Children?s Internalizing, Externalizing, Sexualized Behavior, and Social Competence as Predicted by Maternal Level of Depresion: Are These Asociations Moderated by Child Sex and Mothers? History of Sexual Abuse? by Raven Apollo Pyle A thesis submited to the Graduate Faculty of Auburn University in partial fulfilment of the requirements for the Degree of Master of Science Auburn, Alabama May 3, 2014 Keywords: maternal depresion, child sexualized behavior, child sexual abuse Copyright 2014 by Raven Apollo Pyle Approved by Margaret K. Keiley, Chair, Profesor and Director of Clinical Research of Human Development and Family Studies Scott A. Ketring, Asociate Profesor of Marriage and Family Therapy Program Jacquelyn Mize, Profesor Emerita of Human Development and Family Studies ii Abstract Maternal depresion is often related to child functioning, including child internalizing, externalizing, and sexualized behavior, as wel as child social competence. However, litle research has investigated how child sex and mothers? history of sexual abuse can afect the influence of maternal depresion on these outcomes. The purpose of this study is to examine how maternal depresion afects internalizing, externalizing, and sexualized behavior, as wel as child social competence of their children. Additionaly, this study examines whether these relationships difer acording to child sex and mothers? history of sexual abuse. This study examines 820 children and mothers in a high-risk sample. We found that maternal depresion is more predictive of child internalizing, externalizing, and sexualized behavior in children whose mothers have a history of sexual abuse than those who do not. Furthermore, the relationship betwen mothers? depresion and child internalizing, externalizing, and sexualized behavior is strongest for sons of mothers with a history of sexual abuse. Our results indicate that mothers? depresion is related to child behavioral and emotional adjustment and that child sex and mothers? history of sexual abuse do moderate these relationships. iii Acknowledgments First, I would like to thank my God who provided me with both a pasion for studying and improving human relationships and the opportunity to be a part of such an incredible program of study. I would like to thank my friends, extended family, and my cohort for their unwavering support throughout this proces. I extend the deepest of gratitude to my commite members, Dr. Scott Ketring and Dr. Jacqueline Mize, whose mentorship and reviews have shaped me and encouraged me as a researcher. Finaly, to Dr. Margaret Keiley, my major profesor, who has generously poured into me as a student, clinician, and an individual, I am eternaly grateful for your mentorship. iv Table of Contents Abstract ......................................................................................................................................... ii Acknowledgments ........................................................................................................................ iii List of Tables ................................................................................................................................ v List of Figures .............................................................................................................................. vi Introduction .................................................................................................................................. 1 Literature Review .......................................................................................................................... 3 Consequences of Maternal Depresion ............................................................................ 3 Consequences of Sexual Abuse of Mothers ..................................................................... 5 Defining Child Sexualized Behavior ............................................................................... 7 Correlates of Child Sexualized Behavior ......................................................................... 9 Mothers of Children with Problematic Child Sexualized Behavior .............................. 10 Method ....................................................................................................................................... 12 Participants ..................................................................................................................... 12 Measures ......................................................................................................................... 13 Plan of Analysis ............................................................................................................. 17 Results ........................................................................................................................................ 19 Discussion .................................................................................................................................. 23 References .................................................................................................................................. 29 Appendices .................................................................................................................................. 38 v List of Tables Table 1a ....................................................................................................................................... 38 Table 1b ...................................................................................................................................... 38 Table 2 ........................................................................................................................................ 39 vi List of Figures Figure 1 ...................................................................................................................................... 40 Figure 2 ...................................................................................................................................... 41 Figure 3 ...................................................................................................................................... 42 Figure 4 ...................................................................................................................................... 43 1 Introduction Acording to the Fourth National Incidence Study of Child Abuse and Neglect Report to Congres (US Department of Health and Human Services: ACF, 2011), the total economic burden of child maltreatment has been estimated to be as high as $585 bilion. The widespread and negative individual, familial, and societal consequences of child maltreatment have been widely studied. However, the above statistic establishes the importance of further scientific investigation into the etiology and consequences of child abuse. Investment in these eforts wil provide a solid foundation and direction for both social policy and intervention (Swisher, Silovsky, Stuart, & Pierce, 2008). The consequences of child abuse are broad, with efects at each life stage for the abused child. Mothers who have been maltreated in childhood often suffer from depresion in later life (Dubowitz et al., 2001). Other studies have suggested that mothers? experiences of victimization across their lifetimes and the resulting depresion make it dificult for these mothers to provide their own children with good parenting and helpful support (DiLilo, Tremblay, & Peterson, 2000; Hal, Sachs, & Rayens, 1998; Miranda, de la Osa, Granero, & Ezpleta, 2013). Despite evidence of an exponential efect of a maternal history of sexual abuse on the emotional/interpersonal adjustment of mothers (Cohen, Hein, & Batchelder, 2008), only a few studies have investigated the role of maternal sexual abuse in predictive relationships betwen parent depresion and child level functioning (DiLilo & Damashek, 2003; Spiler, Jouriles, McDonald, & Skopp, 2012). 