by total problems and by externalizing problems), maternal stress was the only variable to enter. Also, in predicting to 1st grade externalizing child group status, only maternal stress entered. Discussion focused on the extension of the EE construct and other FMSS coding to young children, and the need to recognize that to some extent these variables may reflect maternal stress and adjustment.     

Maternal expressed emotion and adjustment in children with epilepsy

Epilepsy in childhood may alter family relationships but the relevance of these changes for the increased rates of psychopathology has been little investigated. This study uses maternal expressed emotion (EE) to examine family relationships of children with epilepsy and the association with high risk for psychiatric disorder. EE was assessed using the Camberwell Family Interview carried out with the mothers of 22 schoolchildren with chronic epilepsy who were attending a general hospital outpatient clinic. Sixteen of these children had similarly aged healthy siblings who served as controls. High risk for psychiatric disorder in the children and mothers was assessed using behavioural, mood, and self-esteem questionnaires completed by mothers, teachers, and children. It was found that mothers showed significantly more emotional overinvolvement and a trend for more hostility towards their children with epilepsy than towards sibling controls. For the 22 children with epilepsy, maternal emotional overinvolvement was not associated with child behavioural deviance. High levels of criticism and, to a lesser extent, hostility did show associations with child behavioural deviance, and the strongest links were between maternal criticism and maternal rated antisocial and overactive behaviour in the child. Fewer positive comments by mothers towards the children were associated with child emotional symptoms and lower self-esteem in a number of areas. This study suggests that further research could consider the appropriateness of psychological intervention for families in which mothers are critical and hostile and whose children show antisocial behaviour.     

How does longitudinally measured maternal expressed emotion affect internalizing and externalizing symptoms of adolescents from the general community?

Background: In previous studies, maternal expressed emotion (EE) has been found to be a good predictor of the course of adolescent internalizing and externalizing symptoms. However, these studies have been cross‐section as opposed to longitudinal. The goal of this study is to examine longitudinal data of perceived maternal EE and adolescent internalizing and externalizing symptoms to determine if maternal EE affected the course of adolescent symptoms (a parent effect model), or if the course of adolescent symptoms affected maternal EE (a child effect model), or if maternal EE and adolescent symptoms affected one another bidirectionally. Methods: Dutch adolescents (N = 497; 57% boys; M = 13 years) from the general community and their mothers were prospectively studied annually for three years. At all waves the mothers completed the Level of Expressed Emotion (LEE) questionnaire and the adolescents completed self‐rated measures of internalizing and externalizing symptoms. Structural equation modeling (SEM) was used to analyze the longitudinal data. Results: The results of the SEM analyses clearly demonstrate that a child effect model best describes the relationship between maternal EE and the course of adolescent internalizing and externalizing symptoms. Conclusions: This longitudinal study of the mothers’ EE perceptions suggests that it is the course of the internalizing and externalizing symptoms of adolescents from the general community that affects maternal EE, and not the mothers’ perceived EE influencing the course of the adolescents’ symptoms. Since this study was based on adolescents from the general community, it is suggested that these findings should also be replicated in clinical samples of adolescents.     

Error‐related brain activity in young children: associations with parental anxiety and child temperamental negative emotionality

Background: There is increasing interest in error‐related brain activity in anxiety disorders. The error‐related negativity (ERN) is a negative deflection in the event‐related potential approximately 50 ms after errors compared to correct responses. Recent studies suggest that the ERN may be a biomarker for anxiety, as it is positively associated with anxiety disorders and traits in adults and older youth. However, it is not known if the ERN in young children is related to risk for anxiety disorders. We addressed this by examining the association of six‐year olds' ERNs with two established risk factors for anxiety: parental anxiety disorder and child temperamental negative emotionality (NE). Method: The ERN was assessed using a Go/No‐Go task in a community sample of 413 six‐year olds. In a prior assessment at age 3, child temperament was evaluated using a laboratory observational measure and parental psychopathology was assessed using semi‐structured diagnostic interviews. Results: Children of mothers with anxiety disorders and children with greater temperamental NE (particularly fearfulness) exhibited significantly smaller ERNs than their peers. Paternal psychopathology, maternal mood and substance use disorders, and child positive emotionality were not associated with children's ERNs. Conclusion: Both maternal anxiety disorders and child NE (particularly fearfulness) were significantly associated with children's ERNs. However, the direction of these associations was opposite to the relations between ERNs and anxiety in older youth and adults. These results suggest that there may be a difference between risk and disorder status in the relation of error‐related brain activity to anxiety between early childhood and late childhood/ early adolescence.     

