Parent-child relations and the etiology of depression

Clinical Psych&a Reuzew, Vol. 6. pp. 133-153, 1986 Printed in the USA. All rights reserved.

0272-7358186 $3.00 + .OO Copyright 0 1986 Pergamon Press Ltd.

PARENT-CHILD RELATIONS AND THE ETIOLOGY OF DEPRESSION

A REVIEW OF METHODS AND FINDINGS

Daniel J. Burbach and Charles M. Borciuin

University of Missouri-Columbia

ABSTRACT. Three distinct methodologies have been used to investigate potential links between parent-child relations and the etiology of depression. These methodologies, as well as the findings obtained with each, are reviewed and critiqued. Irrespective of methodology type, several consistent findings emerge which suggest that specrfic patterns of parent-child relations may be involved in the etiology, maintenance, andlor expression of depressive disorder in children, adolescents, and adults. However, numerous methodological limitations seriously question the validity of these findings. Recommendations for conducting future research in this area are provided.

Considering the frequency with which depression occurs in child (Kashani et al., 1983), adolescent (Kaplan et al., 1984), and adult (Robins et al., 1984) populations, it is not surprising that this disorder has been one of the most intensely studied forms of psychopathology to date. During the last 20 years, much of this research has focused on the potential role of various psychological, psychosocial, biochemical, neuroendocrine, and genetic factors in the etiology of depression [for a review, see National Institute of Mental Health (NIMH), 19811. This research has facilitated recent advancements in the conceptualization, assessment, diagnosis, and treatment of depressive disorder in children (Hodges & Siegel, 1985; Kaslow & Rehm, 1985; Kazdin et al. in press), adolescents (Chartier & Ranieri, 1984; Strober, 1983), and adults (Beckham 8c Leber, 1985).

To a lesser extent, efforts have also been made to investigate the potential role of parent-child relations in the etiology of depressive disorder. More specifically, these studies have attempted to examine the hypothesis that specific patterns of parent-child relations place a child at risk for becoming and/or remaining depressed during various phases of the life-cycle. To date, however, there have been no attempts to review and critique the methods and findings of such studies sys-

Requests for reprints should be addressed to Charles M. Borduin, Department of Psychology,

210 McAlester Hall, University of Missouri, Columbia, MO, 65211.

133

134 Daniel J. Burbach and Churles M. Borduin

tematically. Instead, these studies have received only limited attention from reviewers who were primarily concerned with the genetics of depressive disorder, particularly the epidemiology of depression in the offspring of parents with affective disorders (i.e., familial aggregation studies) or with the negative effects of parental depression (usually maternal depression) on the psychosocial development of children (Beardslee et al., 1983; Orvaschel, 1983; Orvaschel et al., 1980). Con- sequently, much of the literature relevant to the parent-child relations of depressed persons was not evaluated by these reviewers. Considering that the study of the parent-child relations of depressed individuals can provide information pertinent to both the psychosocial (Billings 8c Moos, 1982) and genetic (Gershon et al., 1976; Weissman et al., 1984a) models of depression, a comprehensive and systematic review of these studies appears to be in order. The three-fold purpose of the present paper is: (a) to review the rationale, methods, and findings of studies relevant to the potential link between specific patterns of parent-child relations and depressive disorder; (b) to discuss the methodological problems with existing studies; and (c) to propose several recommendations for future research in this area.

RATIONALE FOR STUDYING THE PARENT-CHILD RELATIONS OF DEPRESSED PERSONS

For the past several decades, an increased search has been made for links between specific patterns of parent-child relations and specific forms of psychopathology (Rosenthal et al., 1975). Although most research has focused on the potential association between parent-child relations and schizophrenia (for reviews, see Jacob, 1975; L iem, 1980), several studies relevant to the potential links between parent-child relations and depressive disorder have also appeared in the literature. The underlying rationale for these studies is similar to the rationale for studying parent-child relations in the families of schizophrenic patients (Liem, 1980). For example, this approach adds a social and interpersonal flavor to the study of etiologic processes in depression (Coyne, 1976). An understanding of these processes may facilitate a clearer delineation of the respective contributions of heredity and environment to the etiology of depressive disorder. Considering that recent genetic research has shown the concordance for unipolar depression to be - 40% for monozygotic twins and - 13% for dizygotic twins (Allen, 1976), factors other than heredity appear to be involved in the etiology of depression. This does not suggest that parent-child relations are the only other class of factors contributing to the etiology of this disorder. Rather, parent-child relations may be one of many classes of nongenetic factors involved in the cause, maintenance, and/or expression of depressive disorder.

An understanding of the parent-child relations of depressed patients may also aid in the assessment of depressive disorder, particularly in children (Cytryn & McKnew, 1972, 1974; McKnew 8c Cytryn, 1973); that is, certain patterns of parent- child relations may be associated with specific subtypes of affective disorders. Im- proved assessment techniques may in turn lead to the development of more specific and efficacious psychotherapeutic and pharmacological interventions for depressive disorder. Interventions that can change the parent-child relations associated with depression may prove to be especially effective (e.g., Hogan & Hogan, 1978; Rubenstein & Timmins, 1978).

Parent-Child Relations and Depression 135

Finally, parent-child relations may be related to the outcome of an existing depressive episode as well as to the frequency and severity of subsequent depressive episodes. As studies by Vaughn and Leff (1976) have indicated, parent-child relations are often reliable predictors of prognosis in schizophrenia. This may also be true of the parent-child relations of depressed persons.

