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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: Child Psychiatry Hum Dev. 2020 Jun;51(3):390–398. doi: 10.1007/s10578-019-00950-0

The Relationship between Maternal Depression, Externalizing and Internalizing Problems in Children, and Caregiving Burden in Urban Low-Income Ethnic and Racial Minority Families

Kevin M Wagner 1, Carmen R Valdez 1
PMCID: PMC7239708  NIHMSID: NIHMS1547362  PMID: 31873822

Abstract

A strong relationship exists between maternal depression and externalizing and internalizing problems in children, and caregiving burden might mediate this relationship. Yet, caregiving burden has rarely been tested as a mechanism underlying the relationship between maternal depression and child emotional and behavioral outcomes. Caregiving burden might be especially high in ethnic and racial minority mother-child dyads in low-income settings where there are more stressors in the environment and rates of maternal depression are elevated. A path analysis with 132 low-income urban mothers who mostly identified as racial and ethnic minorities confirmed our hypothesis that maternal depression has a direct effect on child externalizing and internalizing problems, and also an indirect effect through caregiving burden. We discuss implications of the findings with respect to research, practice, and policy with low-income, ethnic and racial minority families whose mothers have depression and care for children who exhibit externalizing and internalizing problems.

Keywords: caregiving burden, child problems, ethnic and racial minority, maternal depression, parenting

The relationship between maternal depression and externalizing and internalizing problems in children has been well established [1]. Relative to children whose mothers do not have depression, children of mothers with depression exhibit more externalizing symptoms, including conduct problems, ADHD, and substance use problems [2–4]. Children exposed to maternal depression also experience internalizing problems, such as anxiety, fears, and social withdrawal [5–7]. Studies have found the relationship between maternal depression and child externalizing and internalizing problems to be partially explained by quality mother-child interactions [8], positive and negative parenting behaviors [2], and poor locus of control in mothers [6]. However, among these studies, only a few focused on low-income ethnic or racial minority mothers [6–8]. It follows that other aspects related to the experience of caregiving for children, such as caregiving burden, might also explain this relationship, particularly among highly stressed urban, low-income, and other minority populations.

Caregiving Burden

Caregiving burden refers to the emotional or physical strain caregivers experience from meeting the daily needs of a person who is limited in their ability to care for themselves. Caregiving burden has been studied in a range of contexts, including in caretakers who care for individuals with chronic physical health problems, developmental delays, and psychological impairment [9–14]. Caregiving burden can be objective or subjective [15, 16]. Objective burden refers to the concrete and observable results of caregiving, such as losing income, being unable to pay bills because of caregiving, or disruptions in household management. Subjective burden refers to the internal experiences of the caregiver that result from caregiving demands, such as experiencing significant emotional stress, worry, stigma, and pain [15, 16].

Elevated caregiving burden is linked with depression among caregivers [17], and depression in caregivers might, in turn, heighten the experience of burden. Mothers with depression might have an increased sense of caregiving burden because experiencing depression can interfere with day-to-day tasks, including caretaking. Maternal depression might also increase burden through family problems, such as marital dissatisfaction and strain [18, 19] unstable and family finances and employment [20–22]. Because depression and caregiving burden can disrupt quality caregiver-child interactions [23], and quality caregiver-child relationships are important to foster child development, especially in times of adversity [8, 24], it is crucial to understand how maternal depression and burden interact to affect child outcomes.

Caregiving Burden and Externalizing and Internalizing Problems in Children

Parents might experience objective and subjective caregiving burden when caregiving for children who exhibit externalizing and internalizing problems [15]. In studies with children at different developmental stages, objective caregiving burden was found when caregiving for children who exhibit depression or anxiety [9], ADHD [25], conduct problems in people with autism [26], and externalizing and internalizing behavior problems in preschoolers [27]. However, many studies do not focus solely on low-income or ethnic or racial minority populations. Low-income families might have fewer financial, social, and practical resources to secure for their children relative to families with higher incomes. Therefore, the life changes required to accommodate the needs of children and the high costs of healthcare and treatment for children adds to objective caregiving burden by increasing financial strain among caregivers [20, 21, 28]. Furthermore, relative to families with higher incomes, low-income families might already be experiencing higher levels of interpersonal and personal stress because of the hardships associated with living in poverty [29, 30]. Adding to this stress, subjective caregiving burden might also be increased in low-income mothers because of the emotional stress, worry, and stigma associated with caregiving for children who exhibit externalizing and internalizing problems [14, 28].