2 Child sexualized behavior (CSB) is one of the most clearly linked and highly stigmatized outcomes of sexual abuse (Chafin et al., 2008). When taking into consideration other individual/family level factors, we now know that child sexual abuse is not always the sole predictor of problematic CSB (Silvosky & Niec, 2002; Swisher et al., 2008). In fact, problematic CSB in children is often related to the emotional adjustment and sexual abuse history of those children?s mothers (Friedrich, 2005). However, a clear picture of the etiology and normal range of CSB, especialy across child sex, has yet to be established. The few investigations that have examined the cross-generational efects of mothers? history of sexual abuse have focused mostly on scores of child internalizing and externalizing behaviors, or even total scores of child emotional/behavioral adjustment as outcomes (Merrick, Litrownik, Everson, & Cox, 2008; Roberts, O?Connor, Dunn, & Golding, 2004). Our study distinctly considers four measures of child emotional and behavioral adjustment simultaneously (internalizing, externalizing, sexualized behavior, and child social competence). In addition, we investigate mother?s abuse history and child sex as moderators of the relationship betwen mother?s depresion and these child outcomes. Previous research has established higher rates of externalizing behavior in boys and higher rates of internalizing behavior in girls (Keiley, Bates, Dodge & Petit, 2000). However, findings regarding the relationship betwen sexualized behavior and child sex are mixed and also are complicated by changes in the incidence of normative sexualized behavior across development (Chafin, Letourneau, & Silovsky, 2002). This study is one of the first to investigate child sex as a potential moderator of the relationship betwen maternal emotional and child behavioral, emotional, and social adjustment, including sexualized behavior, in a population of mothers with and without a history of sexual abuse. 3 Using data from the Longitudinal Studies in Child Abuse and Neglect (LONGSCAN; se Runyan et al., 1998 for details) project, the following investigation examines the relationship betwen mothers? self-reported depresion when their children are 4 years old and their children?s internalizing, externalizing, sexualized behavior, and social competence four years later controlling for socioeconomic status and child experience of sexual abuse. Furthermore, this analysis investigates child sex and mothers? history of sexual abuse as moderators of this relationship. Review of the Literature Consequences of Maternal Depresion The relationship betwen maternal depresion and child externalizing and internalizing problems is firmly established by previous literature (Carter, Garrity-Rokous, Chazan-Cohen, Litle, & Briggs-Gowan, 2001; Elgar, McGrath, Waschbusch, Stewart, & Curtis, 2004). Children whose mothers experience depresion during their lifetime show significantly more delinquent (e.g. lying, swearing, stealing) and aggresive behavior (e.g. physicaly atacking others, quick temper) than those who had not, even when controlling for mother?s own delinquent/aggresive behavior (Kim-Cohen, Moffit, Taylor, Pawlby, &Caspi, 2005). Diagnoses of depresion and anxiety disorders are also twice as likely in children of mothers with a history of depresion as compared to those whose mothers do not have a history of depresion (Hamen, & Brennan, 2003). Maternal depresion afects parenting, specificaly through negative maternal behavior (e.g. threatening gestures, negative facial expresion, and expresed anger) and disengagement (e.g. ignoring and withdrawal). The largest efect sizes have been found for maternal depresion?s prediction of maternal hostility and irritability toward their children (Lovejoy, 4 Graczyk, O'Hare, &Neuman, 2000). Additionaly, maternal depresion has been linked to child emotional and behavioral adjustment through interruption of atachment betwen mother and child (Cicheti, Togosch, &Toth, 1998), harsh or inefective parenting strategies (Loevejoy et al., 2000), and high levels of family dysfunction and relationship instability (Cummings & Davies, 1994). Previous research indicates a dose and timing efect on the relationship betwen maternal depresion and child emotional and behavioral adjustment. Children whose mothers have more depresive episodes and children whose mothers are currently depresed have significantly more delinquent/aggresive behavior (Kim-Cohen, Moffit, Taylor, Pawlby, & Caspi, 2005). Although timing of depresion is important, with current depresion having largest efects on current child adjustment, the residual efects of prior maternal depresion also have consequences for later child behavior (Elgar et al., 2004). This study wil investigate maternal depresion at child age 4 and examine the residual efects of mothers? depresion at a time point four years later, at child age 8. Although about one-third of women experience depresion at some point in their lifetime, depresion is especialy common in low-income, single mothers (Elgar et al., 2004; Lovejoy et al., 2000). Additionaly, the relationship betwen mothers? depresion and delayed self- regulatory strategies, low social competencies, low levels of self-estem, and high levels of behavioral problems in their children is stronger for economicaly disadvantaged families than for non-economicaly disadvantaged families (Black et al., 2002; Luoma et al., 2001). Thus, we wil investigate the relationship betwen maternal depresion and child internalizing, externalizing, sexualized behavior, as wel as child social competence in an at-risk, low socioeconomic status population. 5 The ways that environmental factors and child sex afect the relationship betwen maternal depresion and child adjustment remain unclear (Elgar et al., 2004). Negative life events are undoubtedly related to the possible intergenerational transmision of risk for emotional and behavioral problems, however how these experiences afect the relationship betwen maternal depresion and child emotional and behavioral adjustment is not clearly established (Goodman & Gotlib, 1999). Some research indicates significant relations betwen maternal depresion and female, but not male, internalizing symptoms (Fergusson, Horwood, & Lynskey, 1995). Other research indicates paralel efects across child sex (Elgar et al., 2003). Our study wil investigate how one specific negative life event (mothers? experience of sexual abuse) afects the relationship betwen maternal depresion and child emotional, behavioral, and social adjustment. We wil also test for moderation of the relationship betwen maternal depresion and child adjustment by child sex. Consequences of Sexual Abuse of Mothers Most research has focused on either current maternal physical victimization within partner relationships or lifetime histories of maternal victimization including sexual, physical, or inter-partner violence as predictors of the behavioral and emotional adjustment of their offspring (DiLilo & Damashek, 2003). Investigations using these indicators of maternal maltreatment have established that mothers? victimization is related to mothers? current depresive symptoms (Dubowitz et al., 2001; Miranda et al., 2013), as wel as their children?s