Research Article: How does perinatal maternal mental health explain early social inequalities in child behavioural and emotional problems? Findings from the Wirral Child Health and Development Study

Date Published: May 24, 2019

Publisher: Public Library of Science

Author(s): Callum Rutherford, Helen Sharp, Jonathan Hill, Andrew Pickles, David Taylor-Robinson, Hudson P. Santos.


This study aimed to assess how maternal mental health mediates the association between childhood socio-economic conditions at birth and subsequent child behavioural and emotional problem scores.

Analysis of the Wirral Child Health and Development Study (WCHADS), a prospective epidemiological longitudinal study of the early origins of child mental health (n = 664). Household income at 20-weeks gestation, a measure of socio-economic conditions (SECs) in pregnancy, was the main exposure. The outcome measure was externalising and internalising problems, as measured by the Child Behaviour Checklist at 5 years. We assessed the association of household income with child behavioural outcomes in sequential linear models adjusting for maternal mental health in the pre- and post- natal period.

Children of mothers in more disadvantaged households had higher scores for externalising behaviour with a difference of 3.6 points comparing the most affluent to the most disadvantaged families (the socio-economic (SEC) gap). In our regression model adjusting for baseline confounders, comparing children of mothers in the most disadvantaged households to the least disadvantaged, we found that most disadvantaged children scored 45 percentage points (95% CI 9, 93) higher for externalising problems, and 42% of this difference was explained in the fully adjusted model. Adjusting for prenatal maternal depressive symptomology attenuated the SEC gap in externalising problems by about a third, rendering the association non-significant, whilst adjusting for pre- and post-natal maternal mental health attenuated the SEC gap by 42%. There was no significant relationship between household income and internalising problems.

Social disadvantage is associated with higher child externalising behaviour problems score at age 5, and about 40% of this was explained by maternal perinatal mental health. Policies supporting maternal mental health in pregnancy are important to address the early emergence of inequalities in child mental health.

Partial Text

Reducing inequalities in mental health outcomes is a public health priority. [1] In the UK, one in ten children and young people (aged 5–16 years) have a clinically diagnosed mental health problem (behavioural 6% and emotional 4%). [2] The prevalence of mental health problems is a growing concern, with 24% of girls and 9% of boys aged 14 years self-reporting high levels of depression in the UK. [3] Poorer socioeconomic conditions (SECs) are associated with worse mental health outcomes. [4] A systematic review of 52 studies from 23 countries found that children and young people from disadvantaged families are two-to-three times more likely to develop mental health problems compared to economically advantaged children. [4] A number of theories describe the pathways through which SECs influence child health, including mental health, with the most commonly cited differentiating between material, psychosocial, behavioural and structural factors. [5] For example, experiences of poverty can have a negative impact on maternal mental health and behaviour, which in turn influences child health. [6]

Table 1 shows sample characteristics stratified by household income. There were differences in mean scores for externalising and internalising behaviour problems by household income. As household income increases, mean scores for internalising and externalising behaviour problems decrease. Scores ranged from 9.9 (8.1 SD) in the lowest income households to 6.3 (6.3 SD) in the highest income households for externalising problems and from 8.1 (5.6 SD) to 5 (4.2 SD) for internalising problems. For all measures of maternal depressive symptoms in the perinatal period, mothers from the lowest income households had higher mean scores. Higher maternal age (> 35 years) was more common in the higher household income groups.

More knowledge is needed for the earliest possible identification of children with behavioural and emotional problems. Whilst we have shown that income and deprivation impact maternal mental health and child externalising behaviour problems, there may be threshold effects, and identifying these in future research may usefully inform public health and welfare policy. Further longitudinal investigation, with an early-years focus, is welcomed.




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