Limitations in the Research Corpus

Although the literature provides useful information to understand the associations between maternal depression, caregiving burden, and externalizing and internalizing problems in children, there remain important gaps. First, although studies have documented caregiving burden while caretaking children with externalizing and internalizing problems [9, 25–27], most of these studies do not report the caregiver’s mental health, thereby limiting our ability to generalize these findings to caregiving burden and externalizing and internalizing problems in children when mothers also struggle with depression. If maternal depression affects parenting and parent-child relationships, then burden may be a component that influences parenting and family wellbeing. That is, maternal depression might tax and burden parenting resources, which in turn might disrupt how mothers model important emotion regulatory skills to their children [6].

Second, research that examines the link between caregiving burden and externalizing and internalizing problems in children has mostly been conducted with White or heterogenous ethnic and racial families or does not specify other contextual factors such as income [9, 10, 14, 25–27]. Low-income mothers might be in a vulnerable position to experience heightened caregiving burden because of single parenting and scarce financial resources to address the costs associated with caregiving for children with high needs [20, 21]. Understanding caregiving burden in the context of maternal depression for populations underrepresented in research, such as low-income ethnic and racial minority mothers, is important because of the high risk for caregiving burden, stress, and limited support in these populations [29, 30]. Children in these families might be vulnerable to hardships that are associated with living in poverty and with a caretaker who has depression [29, 30].

The dearth of studies that focus specifically on ethnic and racial minority families also hinders the development of culturally-adapted interventions tailored to familial and sociopolitical because the unique cultural, and neighborhood needs of minority groups, which is important adapted interventions are more efficacious than unadapted interventions [31].

Purpose of Study

The purpose of this study is to examine a model (Figure 1) that tests the direct effect of maternal depression on the externalizing and internalizing problems in children and the indirect effect of maternal depression on externalizing and internalizing problems in children through caregiving burden. This study aims to expand on the maternal depression literature by sampling from low-income urban mothers who identify mostly as ethnic and racial minorities.

Figure 1.

Figure 1.

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Diagram of the standardized direct effect of maternal depression on caregiving burden, externalizing and internalizing problems in children, and the indirect effect of maternal depression on externalizing and internalizing problems in children through caregiving burden.

Methods

Participants

The sample consisted of 132 mothers who had children between the ages of four and ten. The mean age for the mothers was 31.2 years and the median age was 31 (SD = 6.15). Forty-four percent of participants identified as Black (n = 58), 52% as Latina (n = 69), and 4% as White (n = 5). Mothers had a median annual income of $19,980 and lived in a large metropolitan city in the mid-Atlantic region (other demographics of the sample are reported elsewhere [32–34]). Mothers were recruited from a larger randomized controlled trial (N = 267) that assessed the impact of cognitive-behavioral and medication treatment for depression in low-income women [33]. In that intervention study, participants were randomized to different intervention groups (medication, cognitive-behavioral therapy, or treatment as usual). The intervention study recruited women from Title IX family planning clinics and Women Infant and Child (WIC) programs. Women were eligible for the intervention study if they screened positively for depression, subsequently met criteria for depression using a clinical interview, were not currently in treatment, did not have substance or alcohol use, and did not meet criteria for bipolar or psychotic disorder.

Women were recruited from the intervention study for the present study if they were mothers of children in the targeted age of 4 to 10 years. Eligible mothers were contacted by phone by researchers, who explained in the mothers’ language (English or Spanish) how the substudy was related to the intervention study. If the mothers indicated they were interested in participating in the substudy, researchers attended mothers’ homes to provide more details about the study, consent the mothers in writing, and administer the surveys.

Study procedures in the intervention study and the mother’s substudy were in compliance with and approved by the institutional review boards of the academic institutions in which the research was conducted. Of 133 mothers who agreed to participate in this substudy, there was missing data for one of the mothers and thus was excluded from data analysis. Thus, the present study includes 132 mothers who completed baseline assessments prior to partaking in the intervention study to assess for symptoms of maternal depression, caregiving burden, and externalizing and internalizing problems in their children.