Applications of the expressed emotion construct to young children with externalizing behavior: stability and prediction over time

We explored the utility of the Expressed Emotion (EE) construct with a community sample of young children (N = 91), studying the stability of EE scores over a 2-year period and the extent to which EE was associated with simultaneous and subsequent disruptive behavior. As part of a longitudinal study, families were assessed when the child was in preschool, 1st grade, and 3rd grade. Maternal EE was measured at preschool and 1st grade using the Five Minute Speech Sample and behavior ratings were obtained using the Child Behavior Checklist. At 3rd grade, the Diagnostic Interview Schedule for Children was used to determine DSM-IV diagnoses. The stability of the EE rating over the 2-year period from preschool to 1st grade was statistically significant although modest. At 1st grade, EE ratings were significantly related to the extent of externalizing behavior problems. Regression analyses that controlled for maternal stress levels determined that preschool EE ratings predicted classification of ADHD over 4 years later, at 3rd grade. The relationships between EE and child problem behavior were almost exclusively determined by the EE criticism dimension; the emotional overinvolvement dimension was not related to child behavior. The implications of these findings are discussed.     

Attachment Style and the Association of Spanking and Child Externalizing Behavior

ObjectiveTo examine whether the longitudinal associations between maternal spanking and child externalizing behavior are moderated by attachment style.MethodsThis study used data from the Fragile Families and Child Wellbeing Study (n = 2211), a large cohort sample of low-income urban families. Multiple-group autoregressive cross-lagged models examined the associations between maternal spanking and child externalizing behavior when children were ages 1, 3, and 5. Moderation by attachment style was examined using structural invariance testing.ResultsFor children with an insecure mother-child attachment style, spanking at age 1 was associated with externalizing behavior at age 3. However, for children with a secure mother-child attachment style, the association between maternal spanking at age 1 and child externalizing behavior at age 3 was absent. Attachment style did not moderate the association between maternal spanking at age 3 and externalizing behavior at age 5, suggesting that spanking at age 3 is associated with deleterious outcomes at age 5, regardless of attachment style.ConclusionsResults suggest that even in the context of a secure attachment style, spanking is associated with adverse outcomes in early childhood. Findings support the American Academy of Pediatrics 2018 policy statement, which encourages parents to avoid spanking when disciplining children. Results suggest that children, regardless of attachment style, may benefit from policies and services that promote non-violent forms of discipline.     

Social-psychological correlates of peer victimization in children with endocrine disorders

OBJECTIVE: To examine the relation between victimization by peers and child and parent reports of social-psychological adjustment. STUDY DESIGN: The Social Experience Questionnaire, Children's Depression Inventory, Social Anxiety Scale for Children-Revised, and Asher Loneliness Scale were administered to 93 children diagnosed with various endocrine disorders. The child's parent/guardian completed the Child Behavior Checklist. RESULTS: For the entire sample, peer victimization was positively related to child-reported depression, social anxiety, loneliness, and parent-reported externalizing symptoms. Those children with endocrine disorders without observable features had a stronger relation between peer victimization and depression and internalizing and externalizing behavior problems than did those who had endocrine disorders with observable physical features. CONCLUSIONS: Recognition of the magnitude of the problem and means of evaluating for peer victimization is important for clinicians who see children with chronic diseases.     