externalizing and internalizing behavior (Koverola et al., 2005; Miranda, de la Osa, Granero, & Ezpleta, 2011; Morrel, Dubowitz, Kerr, & Black, 2003). Child sexual abuse (CSA) is also strongly predictive of low levels of psychological functioning in adulthood. Women with a history of CSA report greater levels of depresion and 6 anxiety (Banyard et al., 2001; Buist & Janson, 2001; Schuetze & Eiden, 2005), and greater levels of overal psychological distres as adults than their counterparts (DiLilo et al., 2000). Although the role of depresion in the relationship betwen maternal victimization and child adjustment remains unclear (Thornberry, Knight, & Lovegrove, 2012), victimized women consistently experience themselves as incompetent parents, reporting low confidence, low emotional control, inconsistency, and disorganization as parents (Banyard, 1997; Cole, Woogler, Power, & Smith, 1992; Roberts et al., 2004). Current negative family dynamics, including negative life events in general (Banyard et al., 2001) and/or current partner violence, and the cumulative efect of such experiences intensify these direct efects (Schuetze & Eiden, 2005). Women with a history of child sexual abuse are two times more likely to experience sexual victimization by both non-partners and partners in their adult life, even when controlling for demographic factors and their own childhood physical abuse. As adults, these women are three times more likely to be sexualy victimized by a non- partner and six times more likely to be abused by their current partners (Desai, Arias, Thompson, &Basile, 2002). Mothers victimized only as children or only as adults report similar levels of depresive symptoms in themselves and similar emotional and behavioral adjustment in their children. However, Cohen, Hein, and Batchelder (2008) found that mothers? history of multiple traumas is more strongly predictive of their own children?s abuse than is any single instance of abuse, and mothers victimized during both childhood and adulthood report greater depresive symptoms and more child internalizing and externalizing problems (Dubowitz et al., 2001). Thus, the cumulative efects of mothers? CSA may be predictive of the emotional, behavioral, and social adjustment of their children (Paredes, Leifer, & Kilbane, 2001; Schuetze & Eiden, 2005). 7 Some studies find that mothers with a history of CSA report more conduct, aggresion, anxiety, depresion, and peer problems in their children than mothers without a history of CSA (Roberts et al., 2004), but other studies fail to find support for this relationship (DiLilo & Damashek, 2003). Despite evidence suggestive that mothers? histories of sexual abuse may be predictive of high levels of externalizing and internalizing problems and low levels of prosocial behavior in their children, this relationship has not been investigated thoroughly (Paredes, Leifer, & Kilbane, 2001). Our study wil extend the research on the consequences of mothers? victimization by focusing on how the relationship betwen mothers? psychological functioning and their children?s emotional and behavioral outcomes is afected by mothers? history of sexual abuse. Defining Child Sexualized Behavior (CSB) Child sexualized behavior (CSB) is the least understood and most socialy stigmatized behavior that has been linked to sexual abuse (Chafin et al., 2002). The following review wil define children?s sexualized behavior within a developmental psychopathology framework as recommended by Elkovitch, Latzman, Hansen, and Flood (2009). This framework wil alow us to understand one possible pathway toward CSB, taking into acount the role of development, context, as wel as maternal history of sexual abuse in the development of CSB (Rutter & Sroufe, 2000). The definition of normative sexual behavior in school age children varies across development and culture. Therefore, diferentiation betwen normative and non-normative sexualized behavior should occur on an individual level, taking into consideration social norms as wel as the developmental level of the child (Kelogg, 2009;Silovsky & Niec, 2002). Sexualized behavior is labeled as problematic when it is characterized by aggresion, causes 8 harm or emotional distres for the child or others, occurs betwen children of diferent ages, size, or developmental levels, and/or occurs betwen children who do not know each other wel. Sexualized behavior also becomes problematic when it persists despite appropriate caregiver intervention or disrupts normal childhood activities (Silovsky & Bonner, 2004). The American Asociation for the Treatment of Sexual Abusers Task Force on Children with Sexual Behavior Problems defines problematic CSB as behaviors involving sexual body parts (i.e. genitals, anus, buttocks, or breasts) that occur in children younger than 12 that are developmentaly inappropriate or potentialy harmful to themselves or others. These behaviors may stem from curiosity, impulsivity, anxiety, trauma, and/or atention seking. Sexualized behaviors in children do not represent a medical or psychological syndrome or a diagnosable disorder, but a set of behaviors outside of aceptable societal limits. That is, child sexualized behavior is normative in children, however becomes problematic when interrupting personal or interpersonal functioning. Children who engage in CSB are a heterogeneous group, have few characteristics to diferentiate them from other children (Chafin et al., 2002), and no profile of children with CSBs has been established (Bonner, Walker, & Berliner, 1999). Children with CSBs have been found to be distinct from adolescent or adult sexual offenders in that they are not frequently held liable in court (Letourneau, Schoenwald, & Sheidow, 2004). They are usualy not capable of using the characteristic behaviors of older offenders (planning, grooming, or rationalizing). Rather, children are mostly self-focused and have dificulty connecting their sexualized behavior to the consequences (Chafin et al., 2002). As a result, criminal justice definitions or labels of sexual offender are inappropriate for children displaying such behavior and the term child 9 sexualized behavior problems more appropriately labels the behaviors of children, rather than the children themselves (Chafin et al., 2002). Correlates of Child Sexualized Behavior (CSB) Children with problematic CSB are not a homogeneous group in terms of individual characteristics. However, as a group, children displaying problematic CSBs also display other types of behavioral dificulties (Bonner et al., 1999; Chromy, 2007; Friedrich, Davies, Feher, & Wright, 2003). Gray, Busconi, Houchens, and Pithers (1997) found that 93% of children with CSBs meet a second DSM-IV diagnosis and 45% of these children met two additional diagnoses. In the Gray et al. study, 73% of children with problematic CSBs are diagnosed with Conduct Disorder, 41% with an Atention Deficit Disorder, and 27% with Oppositional Defiant Disorder. Children displaying problematic CSBs have high levels of externalizing and social behavior problems (Letourneau et al., 2004), poor boundaries (Silovsky & Niec, 2002), and low levels of peer aceptance and self-estem as compared to children without problematic CSB (Bonner et al., 1999). High rates of comorbidity of CSBs with externalizing problems have even resulted in questioning the legitimacy of distinguishing CSBs from other behavior problems (Silovsky, Niec, Bard, & Hecht, 2007). However, young age and explicit family sexuality uniquely predict problematic CSB when controlling for externalizing problems; in addition, verbal abuse is often the only