Measures

Maternal depression.

Maternal depression was assessed by using the 31-item Hamilton Depression Rating Scale (HDRS), which measures the severity of depression in adults [35]. The measure consists of 31 Likert scale items that range from 0 to 4 or 0 to 2. Higher summed scores indicate more severe depression. The HDRS does not suggest cutoff scores for severity, however a recent study recommends the following for interpretation: ≤7 = no depression or remission; 8–16 = mild depression; 17–23 = moderate depression; and ≥24 = severe depression [36]. The measure demonstrates good internal consistency, good convergent validity with other measures of depressive symptoms, and differentiates between depression individuals who do and do not have [37]. In our sample, Cronbach’s alpha for the HDRS was reliable at α = .95.

Externalizing and internalizing problems in children.

Externalizing and internalizing problems in children were assessed by using the Behavior Assessment System for Children (BASC) [38]. The BASC is a standardized teacher and parent questionnaire that contains five scales: externalizing problems, internalizing problems, behavioral symptoms index, adaptive skills, and school problems in children [38]. The BASC has been normed on a national sample and shows good internal consistency and convergent validity with other measures that assess child maladjustment [39]. In this study, results were drawn from the mothers’ clinical composite scores of externalizing disorders and internalizing disorders from the Parent Rating Scale. In our study, reliability coefficients for externalizing disorders was reliable at α = .81 and for internalizing disorders it was α = .84.

Caregiving burden.

A scale of caregiving burden was developed for this study. The scale was developed to tap into the caregiving burden that low-income mothers are likely to experience from caretaking children who have problems related to physical health, emotions, behaviors, and learning abilities, which are common problems in this high-risk population [40, 41]. Respondents answered six questions on a 4-point Likert scale ranging from 0 to 3. Items (see Table 1) were summed to provide a total score ranging from 0 to 12; higher scores indicated more caregiving burden. The reliability coefficient for this scale was α = .71.

Table 1.

Caregiving Burden

1. During the past year, how much worry or concern did [CHILD]’s physical health cause you?
2. During the past year, how much did [CHILD]’s physical health cause you to limit your activities or change your plans, such as not going shopping or not going on vacation?
3. During the past year, how much worry or concern did [CHILD]’s emotions, behavior, or learning abilities cause you?
4. During the past year, how much did [CHILD]’s emotions, behaviors, or learning abilities cause you to limit your activities or change your plans such as not going shopping or not going on vacation?
5. During the past year, how often have you missed work because of [CHILD]’s physical health?
6. During the past year, how often have you missed work because of [CHILD]’s emotional, behavioral, or learning problems?
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Data Analytic Procedure

We conducted a just-identified path analysis model using the built-in procedures in Mplus (version 7.4) [42] to test a single model of the direct effect of caregiving burden on child externalizing and internalizing problems, as well as the indirect effect of maternal depression on child externalizing and internalizing problems through caregiving burden (Figure 1). Just-identified models are an appropriate method to test path models, however since they fit the data perfectly, goodness of fit indices are not meaningful and therefore are not reported [43, 44]. We obtained bias corrected bootstrapped standard errors for the indirect effect. We handled the missing data using Full Information Maximum Likelihood (FIML) in our just-identified path analysis to allow for data from all participants to be included, regardless of their missing data [45]. Although it is not possible to statistically test if data were missing at random (MAR), a review of our data suggested that missingness was not due to the variables themselves, meaning that the assumption that our data were missing at random is reasonable [46]. MAR is an acceptable condition for missing data in FIML [47, 48]. We report the standardized model results.

Preliminary Findings

Factor Analysis.