Expressed emotion,attributions and depression in mothers of children with problem behaviour

BACKGROUND: This was an initial study seeking to examine the relationship between Expressed Emotion (EE), spontaneous causal attributions and depression in mothers of children referred for problem behaviour. METHOD: Sixty-one mothers were interviewed using the Camberwell Family Interview (CFI). The CFI was coded for maternal EE and spontaneous causal attributions regarding the child's behaviour. Self-report measures of child problem behaviour and maternal depressive symptoms were also completed. RESULTS: Consistent with previous research, high EE mothers, compared to low EE mothers, were more likely to make attributions thatjudged the cause of problem behaviour to be personal to and controllable by the child and also made more 'child-blaming' attributions than low EE mothers. Mothers' scores on the Beck Depression Inventory were found to be associated with 'child-blaming' attributions and higher levels of EE. Regression analyses did not support the hypothesised role of attributions as a mediator between depression and EE but did identify EE as a potential mediator in the relationship between maternal depressed mood and ratings of child problem behaviour. CONCLUSIONS: These results indicate the relevance of both EE and attributions in mothers of children with problem behaviour and suggest that maternal depressed mood is an important factor which is related to both of these.     

Genetic and environmental influences on the transmission of parental depression to children’s depression and conduct disturbance: an extended Children of Twins study

Background: Despite the increased risk of depression and conduct problems in children of depressed parents, the mechanism by which parental depression affects their children’s behavioral and emotional functioning is not well understood. The present study was undertaken to determine whether parental depression represents a genuine environmental risk factor in children’s psychopathology, or whether children’s depression/conduct can be explained as a secondary consequence of the genetic liability transmitted from parents to their offspring. Methods: Children of Twins (COT) data collected on 2,674 adult female and male twins, their spouses, and 2,940 of their children were used to address whether genetic and/or family environmental factors best account for the association between depression in parents and depression and conduct problems in their children. Data collected on juvenile twins from the Virginia Twin Study of Adolescent Behavioral Development (VTSABD) were also included to estimate child‐specific genetic and environmental influences apart from those effects arising from the transmission of the parental depression itself. The fit of alternative Children of Twin models were evaluated using the statistical program Mx. Results: The most compelling model for the association between parental and juvenile depression was a model of direct environmental risk. Both family environmental and genetic factors accounted for the association between parental depression and child conduct disturbance. Conclusions: These findings illustrate how a genetically mediated behavior such as parental depression can have both an environmental and genetic impact on children’s behavior. We find developmentally specific genetic factors underlying risk to juvenile and adult depression. A shared genetic liability influences both parental depression and juvenile conduct disturbance, implicating child conduct disturbance (CD) as an early indicator of genetic risk for depression in adulthood. In summary, our analyses demonstrate differences in the impact of parental depression on different forms of child psychopathology, and at various stages of development.     

Predictors of parent training efficacy for child externalizing behavior problems--a meta-analytic review

BACKGROUND: The differential effectiveness of parent training has led researchers to examine a variety of child, parent, and familial variables that may predict treatment response. Studies have identified a diverse set of child, parent psychological/behavioral and demographic variables that are associated with treatment outcome and dropout. METHOD: The parent training literature was examined to isolate child, parent, and family variables that predict response to parent training for child externalizing behavior problems. A literature review was conducted spanning articles published from 1980 to 2004 of indicated prevention (children with symptoms) and treatment (children with diagnosis) studies. Meta-analyses were conducted to determine standardized effect sizes associated with the identified predictors. RESULTS: Many of the predictors of treatment response examined in this meta-analysis resulted in moderate standardized effect sizes when study results were subjected to meta-analytic procedures (i.e., low education/occupation, more severe child behavior problems pretreatment, maternal psychopathology). Only low family income resulted in a large standardized effect size. Predictors of drop-out resulted in standardized effect sizes in the small or insubstantial range. CONCLUSIONS: Response to parent training is often influenced by variables not directly involving the child, with socioeconomic status and maternal mental health being particularly salient factors.     