predictor of both externalizing problems and CSB (L?vesque, Bigras, & Pauz?, 2010). Based on the moderate relationship betwen CSB and externalizing problems, CSB should be addresed and investigated as a specific and distinct type of externalizing behavior. The role of child sex in the prediction of problematic CSB remains unclear. Several studies indicate that problematic CSB is more common in girls (Gray, Pithers, Busconi, & 10 Houchens, 1999; Letourneau et al., 2004; Taren-Sweney, 2008), whereas other studies indicate that boys are two times more likely to display problematic CSB (L?vesque et al., 2010) and may display more aggresive CSB when compared to girls (Bonner et al., 1999). Other studies indicate no diference in CSB across sex (Friedrich et al., 2003; Silovsky & Niec, 2002). However, studies showing no sex diferences include children across wide age ranges and may fail to detect diferences in the role of sex because the characteristics of children displaying CSB change significantly across early, middle, and late childhood/adolescence (Kelogg, 2009; Swisher et al., 2008). For example, although Gray et al. (1997) fails to find sex diferences in rates of change in CSB across time, the rates of change in CSB are diferent for boys and girls when child age is considered. In boys, rates of CSB are two times higher in boys 6-9 years old when compared to boys 10-12 years old. Girls? scores remain similar across time. Our investigation focuses on CSB at age 8 because middle childhood has been established as a time in which CSB begins to decrease as children become more aware of social norms regarding sexual behavior (Friedrich, 2005). One of the most consistent findings about sexualized behaviors in children is that children?s sexual abuse is not as uniquely predictive of CSB when considering other individual/family level factors such as total life stres and domestic violence (Friedrich et al., 2003; Silvosky & Niec, 2002; Swisher et al., 2008). Although children who have been sexualy abused have been found to engage in more sexualized behavior and a large percentage of children displaying sexualized behavior have been sexualy abused (Letourneau et al., 2004), many children with problematic CSB do not have a history of sexual abuse (Silovsky & Niec, 2002). For example, Bonner et al. (1999) found that 52% of children exhibiting CSBs have no reported history of sexual abuse and 41% have no experience of abuse of any type. Thus, in 11 order to investigate the unique efect of mothers? history of sexual abuse beyond that of any possible sexual abuse of the children themselves, we control for children?s history of sexual abuse. We also control for the socioeconomic status of the families in our study, specificaly family income and number of dependents in the household. Previous research has established that one of the biggest dificulties in child development research is determining the extent to which environmental stresors acount for al or part of the negative influence following abuse/neglect/family violence (Herrenkohl & Herrenkohl, 2007). One such environmental stresor that has a negative influence on families in which sexual abuse occurs is economic disadvantage (Freisen, Woodward, Horwood, & Fergusson, 2010). Furthermore, Friedrich, Davies, Feher, and Wright (2003) found that family income and total life stres were strongly related to maladaptive sexual behavior in children, and strongly suggest controlling for family income in the study of CSB. Mothers of Children with Problematic CSB Mothers of children with problematic CSB report more negative life experiences in their childhood and adulthood, including domestic violence and arrest (Gray et al., 1999; Pithers, Gray, Busconi & Houchens, 1998). Furthermore, biological parents of children with CSBs report a history of abuse and neglect themselves (Bonner et al., 1999). These maternal experiences of abuse are related to the severity of CSBs in their children. Acording to Hal et al. (1998), mothers of children showing higher levels of CSBs report a greater range of negative experiences in their own childhoods and adulthoods than do mothers of children showing les intrusive and problematic behaviors. 12 Whether as a consequence of their own histories of abuse or of their children?s behavior, mothers of children displaying problematic CSB view their children more negatively (Bonner et al., 1999), experience their children as excesively demanding of time and atention, and find their interactions with their children unrewarding compared to mothers of children without CSBs (Pithers et al., 1998). Although mothers who report having trauma symptoms in adulthood have children with behavior problems and problematic CSB (Paredes et al., 2001), the role of mothers? histories of abuse in the prediction of problematic CSB is not clear. The following investigation extends past research by linking maternal level functioning, specificaly maternal depresion to children?s outcomes (externalizing, internalizing, and sexualized behavior, and social competence). In addition, the moderation of these efects by child gender and mothers? histories of abuse are tested. Method Data for this analysis were collected as part of the Consortium of Longitudinal Studies in Child Abuse and Neglect (LONGSCAN) project. LONGSCAN is a longitudinal study examining the etiology and efects of child maltreatment in high-risk samples. Researchers followed children from childhood through adulthood in a nation-wide study. We conducted a secondary data analysis of this dataset. Participants This study follows 820 children and their biological mothers across four years, from age 4 to 8. This analytic sample was selected from the larger sample based on the caregiver being the biological mother. Participants were recruited as caregiver-child dyads from 5 sites across the United States, located in the East (EA; 16%), Midwest (MW; 29%), South (SO; 24%), Northwest (NW; 21%), and Southwest (SW; 10%). Each site used slightly diferent enrollment strategies, and 13 each selected children with varying levels of exposure to maltreatment. The East site focused on low-income children with varying levels of risk of maltreatment: one group defined by child risk factors (inadequate growth in the first two years of life), one by parent risk factors (HIV infection/drug use), and a comparison group simply at risk based on low-income status. The Midwest site focused on families reported to CPS and a group of neighborhood controls. The Northwest site focused on children indicated to be at moderate risk following CPS reports. The Southern site included children identified as high risk at birth and a group of matched low-risk children. The Southwest site focused on children placed in foster care. Data collected from biological mothers were included from this site. The majority of this sample is made up of racial minorities, with 52% of the children being African-American (n=429), 27% percent being European-America (n=224), and 21% percent reporting another race/ethnicity (n=167). The majority of the families are low-income households, with 76% making les than $20,000 per year (n=627). Of the mothers in this sample, 53% are single mothers (n=433). Average age of mothers is 30 years. At child age 4, 58% of mothers reported that they had been sexualy abused as children, tens, or adults (n= 476). Of the children in this sample, 52% are female (n= 426). We were able to examine diferences in the proposed model across four groups based on maternal history of sexual abuse and child sex: sexualy abused mothers of boys (n=167, 20%), sexualy