We ran an exploratory factor analysis using the built-in procedures in Mplus (version 7.4) [42] to test the number of underlying factors present in the caregiving burden scale for our sample. We used an oblique rotation, a rotation that assumes the factors are correlated [49]. We used weighted least squares as an estimator. Table 2 and Table 3 provide factor loadings and fit indices for the factor analysis. We evaluated absolute model fit per the chi-square estimate, relative model fit per the Comparative Fit Index (CFI) and Tucker Lewis Index (TLI), and approximate model fit with the root mean square error approximation (RMSEA). Models have acceptable fit with a RMSEA value under .08 and CFI and TLI values above .95 [50]. Two of the four fit indices (chi-square and CFI) suggest we settle on a two-factor solution. The two-factor solution was significantly different from the one-factor solution (χ2 = 15.167, df = 5, p < .01) and had better absolute model fit (χ2 = 15.659, df = 4). However, one of the factors in the two-factor solution contained a single item and the item was not interpretable conceptually. Thus, we retained a one-factor solution. In the path analysis, we summed the scores to yield a single, overall measure of caregiving burden.

Table 2.

Item Loadings for the Exploratory Factor Analysis

One-factor model Two-factor model
Items Factor 1 Factor 1 Factor 2
Item 1 .830 .381 .763*
Item 2 .722 .090 .845*
Item 3 .765 1.742* .232
Item 4 .721 .406 .553*
Item 5 .816 .113 .878*
Item 6 .605 .036 .546*
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We then calculated Cronbach’s alpha to gauge the scale’s internal consistency. The caregiving burden scale was reliable at α = .71. Since no other caregiving burden assessment was included in the original data collection, it was not possible to compare it to other scales that also assess caregiving burden. Thus, to assess convergent and concurrent validity, we correlated the caregiving burden scale with child externalizing problems (r = .52, p < .001) and child internalizing problems (r = .45, p < .001), which research has linked to caregiving burden [14].

Correlations.

Prior to examining the paths in the specified model, we first explored correlations between each variable to ensure there would be no multicollinearity (Table 4). There was a strong correlation between externalizing and internalizing problems in children (r = .64, p < .001).

Table 4.

Correlations of the measures used to assess maternal depression, child externalizing and internalizing problems, and caregiving burden

Measure 1 2 3 4
1. Depression -
2. Externalizing .49*** -
3. Internalizing .47*** .64*** -
4. Burden .39*** .52*** .46*** -
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Primary Findings

Just-Identified Path Analysis.

In the just-identified path analysis, maternal depression directly and positively predicted child externalizing problems (β = .35, t = 3.49, SE = .10, R2 = .37, p < .001) and internalizing problems (β = .34, t = 3.97, SE = .09, R2 =.30, p < .001). Maternal depression also directly and positively predicted caregiving burden (β = .39, t = 4.78, SE = .08, R2 =.15, p < .001). Caregiving burden directly and positively predicted child externalizing (β = .38, t = 3.68, SE = .10, p < .001) and internalizing (β = .32, t = 3.16, SE = .10, p = .002) problems. The indirect effect of maternal depression through caregiving burden was significant on both child externalizing (β = .16, t = 2.53, SE = .06, p = .011) and internalizing (β = .13, t = 2.56, SE = .05, p = .010) problems.

Discussion

Our study assessed the relationship between maternal depression, externalizing and internalizing problems in children, and caregiving burden in an urban sample of low-income mothers who were ethnic and racial minorities. Although causality cannot be established given the nature of our study, our results allow us to draw important inferences.

Our first finding replicated previous research that has shown a direct effect between maternal depression and externalizing and internalizing problems in children [1]. In our study, mothers with more severe depression had children with more severe externalizing and internalizing problems. Previous research offers explanations for this finding, mainly that mothers with depression compared to mothers without depression express fewer demonstrations of warmth to their children [51–53] and model emotion regulation strategies less effectively to their children [6]. Thus, in our study, it is plausible that the mothers with more severe depression symptoms tended to model important positive emotion regulation skills less often than mothers with less severe depression, which contributed to externalizing and internalizing problems in children. Alternatively, albeit not tested in this study, one could expect that children with more severe externalizing and internalizing problems placed more caregiving demands on the caregivers, which might have heightened their depression. Future research is warranted to understand the mechanisms through which maternal depression can influence behavioral problems in children and how behavioral problems in children can influence maternal depression.