Maternal psychosocial factors around delivery,and the behavior of 2‐year‐old children

Background: The objectives of the present study were to explore whether maternal psychosocial factors, mental health and work stress around delivery, are related to the behavior of 2‐year‐old children. Methods: In a prospective cohort study design, pregnant women attending the National Taiwan University Hospital for delivery and post‐partum care from April 2004 to January 2005 were recruited and their children were observed at 24 months. A total of 186 mother–term‐born child dyads completed the measurement. The five‐item Mental Health Index (MHI‐5) self‐report data of maternal psychosocial factors were selected from the Taiwanese version of the short form 36 (SF‐36). The Child Behavior Checklist for age 1½–5 (CBCL/1½‐5) was completed by the parents when the child was 2 years old. Results: The mean score of mental health around delivery was 68.11. The proportion of mothers with work stress seldom and always was 61.8% and 24.7%, respectively. The mean of the total CBCL score, and internalizing, externalizing behavior and sleep problems scores was 45.95, 11.89, 15.59 and 4.23, respectively. After adjusting for the potential confounders, maternal work stress around delivery was found to have a significant effect on the total CBCL and externalizing, attention and aggressive, behavioral problems of 2‐year old children. Maternal mental health around delivery, however, did not show significant effects on child behavior. Conclusions: Work stress around delivery seems to aggravate children's externalizing behavior problems at 2 years old. It is therefore important to improve the psychosocial health and reduce the stress of pregnant women.     

Are there psychosocial differences in diagnostic subgroups of children with recurrent abdominal pain?

OBJECTIVES: To examine psychosocial differences in diagnostic subgroups of children with recurrent abdominal pain (RAP). METHODS: Children meeting Apley's 1975 definition of RAP were divided according to physician ratings into three subgroups, based on the Rome II diagnostic criteria of functional gastrointestinal disorders: functional dyspepsia (n=17), irritable bowel syndrome (n=18), and functional abdominal pain (n=27). Groups were compared using measures of (a) child psychopathology, (b) parent psychopathology, and (c) child pain, somatization, and functional disability. RESULTS: Multivariate results from a discriminant function analysis demonstrated that children classified according to these criteria could not be differentiated with respect to parent reported child psychopathology or child pain, somatization, and functional disability. There were significant univariate differences, however, between groups on parental psychopathology (F=4.39, P=0.02); parents of children with functional dyspepsia reported greater parental psychopathology symptoms than the other two groups. CONCLUSIONS: This study provides a preliminary comparison of pain, somatization, functional impact, and psychopathology ratings in the Rome II diagnostic subclassifications of children with RAP. Further investigation utilizing larger sample sizes, pain measures specifying pain location, and parental modeling of somatic behavior is indicated to better understand potential similarities and differences between these subgroups.     

Unraveling the effect of genes and environment in the transmission of parental antisocial behavior to children's conduct disturbance, depression and hyperactivity

Background: A critical issue in devising effective interventions for the treatment of children’s behavioral and emotional problems identifying genuine family environmental factors that place children at risk. In most twin and family studies, environmental factors are confounded with both direct genetic risk from parents and the indirect effect of genes influencing parents’ ability to provide an optimal rearing environment. The present study was undertaken to determine whether parental psychopathology, specifically parental antisocial behavior (ASP), is a genuine environmental risk factor for juvenile conduct disturbance, depression and hyperactivity, or whether the association between parental ASP and children’s behavioral and emotional problems can be explained as a secondary consequence of the intergenerational transmission of genetic factors. Methods: An extended children of twins design comprised of data collected on 2,674 adult female and male twins, their spouses, and 2,454 of their children was used to test whether genetic and/or family environmental factors best accounted for the association between parental antisocial behavior and children’s behavioral problems. An age‐matched sample of 2,826 juvenile twin pairs from the Virginia Twin Study of Adolescent Behavioral Development was also included to examine developmental differences in gene expression by partitioning child‐specific transmissible effects from those effects that persist into adulthood. The fit of alternative models was evaluated using the statistical program Mx. Results: We found distinct patterns of transmission between parental antisocial behavior and juvenile conduct, depression and hyperactivity. Genetic and family environmental factors accounted for the resemblance between parents’ ASP and children’s conduct disturbance. Family environmental factors alone explained the association between child depression and parental ASP, and the impact of parental ASP on hyperactivity was entirely genetic. Conclusions: These findings underscore differences in the contribution of genetic and environmental factors on the patterns of association between parental antisocial behavior and juvenile psychopathology, having important clinical implications for the prevention and amelioration of child behavioral and emotional problems.     