abused mothers of girls (n=179, 22%), non-sexualy abused mothers of boys (n=226, 28%), and non-sexualy abused mothers of girls (n=248, 30%). Measures Outcome Measures Child Behavior Check List (CBCL). Child emotional/behavioral functioning was asesed at age 8 using the Child Behavior Checklist (Achenbach, 1991). Caregivers were alowed to 14 complete paper forms unles they required asistance in reading instruments, in which case the questionnaires were administered oraly. The 113-item CBCL items are al scored from 0 to 2 (0=not true, 1=somewhat true, and 2=very true or often true) and are caregiver reports of observed behaviors over the past 6 months. This study looks at the Internalizing Behavior, Externalizing Behavior, and Social Competence scales. The Internalizing Problems subscale is made up of 33 items, with possible scores ranging from 0 to 62, and includes subscales of Social Withdrawal, Somatic Complaints, and Anxiety/Depresion. The Externalizing Problems Subscale is 33-items, with possible scores ranging from 1 to 66, and includes subscales of Delinquent Behavior and Aggresive Behavior scores as wel as Social Competence scores of the CBCL at age 8. The Social Competence Subscale contains 20 items, with possible scores ranging from 0 to 60, grouped into 3 scales (Activities, Social, and School).The CBCL has been shown to have internal and test-retest reliability with an internal reliability coeficient of .87 for the internalizing scale and .93 for the externalizing subscale. Many studies have shown that the CBCL is valid and scores are consistent with psychiatric diagnoses (Achenbach, 1991). Child Sexual Behavior Inventory (CSBI). The Child Sexual Behavior Inventory was used to ases presence and frequency of a range of sexual behaviors in the previous 6 months (Friedrich, 1997). Caregivers were alowed to complete paper forms unles they required asistance in reading instruments, in which case the questionnaires were administered oraly. The CSBI is comprised of 38 items indicated on a 4-point scale ranging from 0 (never) to 3 (at least once a wek). Average raw scores wil be used in this analysis. The instrument has demonstrated good internal consistency with internal reliability coeficient of .93. Construct validity has also been established through correlation of parent and teacher report on the CSBI (Friedrich et al., 1992). Predictor Measure 15 Center for Epidemiologic Studies Depresion Scale (CES-D). Maternal depresion was measured when children were 4 by the Center for Epidemiologic Studies Depresion Scale (CES-D) developed by Radloff (1977). Caregivers completed paper forms of the Center for Epidemiologic Studies Depresion Scale at this time point, unles they required asistance in reading instruments, in which case the questionnaire was administered oraly. The CES-D is comprised of 20 items reflecting depresed mood, felings of guilt, worthlesnes, and hopelesnes, and somatic symptoms. Items are rated on a 4-point scale based on frequency, with 0 for rarely or none of the time to 3 for most or al of the time. Scores range from 0 to 60, with a score of 16 commonly used as a cut-off for a diagnosis of clinical depresion (Radloff, 1977). The CES-D has been shown to be a reliable measure with high internal consistency indicated by Cronbach?s alpha coeficient of .90. Radloff (1977) has also established concurrent and construct validity of the CES-D as a measure of depresive symptoms. Moderating Measures Maternal History of Sexual Victimization. The primary caregivers? histories of childhood sexual abuse were asesed when their children were 4 using the Caregiver?s History of Loss and Victimization developed by Hunter and Everson (1991). This retrospective self-report measure includes three items indicating Childhood Sexual Abuse, three items indicating Adolescent Sexual Abuse, and two items indicating Adult Sexual Asault. A score of 1 on any of these items indicates a history of sexual abuse; a score of 0 indicates an absence of sexual abuse (Dubowitz et al., 2005; Koverola et al., 2005). The Caregiver?s History of Los and Victimization has been established to be a valid measure of a history of sexual abuse with scores on this asesment being highly correlated to actual experience of abuse (Hunter & Everson, 1991). If the mother designated a score of 1 on any of these items, she was clasified as having been abused prior to the study. 16 Child Sex. Child sex was designated as a dichotomous variable with females being coded as 1 and males as 0. Control Measures Child History of Sexual Abuse. A LONGSCAN modified version of Barnet, Manly, and Cicheti?s (1993) Modified Maltreatment Clasification System (MMCS; English & the LONGSCAN investigators, 1997) was used to code official Child Protective Services records of child sexual abuse. A lead abstractor trained from each site conducted reviews of Case Records and Maltreatment Data Forms from Child Protective Services and Central Registry records in order to gather information regarding child sexual abuse up to age 8. This study defines child sexual abuse (CSA) as any alegation of sexual abuse made at age 4 or earlier, as reported by Child Protective Services. Previous research indicates no significant diferences in behavioral and emotional outcomes betwen children with substantiated reports and children with unsubstantiated reports of child abuse from age 4 to 8 (Hussey et al., 2005), and Litrownik?s (2009) presentation on LONGSCAN data use suggests using alegations of abuse in analyses. Thus, we used alegations rather than substantiations of abuse as indicators of sexual abuse. Alegations were established as reliable indicators of sexual abuse with a Kappa of .77 (English & the LONGSCAN investigators, 1997). A score of 1 on any of these items wil indicate any history of sexual abuse; a score of 0 will indicate an absence of sexual abuse. Family Income and Mothers? Education. A family profile questionnaire developed by LONGSCAN was used to establish data on the family income and mothers? level of education in the study. This family profile includes information on the two other measures that we use as controls: family income and number of dependents. Family income was measured on an 11-point scale (1=<$5,000 per year, 11=>$50,000 per year). Mothers? level of education was measured on a 20- 17 point scale acording to the highest grade in school or year of college completed by mothers (0=none, 20+=graduate/profesional). Demographic Controls. We also controlled for mothers? partner status, mothers? age, number of dependents, and race. Plan of Analysis After conducting a univariate and bivariate analysis in SAS (Version 9.2; SAS Institute Inc., 2009), we conducted a path analysis in MPLUS (Version 6; Muthen & Muthen, 1998-2010) to test the prediction of four indicators of child emotional, behavioral, and social adjustment(internalizing, externalizing, and sexualized behavior, and social competence) by maternal depresion. First, an unconditional model was fit alowing mothers? depresion at child age 4 to predict child internalizing, externalizing, and sexualized behavior, and social competence at child age 8. For these and al fited models, adequate model fit was asesed by a ? 