Our second finding was that caregiving burden partially explained the relationship between maternal depression and externalizing and internalizing problems in children. Although some studies have examined different mechanisms underlying this relationship, such as quality of mother-child interactions, positive and negative parenting behaviors, and poor locus of control in caregivers [2, 6, 8], our study shows that caregiving burden also plays an important role. Specifically, the results of our study suggest that not only is there a direct relationship between maternal depression and externalizing and internalizing problems in children, but experiencing depression also contributes to a sense of caregiving burden, which uniquely contributes to externalizing and internalizing problems in children. This finding suggests an association between caregiving burden and child outcomes. Similar to experiencing depression, experiencing high levels of caregiving burden might limit the amount of quality time that caregivers spend with their children and therefore limit the opportunities caregivers have to model important emotional regulatory strategies to their children [6], thereby increasing externalizing and internalizing problems in children. However, future research is needed to assess the role of caregiving burden on child outcomes in the context of maternal depression.

Our third finding was that mothers with depression experienced more caregiving burden relative to mothers without depression. Although past studies have shown an association between caregiving burden and the mental wellbeing of mothers with children who have chronic conditions [54, 55], our study demonstrates an association between caregiving burden and maternal depression in an urban sample of low-income predominantly ethnic and racial minority mothers, a population underrepresented in research. The increase in caregiving burden in mothers who have depression is alarming because low-income ethnic and racial minority caregivers and children are already vulnerable to the hardships associated with poverty, such as stress and limited support [30].

Our fourth finding was that mothers whose children exhibited externalizing and internalizing problems experienced more caregiving burden relative to mothers whose children did not exhibit these problem behaviors, consistent with other studies [9, 14, 20, 21, 25–28]. Taking care of a family member with high needs creates a sense of objective burden (e.g., financial costs of healthcare) and subjective burden (e.g., emotional stress, stigma, worry) on caregivers because of the significant life changes that caregivers have to make to accommodate their children [14, 16, 20, 21, 28]. Notably in our study, there was a stronger association between caregiving burden and child externalizing problems than caregiving burden and child internalizing problems. Relative to externalizing problems in children, internalizing problems may not be immediately felt by the caregiver, and thus may not be an immediate source of caregiving burden. However, internalizing problems may also go unnoticed by caregivers, and therefore unaddressed.

Limitations

There are notable limitations to our study. A first limitation is that we cannot make causal inferences about the relationship between maternal depression, caregiving burden, and child outcomes because this study was conducted cross-sectionally. It is plausible that depression was predicted by caregiving burden or externalizing and internalizing problems in children. Future studies in this area should be conducted longitudinally to allow for causal inferences and to examine changes over time in the relationship between maternal depression, caregiving burden, and child externalizing and internalizing problems.

Secondly, future research should be conducted on a larger scale to test other directional pathways and constructs. In the present study, we may not have included important moderators in our analysis, such as whether another parent or caretaker was living in the home. Taken together, conducting a robust longitudinal study with a diverse population could clarify the mechanisms through which maternal depression, caregiving burden, and child outcomes are associated, and any relevant interactions with family structure and support.

A third limitation is that our findings are based on mothers’ reports of maternal depression, caregiving burden, and child externalizing and internalizing problems. Using mother reports represents a single-method approach to measuring these constructs. Many of the mothers in this study had depression, which might influence their self-assessments of depression, caregiving burden, and child externalizing and internalizing problems [56]. Thus, the strong association between these variables might in part be influenced by method bias rather than true relationships [57]. Moreover, although judgements can vary between primary caregivers and non-primary caregivers, incorporating judgements on a child’s externalizing and internalizing problems from another informant who knows the child, such as a teacher, could be a useful way to enhance the validity of the judgements. However, a limitation of teacher reports is that they have been found to pathologize ethnic minority children more often than Caucasian children or rate the problems of ethnic minority children as more severe than the ratings from primary caregivers [58–60]. Moreover, with respect to rating agreements between primary caregivers and teachers, rating externalizing problems tends to produce higher levels of agreement than rating internalizing problems [61–62].

A fourth limitation is the caregiving burden scale that was developed for this study. Although the scale held good internal consistency and convergent and concurrent validity, the scale is purported to measure caregiving burden as a single, general construct. This is a limitation because past research has highlighted the subjective and objective dimensions of caregiving burden [15, 16], which this scale does not capture. Future studies that assess caregiving burden should clearly delineate the extent to which the caregivers are experiencing objective and subjective caregiving burden and how different components of child wellbeing can affect the different dimensions of caregiving burden in high-risk populations. To that end, more robust and widely-used measures of caregiving burden exist and should be used or adapted in future studies to assess the relationship between caregiving burden, maternal depression, and externalizing and internalizing problems in children [63–66].