Area and family effects on the psychopathology of the Millennium Cohort Study children and their older siblings

Background: To model and compare contextual (area and family) effects on the psychopathology of children nested in families nested in areas. Method: Data from the first two sweeps of the UK’s Millennium Cohort Study were used. The final study sample was 9,630 children clustered in 6,052 families clustered in 1,681 Lower‐layer Super Output Areas. The mean age of the children at Sweep 2 was 4.96 (SD = 2.76) years. Contextual risk was measured at area level with the Index of Multiple Deprivation (Sweep 1), and at family level with the number of proximal (Sweep 2) and distal (Sweep 1) adverse life events experienced. Psychopathology was measured at Sweep 2 with the Strengths and Difficulties Questionnaire. Results: At baseline, both proximal and distal family risk and area risk predicted broad psychopathology, although the most parsimonious was the proximal family risk model, and both the family‐level and the area‐level variability were significant. The area risk/broad psychopathology association remained significant even when family risk was controlled, but not when family socioeconomic status was controlled. The full model added parenting and paternal and maternal psychopathology. When parental qualifications were excluded from the family‐level contextual controls the effect of area risk remained significant on both externalizing and internalizing psychopathology. Conclusions: The effect of area on child psychopathology operated via the socioeconomic characteristics of the child’s family, not just the adverse characteristics of the neighbors. Multiple family risk predicted child psychopathology directly and independently, and not because it was associated with family socioeconomic status. Family socioeconomic status explained the association between area risk and broad psychopathology.     

Longitudinal pathways linking child maltreatment,emotion regulation,peer relations,and psychopathology

Background: The aim of this study was to investigate longitudinal relations among child maltreatment, emotion regulation, peer acceptance and rejection, and psychopathology. Methods: Data were collected on 215 maltreated and 206 nonmaltreated children (ages 6–12 years) from low‐income families. Children were evaluated by camp counselors on emotion regulation and internalizing and externalizing symptomatology and were nominated by peers for peer acceptance and rejection. Results: Structural equation modeling analyses revealed that experiencing neglect, physical and/or sexual abuse, multiple maltreatment subtypes, and earlier onset of maltreatment were related to emotion dysregulation. Lower emotion regulation (Time 1) was associated with higher externalizing symptomatology (Time 1) that contributed to later peer rejection (Time 2), which in turn was related to higher externalizing symptomatology (Time 2). Conversely, higher emotion regulation was predictive of higher peer acceptance over time, which was related to lower internalizing symptomatology controlling for initial levels of symptomatology. Conclusions: The findings emphasize the important role of emotion regulation as a risk or a protective mechanism in the link between earlier child maltreatment and later psychopathology through its influences on peer relations.     

Fear, Anxiety and Perceived Control in Children of Agoraphobic Parents

Sixteen children ( M = 11 years) of agoraphobic parents were compared with no children of parents with no history of psychopathology, matched on age. gender and socioeconomic status The majority (68%) of children of agoraphobic parents met DSM-III-R diagnostic criteria, anxiety disorders being must common. They reported more fear and anxiety and less control over various risks than did comparison children. Groups' perceptions of the prevalence and their vulnerability to these risks did nut differ. Agoraphobic mothers reported more separation anxiety than did comparison mothers, and maternal separation anxiety was negatively correlated with children's perceived control. Results are related to models of anxiety transmission.     