2 statistic/degrees of freedom ratio les than 5 and a RMSEA les than .10 (Wheaton et al., 1977). We then fit a conditional model in which we added control variables and tested for significance in this order: child history of sexual abuse, LONGSCAN site, family income, number of dependents, mothers? partner status, mothers? age, mothers? level of education, and race. Delta chi-square tests indicated that only family income, mothers? education, and child history of sexual abuse were significant in predicting mothers? depresion. These three variables were retained. We re-fit the conditional model with only the 3 control variables that were significant. Finaly, we tested for diferences across four groups: female children with maltreated mothers (MAF), male children with maltreated mothers (MAM), female children with non- maltreated mothers (MNF), and male children with non-maltreated mothers (MNM). In other words, we tested if the conditional model was moderated by child sex and mothers? abuse history. To do so, each of the paths representing the relationship betwen the predictor and 18 each outcome variable one at a time was constrained to be equal across the four groups and delta-chi square tests were used to determine which paths were significantly diferent across these groups. To determine if mother?s depresion predicted a diferent amount of variance in each of the child behaviors (internalizing, externalizing, and sexualized behavior, and child social competence) across each of the 4 groups, the residual variances of child internalizing, externalizing, and sexualized behavior, and child social competence were constrained to be equal and delta-chi square tests were again used to determine if the amounts of variance predicted were diferent as wel. Mising data were not imputed; rather, available data from al 820 children were used in analyses using full information-maximum likelihood (FIML) estimation with robust standard errors. FIML estimation is one of the best methods of dealing with mising data (Acock, 2005). 19 Results Descriptive Statistics The descriptive statistics for al of the study variables for the full sample and the four groups determined by maltreatment status of the mother and sex of the child are presented in Table 1a and the descriptive statistics for control variables are presented in Table 1b. Child social competence was fairly symmetricaly distributed, but maternal depresion, child externalizing, internalizing, and sexualized behavior were al skewed towards lower values. We wil continue to use the labels maternal depresion, child externalizing, internalizing, and sexualized behavior, but to create more normal distributions for use in multivariate analyses these variables were logged. Although we did not test for diferences across the four groups, mothers? depresion, on average, was higher for the groups in which mothers had been abused than for those who had not. Furthermore, child internalizing and externalizing symptoms were higher, and child social competence lower for the groups in which mothers had been abused than for those who had not, on average. On average, girls scored higher on social competence than boys, despite mothers? history of sexual abuse. Although boys and girls in groups in which mothers had a history of sexual abuse scored similarly on externalizing and internalizing symptoms, boys indicated higher levels of internalizing and externalizing symptoms than girls in groups in which mothers did not have a history of sexual abuse. With respect to control and demographic variables, mothers? level of education was symmetricaly distributed, and there were about equal numbers of male (n=393) and female (n=427) children, and sexualy abused (n=346) and not sexualy abused (n=474) mothers in our 20 sample. There were fewer children with a history of sexual abuse (n=346) than without such a history (n=736) in our sample. The total income of the families included in this study was skewed toward lower values, with 76% of families making les than $20,000 per year. Mean family income for the whole sample is around $10,000 per year, on average. On average, the eleventh grade was the highest grade in school completed by mothers in this sample. Bivariate Analysis Pearson correlations were estimated among all variables used in our analysis. Results are presented in Table 2. Child internalizing, externalizing, and sexualized behavior, as wel as social competence at child age 8 are al significantly related to maternal depresion at child age 4. Furthermore, child internalizing, externalizing, and sexualized behavior, and child social competence at child age 8 are positively related, such that high levels of one outcome are asociated with high levels of the others, and vice versa. Bivariate plots of the relationships betwen mothers? depresion and child internalizing, externalizing, and sexualized behavior, and social competence were also examined, and these plots denote linear relationships betwen each of these outcome variables and maternal depresion at child age 4. Multivariate Analysis The main efects model fit statistics including controls, indicates good fit (? 2 /df =3.47, p =. 00; RMSEA =. 06, p =. 31). Mother?s depresion at child age 4 predicts child externalizing (?=. 20, r=. 22, p<. 001), internalizing (?=. 22, r=. 23, p<. 001), and sexualized behavior (?=. 01, r=. 10, p<. 10) at child age 8. Controlling for al else in the model, 0.5% of the variance in child externalizing behavior, 0.3% of the variance in child internalizing behavior, and 4.8% of the variance in child sexualized behavior at child age 8 is predicted by mother?s depresion at child age 4. 21 We tested the moderation of the main efects model by child sex and mothers? history of sexual abuse. The model fit statistics for this multi-group model with control variables indicate excelent model fit (? 2 /df= 1.87, p=. 00; RMSEA=. 06, p=. 11). In the final fited multi-group model, the regresion coeficients for mothers? depresion predicting child internalizing, externalizing, and sexualized behaviors are significantly diferent acording to child sex and mothers? history of sexual abuse. For al groups, maternal depresion significantly predicts both child internalizing (? MAF =. 26, r=. 27, p<. 001; ? MAM =. 28, r=. 32, p<.001; ? MNF =. 15, r=. 32, p<.001; ? MNM =. 17, r=. 18, p<. 001) and externalizing (? MAF =. 21, r=. 22, p<. 01; ? MAM =. 27, r=. 34, p<.001; ? MNF =. 16, r=. 34, p<.001; ? MNM =. 10, r=. 10, p<. 05)behavior at age 8. If mothers are very depresed when a child is four then the child?s levels of internalizing and externalizing behavior four years later are also high, vice versa. More specificaly, this relationship betwen maternal depresion and child-internalizing symptoms is strongest for the MAM group, followed by the MAF group, the MNF group, and finaly the MNM group. Maternal depresion is most predictive of child externalizing symptoms for the MAM group, followed by the MAF group, the MNM group, and finaly the MNF group. In other words, maternal depresion has the greatest efect on male children who have mothers who are abused and the least efect of maternal depresion is on male children who have mothers who are not abused. When sexualy abused mothers are very depresed when their children are 4 years old, levels of child sexualized behavior is also high when their children are 8 years old, and vice versa for both males (? MDEP->CSB =. 02, r=. 15,p<. 001) and females (? MDEP->CSB =. 01, r=. 07, p<. 