A final limitation concerns the just-identified path model. Although our theoretical model (Figure 1) was guided by theory, the statistical model was just-identified, meaning that goodness of fit indices are not meaningful because just-identified models fit the data perfectly. Although some have argued for the use of over-identified models instead of just-identified models, others have suggested that just-identified models might be preferable to over-identified models [43, 44]. An over-identified model would be necessary in future studies that add latent variables and compare other models of interest. Although the merits of each statistical technique are beyond the scope of this study, we acknowledge the limitation that model fit cannot be utilized with just-identified models.

Clinical Implications

The findings underscore a significant and positive relationship between maternal depression, caregiving burden, and externalizing and internalizing problems in children. Our results highlight the importance of broaching the topic of caregiving burden when treating mothers with depression. Understanding the caregiver’s experience with caregiving burden informs treatment planning and choosing what societal resources to offer the caregiver to address caregiving burden (e.g., financial assistance, childcare services, parenting support). Women experiencing caregiving burden or early symptoms of depression can be referred to prevention services, such as home visiting, wrap-around, and social work programs [67].

The results also highlight the intergenerational influence of maternal depression [1]. Family support programs that include the mother with depression, other caregivers, and the child might be especially relevant to addressing both the maternal depression and externalizing and internalizing problems in children. Programs developed for low-income populations, such as Fortalezas Familiares (Family Strengths), aim to help mothers with depression and other caregivers identify sources of stress that contribute not only to depression, but also to parenting disruptions and child coping and wellbeing [19]. As often these sources are interpersonally-based, the presence of partners or other caregivers (e.g., grandparents) aims to decrease interpersonal stress and increase instrumental and emotional support for mothers with depression. The program is especially designed for low-income women, acknowledging the resilience of these women in light of structural, social, community, and family adversity.

Limitations notwithstanding, this work with low-income urban mothers who identified mostly as Black and Latina can inform future research, clinical work, and social policies aimed to improve the wellbeing of parents with depression who care for children who exhibit externalizing and internalizing problems. Routine clinical assessments of a caretaker’s caregiving burden, coupled with targeting interventions to address externalizing and internalizing problems in children, might facilitate depression treatment among caregivers and promote overall family wellbeing.

Summary

There is a strong relationship between maternal depression and externalizing and internalizing problems in children [1], and caregiving burden might mediate this relationship. Yet, caregiving burden has rarely been tested as a mechanism underlying the relationship between maternal depression and child outcomes. Caregiving burden might be especially high in racial and ethnic minority parent-child dyads in low-income settings where there are more stressors in the environment and rates of maternal depression are elevated [29, 30]. In this study, we tested the hypothesis that maternal depression has a direct effect on child externalizing and internalizing problems, and also an indirect effect through caregiving burden. We conducted a just-identified path analysis model with an urban sample of 132 low-income mothers who identified mostly as Black or Latina [43, 44]. Confirming our hypothesis, results indicate a significant direct and positive link between maternal depression and externalizing and internalizing problems in children. Results also suggest an indirect positive effect of maternal depression on externalizing and internalizing problems in children through caregiving burden. The results of this study also highlight the importance of broaching the topic of caregiving burden in clinical practice when working with mothers who have depression who care for children with behavioral problems, and also points to the importance of providing resources to assist with caregiving for this vulnerable population.

Table 3.

Fit Indices for the Exploratory Factor Analyses

χ2(df) p-value RMSEA CFI TLI
One-factor model 28.480(9) < .001 .129 .922 .871
Two-factor model 15.659(4) < .01 .150 .954 .826
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Acknowledgments

The project described was supported by grants from the National Institute of Mental Health: MH-58384 to Dr. Anne Riley and MH-56864 to Dr. Jeanne Miranda.

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Conflict of Interest. The authors declare that they have no conflict of interest.

Ethical Approval. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent. Informed consent was obtained from all individual participants included in the study.

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