Maternal emotion coaching,adolescent anger regulation,and siblings’ externalizing symptoms

Background: Increases in externalizing behaviors during the transition to adolescence may put children at risk for developing mental disorders and related problems. Although children’s ability to regulate their emotions appears to be a key factor influencing risk for maladjustment, emotion processes during adolescence remain understudied. In this longitudinal study, we examined a multi‐level mediational model in which emotion coaching by parents was posited to influence the ability of adolescents to regulate their emotions, which in turn influences their expression of problem behaviors. Methods: We recruited a representative community sample of 244 families with biological sibling pairs comprising a child in late elementary school and a child in middle school. Maternal meta‐emotion interviews were coded for mother emotion coaching and adolescent difficulty with anger. Mothers also completed questionnaires on adolescent irritability. Ratings of adolescent problem behaviors were obtained from mother and teacher questionnaires completed at two time points. Using structural equation modeling, constructs were partitioned into components across older and younger siblings to examine shared and nonshared variance and contextual effects. Results: Cross‐sectional data indicated that mothers' emotion coaching of anger was related to better anger regulation in adolescent siblings, which was, in turn related to less externalizing behavior. Although support for mediational effects was limited in the longitudinal data, both older and younger siblings' difficulties in regulating anger predicted adolescent externalizing behavior three years later. Additional longitudinal predictors of externalizing behavior were observed for younger siblings. In particular, emotion coaching of anger by mothers was associated with decreased externalizing behavior, while conversely, older siblings' externalizing behavior was associated with increased externalizing behavior in the younger siblings over time. Conclusions: The findings highlight the importance of considering family emotion processes in understanding adolescent problem behavior. Both maternal emotion coaching of adolescent anger and adolescent difficulty in regulating anger influenced adolescent externalizing behavior. Emotion coaching interventions seem worthy of consideration for enhancing the impact of prevention and intervention programs targeting youth externalizing behaviors.     

The representation of fathers by children of depressed mothers: refining the meaning of parentification in high‐risk samples

Background: Children’s representations of mothers in doll‐play are associated with child adjustment. Despite the importance of fathers for children’s adjustment, especially in the context of maternal psychopathology, few studies have considered children’s representations of their fathers. Method: We examined the portrayal of fathers by 5‐year‐old children of depressed (N = 55) and non‐depressed (N = 39) mothers in a doll‐play procedure concerning family experience. Results: Children gave equal prominence in their play to mothers and fathers. Representations of fathers were unrelated to maternal mood, but were associated with parental conflict. Representations of child care for the father that was unreciprocated predicted poor child adjustment in school, but only in children exposed to maternal postnatal depression. Conclusions: It may be clinically useful to consider children’s distinctive representations of their mother and father; but the concept of parentification in relation to risk and resilience effects requires refinement.     

Maternal depression, child behavior, and injury.

BACKGROUND: Few data exist on the effect of maternal depression on child injury outcomes and mediators of this relationship. OBJECTIVE: To examine the relationship between mothers' depressive symptoms and medically attended injuries in their children and the potential mediating role of child behavior. DESIGN/ METHODS: A cohort of mother-child dyads from the National Longitudinal Study of Youth followed from 1992 to 1994. The primary exposure variable was maternal depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale in 1992. Child behavior was assessed by the Behavior Problems Index externalizing subscale. Logistic regression was used to examine the relationship between depressive symptoms, child behavior, and injury reported in the prior year in 1994. RESULTS: 94 medically attended injuries were reported in the 1106 children (8.5%); two-thirds were sustained in the home environment. Maternal depressive symptoms significantly increased the risk of child injury; injury risk increased 4% for every 1-point increase in depressive symptoms (adjusted OR 1.04, 95% CI 1.01 to 1.08, p=0.02). Increasing maternal depressive symptoms also increased the risk of externalizing behavior problems (adjusted OR 1.06, 95% CI 1.03 to 1.09), but externalizing behavior problems did not significantly mediate the relationship between maternal symptoms and child injury. CONCLUSIONS: Increasing depressive symptoms in mothers was associated with an increased risk of child injury. Child behavior did not significantly mediate the association between maternal depressive symptoms and child injury in this cohort. Greater recognition, referral, and treatment of depressive symptoms in mothers may have effects on child behavior and injury risk.