10). Mother?s depresion is most predictive of child sexualized behavior in the MAM group, followed by the MAF group. Mother?s depresion was not found to be predictive of child 22 sexualized behavior in the groups with male and female children whose mothers did not have a history of sexual abuse. In other words, maternal depresion again has the greatest efect on male children who have mothers who are abused and the least efect of maternal depresion is on female children who have mothers who are abused. Residual variances were constrained to be equal and delta-chi square tests were used to determine whether R 2 values were diferent across groups. Based on this analysis, the amounts of variance in child internalizing and sexualized behavior are significantly diferent across groups. Controlling for al else in the model, maternal depresion at child age 4 predicts the largest amount of variance in child internalizing behavior in the MAM group (10.4%), followed by the MAF group (7.3%), the MNF group (3.1%), and finaly the MNM group (2.1%). Controlling for al else in the model, maternal depresion at child age 4 predicts the largest amount of variance in child sexualized behavior in the MAM group (2.3%), followed by the MNF group (0.6%), the MAF group (0.5%), and lastly the MNM group (0.1%). The amount of variance explained in either child externalizing behavior or child social competence was not found to vary acording to group membership. 23 Discusion We hypothesized that self-reported maternal depresion at child age 4 would predict child internalizing, externalizing, and sexualized behavior, and child social competence four years later, expecting that these relationships would be moderated by child sex and mothers? history of sexual abuse (DiLilo et al., 2000; Dubowitz et al., 2001). Some, but not al, of our results support these hypotheses. Mothers? depresion at child age 4 is positively and significantly predictive of child internalizing, externalizing, and sexualized behavior at child age 8. Contrary to our hypotheses, mothers? depresion at child age 4 is not predictive of child social competence. Our results indicate support for previous research that has established that boys often show higher levels of externalizing behavior as compared to girls (Broidy et al., 2003), and that maternal depresion predicts child externalizing behavior (Leve, Kim, & Pears, 2005). For example, maternal depresion at child age 4 is positively predictive of externalizing behavior for boys and girls whose mothers do have a history of sexual abuse. For females and males whose mothers are not abused a significant, but weaker, relationship exists betwen mothers? depresion and externalizing behavior. On average, more variance in externalizing behavior is predicted by mother?s depresion if the mother is abused, especialy for boys. Perhaps the stronger relationship betwen mothers? depresion and child externalizing behavior is a result of harsh or inconsistent parenting in families where mothers have history of sexual abuse. Mothers who have a history of sexual abuse report both higher levels of harsh parenting and les emotional control (Banyard, 1997; Cole et al., 1992; Roberts et al., 2004), and maternal depresion is also 24 related to such parenting practices (Lovejoy et al., 2000). It may be that our results are evidence of a cumulative efect of maternal depresion and history of sexual abuse such that depresed mothers with a history of sexual abuse engage in more harsh and inconsistent parenting behaviors than those depresed mothers without such a history. Our findings with regard to the relationship betwen maternal depresion and child internalizing symptoms are particularly interesting. Previous research has provided partial evidence that maternal depresion may reverse the typical paterns of gender diferences in internalizing symptoms with boys of depresed mothers reporting more internalizing symptoms than girls (Watson, Potts, Hardcastle, Forehand, & Compas, 2012). Our results extend such research showing that mothers? history of sexual abuse is a moderator of the relationship betwen mothers? depresion and child internalizing symptoms. We also found that boys have higher levels of internalizing symptoms as Watson and colleagues discussed, however only when mothers have a history of sexual abuse. In our study, mothers who have a history of sexual abuse have higher levels of depresion than those who do not have such a history. It may be that a history of sexual abuse is one negative life experience that contributes to higher levels of depresion that then reverse gender effects in child internalizing symptoms. Future research should continue to investigate this reversal of efect in order to inform practitioners of possible diferences in symptomology depending on family history and functioning. Contrary to previous research indicating that mothers? history of sexual abuse may be predictive of low levels of social competence, maternal depresion at child age 4 is not significantly predictive of child social competence at age 8. Furthermore, no diference exists in the amount of variance in child social competence predicted by maternal depresion by child sex and mothers? history of sexual abuse. Perhaps this is evidence of resilience in children?s ability 25 to relate to their peers, or perhaps peer relationships are a separate sphere that independently contributes to child internalizing, externalizing, and sexualized behaviors. Future research should compare child sexualized behavior with other child behavior that may negatively afect peer relationships such as peer aggresion or externalizing behavior in order to determine if this behavior is unique in its role as either a predictor or covariate of peer relationship status. Although some research fails to find gender diferences in CSB (Friedrich et al., 2003; Silovsky & Niec, 2002), our results indicate that child sex moderates the relationship betwen maternal depresion and CSB. It may be that the stronger relationship betwen maternal depresion and CSB in boys as compared to girls is related to the stronger relationship betwen maternal depresion and child internalizing symptoms in boys as compared to girls when mothers have a history of sexual abuse. Perhaps boys of very depresed, sexualy abused mothers do not know how to cope with their own higher levels of internalizing symptoms and sexualized behavior serves as a means of regulating these emotions. It may be that at very high levels of environmental stres, boys are les adept at regulating their emotions than girls and resort to CSB to soothe themselves (Merrick et al., 2008). Previous research has established that mothers of children showing higher levels of CSB report a greater range of negative life events as compared to mothers whose children do not show CSB, and our results indicate that the relationship betwen maternal depresion and CSB is moderated by mothers? history of sexual abuse. However, the amount of variance predicted in CSB taking into acount al else in our model was smal. Despite this fact, our results remain important, as previous research has suggested that we need further investigation of possible predictors of CSB beyond child sexual abuse (Chafin, 2008). Additionaly, our study is one of the first to atempt to predict such behavior rather than merely examining how CSB covaries 26 with other variables. It may be that maternal behavior, whether independently or as a result of a mothers? emotional adjustment, predicts such behavior. Future research should continue to try to identify alternate predictors of CSB beyond child sexual abuse in order to inform practitioners of possible points at which to intervene with children who show such behavior but do not have a history of sexual abuse. Across groups, maternal depresion predicts the largest amount of variance in child internalizing and sexualized behavior when mothers have a history of sexual abuse and the child is a boy. These findings can be understood in terms of current research on the importance of biology by environment interactions. Weter and El-Sheikh (2012) found that boys who had higher physiological reactivity whose mothers had higher levels of depresion showed higher levels of internalizing symptoms as compared to girls. Perhaps maternal depresion is related to child internalizing symptoms is physiological reactivity and/or a mothers? ability to help her children learn to regulate their emotions. Additionaly, it may be that mothers with a history of victimization treat their sons diferently than their daughters, perhaps being more emotionaly dependent on them as a result of their experiences with males. Although al results must be considered in terms of the smal amount of variance in child internalizing, externalizing, and sexualized behavior that is explained by maternal depresion, this study provides evidence of the need to consider maternal psychological functioning in the understanding and treatment of child emotional and behavioral dificulties. In fact, the smal amount of variance predicted by maternal depresion makes sense, as this investigation predicts child emotional and behavioral functioning by a single measure of maternal psychological functioning across four years. Surely, maternal depresion is not the only parent level factor that plays a role in these child outcomes, and future investigations should consider the simultaneous 27 and reciprocal efects of maternal depresion and child adjustment as child behavior undoubtedly afects maternal psychological functioning (Civic & Holt, 2000; Wickramaratne et al., 2011). This investigation is limited as we only examined children whose primary caregiver is their mother, excluding those who are cared for by grandparents, single fathers, and foster parents. Measures are either self or mother report, which may be biased as mothers who are depresed may have skewed perceptions of their children?s functioning. Additionaly, CSB is dificult to measure because of the social stigma surrounding such behavior. Mothers may underreport to protect their children or they may not be aware of the level of their children?s sexualized behavior. Lastly, we did not consider information about the perpetrators of the sexual abuse or the severity and duration of mothers? history of sexual abuse. These limitations are understandable for such a study, but should be addresed in the future if possible. Strengths of this study include its consideration of the role of maternal depresion in predicting multiple levels of children?s adjustment: behavioral, emotional, and social. This study is one of the first to investigate children?s sexualized behavior as predicted by maternal depresion. Furthermore, it is one of only a few studies that look at child sex as a potential moderator of the relationship betwen these multiple levels of child adjustment. The validity of our findings is strengthened by the large sample size and longitudinal design spanning four years. This study provides a unique contribution to our understanding of the role of mothers? history of sexual abuse and child sexualized behavior since the relationship betwen mothers? depresion at child age 4 and child internalizing, externalizing, and sexualized behavior at child age 8 is diferent acording to child sex and mothers? history of abuse. Based on previous research, it appears as though the efects of maternal depresion are specificaly enduring for young children whose mothers have several major depresive episodes, 28 while older children may be able to adjust their behavior to receive adequate care and support from their depresed caregivers (Elgar et al., 2004; Hamen, & Brennan, 2003; Lovejoy et al., 2000). Additionaly, significant improvements in child problem behavior and emotional functioning have been found to result from intervention with depresed mothers (Wickramaratneet al., 2011). Our findings add to such evidence of the value in asesing psychological functioning and intervening early with mothers whose children are showing emotional and behavioral maladjustment, especialy when children are displaying CSB. This study informs the field of child development about the relationship betwen mother mental health and child behavioral and emotional adjustment. In general, we found that maternal depresion predicts child internalizing, externalizing, and sexualized behaviors. These relationships are found to vary acording to both child sex as wel as mothers? history of sexual abuse. Maternal depresion is more predictive of child externalizing and internalizing symptoms in children whose mothers have a history of sexual abuse. Furthermore, this relationship is strongest for sons of mothers with a history of sexual abuse. 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American Journal Of Psychiatry, 168, 593-602. 38 Table 1a Descriptive statistics for main predictor and outcome variables Overal Sample (N=820) Daughters of Non- Maltreated oms (n=179) Sons of Non- Maltreated oms (n=167) Daughters of Maltreated oms (n=248) Sons of Maltreated oms (n=226) M SD M SD M SD M SD M SD Main Predictors (Age 4) MDEP 14.29 11.24 12.88 10.08 12.93 10.45 16.26 12.42 16.09 12.42 Outcomes (Age 8) CEXT 11.87 8.73 9.51 7.68 11.39 9.03 14.85 8.71 14.85 8.71 CINT 6.94 6.31 5.71 5.39 6.20 6.45 8.52 6.93 8.52 6.93 CSB 0.11 .16 .06 .12 .10 .15 .16 .19 .16 .19 SCOM 5.61 1.96 5.71 1.97 5.57 2.02 5.58 2.03 5.57 2.03 Table 1b. Descriptive statistics for control variables Overal Sample (N=820) Daughters of Non- Maltreated oms (n=179) Sons of Non- Maltreated oms (n=167) Daughters of Maltreated oms (n=248) Sons of Maltreated oms (n=226) M SD M SD M SD M SD M SD Total Income 3.07 2.15 3.07 2.21 3.09 2.23 2.90 1.82 3.24 2.27 Mom Education 11.5 1.92 11.61 1.80 11.42 1.84 11.41 1.92 11.54 2.17 Child Sexual Abuse 0.10 0.30 .09 .29 .05 .22 .20 .40 .09 .29 39 Table 2 Correlations between variables 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. MD -- 2. Ext Age 8 .21** -- 3. Int Age 8 .23** .65** -- 4. Soc Age 8 .25** .62** .60** -- 5. CSB Age 8 .06~ .36** .29** .29** -- 6. Income .22** -.04 -.03 -.10* .08* -- 7. Mom Ed. .18** -.06 .02 -.11* .03 .33** -- 8. CSA .06~ .14~ .15** .16** .16** .10* .10* -- 9. Mat Abuse .12** .20** .21** -.10* .18** -.00 -.01 .12** -- 10. Sex .02 -.10* .00 .00 -.10* -.04 .01 .11** -.01 -- Note. ** p<.01; *p<.01; *p<.05; ~p<.10 40 Figure 1. The relationship betwen maternal depresion at child age 4 and child externalizing, internalizing, and sexualized behavior, and child social competence at child age 8 for females with sexualy abused mothers. (Pathways and residual variances that difer acording to child sex and maternal history of sexual abuse are bolded.) 41 Figure 2. The relationship betwen maternal depresion at child age 4 and child externalizing, internalizing, and sexualized behavior, and child social competence at child age 8 for males with sexualy abused mothers. (Pathways and residual variances that difer acording to child sex and maternal history of sexual abuse are bolded.) 42 Figure 3. The relationship betwen maternal depresion at child age 4 and child externalizing, internalizing, and sexualized behavior, and child social competence at child age 8 for females with non-sexualy abused mothers. (Pathways and residual variances that difer acording to child sex and maternal history of sexual abuse are bolded.) 43 Figure 4. The relationship betwen maternal depresion at child age 4 and child externalizing, internalizing, and sexualized behavior, and child social competence at child age 8 for males with non-sexualy abused mothers. (Pathways and residual variances that difer acording to child sex and maternal history of sexual abuse are bolded.) 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61