Existing studies relevant to this area will now be discussed. A study’s relevance to the present review was determined in the following manner. First, if a psychiatric population was studied, one of the samples had to consist entirely of patients who received a diagnosis of unipolar or nonbipolar depression. Second, if a nonclinical (i.e., community) population was studied, some measure of depression had to have been administered. Finally, a measure of parent-child relations had to have been included in the research protocol.

PARENT-CHILD RELATIONS AND DEPRESSM DISORDER: EMPIRICAL DATA

Researchers have used three distinct methodologies to investigate the potential links between parent-child relations and depressive disorder. The most common of these methodologies involves identification of depressed adults who are then interviewed concerning their relations with their parents as children and adolescents. A second methodology involves an examination of parent-child relations in families in which a child or adolescent has received a diagnosis of depressive disorder. A third methodology involves the study of parent-child relations in families in which a parent has received a diagnosis of depressive disorder. This last methodology is based on the assumption that parental depression disrupts parent-child relations in such a way that the offspring of depressed parents are placed at risk for depressive disorder as well as for other forms of psychopathology (Philips, 1979; Orvaschel, 1983).

More specific aspects of these three methodologies will now be considered. Find- ings obtained with each will also be presented.

Parent-Child Relations and Adult Depression

Methods. An extensive review of the literature revealed 14 studies that retrospectively examined the parent-child relations of depressed adults. The samples and measures used in these studies are indicated in Table 1.

As Table 1 illustrates, these studies vary markedly with respect to sample characteristics, control groups, depression measures, and parent-child relations measures. Several other features of these studies not described in Table 1 also warrant consideration. First, none of the authors reported interrater reliability coefficients for diagnostic procedures, and only one investigative team (Blatt et al., 1979) reported interrater reliability coefficients for third-party ratings of parent-child relations (i.e., ratings made by experimenters based on interviews with depressed patients). Second, only one study included data concerning the test-retest reliability of the parent-child relations measure that was used (Parker, 1981). Third, only one attempt was made to use third-party raters of parent-child relations who were unaware of the diagnostic status of subjects (Blatt et al., 1979).

One final note: Several authors of the studies to be reviewed in this section do

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not explicitly state that parental behaviors, as remembered by depressed patients, actually occurred (e.g., Blatt et al., 1979; Parker, 1982). Rather, these authors emphasize the importance of parental “representations” or memories in the etiology of depressive disorder. Thus, although the validity of retrospective reports may be suspect, these authors argue that different individuals may experience similar parent-child relations in different ways. Consequently, these authors believe that both the patterns of parent-child relations and the ways in which these patterns are perceived by the depressed patient must be understood if an etiological link between parent-child relations and depressive disorder is to be found.

Findings. Although these studies vary with respect to assessment methods and set- tings, there is much similarity between them with respect to their findings. For example, five studies conducted by Parker (1979a, 1979b, 1981, 1982) support a link between low maternal and paternal care (e.g., “Did not help me as much as I needed”), high maternal, but not paternal, overprotection (e.g., “Did not want me to grow up”), and depression in adults. Raskin and his colleagues (1971) found that depressed patients perceived their mothers and fathers to be less positively involved and more likely to use negative/punitive child-rearing strategies than did normal adults. In addition, and in contrast with the findings of Parker (1979a, 1979b, 1981, 1982), these authors discovered that depressed patients perceived their mothers to be overpermissive, not overprotective. No differences between normal and depressed samples were obtained with respect to perceptions of paternal protectiveness.

Research by Lamont and his associates (1976) and Lamont & Gottlieb (1975) revealed a relation between various maternal characteristics (e.g., low involvement, high guilt induction, overintrusiveness, egocentricism) and adult depression. These authors also identified a relation between several paternal characteristics (e.g., unloving, authoritarian) and adult depression. Blatt et al. (1979) presented data supporting an association between adult depression and low levels of maternal and paternal nurturance, support, and affection.

Themes of maternal and paternal rejection in the early parent-child relations of depressed adults were noted by Crook et al., (1981). These authors also found that depressed adults reported that they had received more negative evaluations from their parents and that they had experienced more withdrawal of parental affection than had normal adults.

Two other studies suggested a link between disturbed/unsatisfactory parent- child relations and depression in adults (Abrahams & Whitlock, 1969; Munro, 1966). It is unfortunate that the specific aspects of the parent-child relations judged by these depressed adults to be disturbed/unsatisfactory were not investigated.

Parent-Child Relations and Childhood Depression

As compared with the number of studies that have examined the parent-child relations of depressed adults, few attempts have been made to investigate the parent-child relations of depressed children. There are at least two major reasons why the relations between depressed children and their parents have been frequently ignored.

140 Daniel J. Burbach and Charles M. Borduin

First, until recently, many clinicians and researchers did not acknowledge the existence of depressive disorder in children For example, proponents of traditional psychoanalytic theory have postulated that depression is essentially a superego phenomenon which results from prolonged inner-directed anger felt toward a real or symbolic object loss (Rie, 1966). Because these theorists believe that prepubertal children have immature superegos, they consider them invulnerable to depressive disorder (Rie, 1966). Other clinicians and researchers have proposed that depression is a normal, transitory, developmental phenomenon and thus is not a clinical syndrome or disorder (Lefkowitz & Burton, 1978). Another group of clinicians and researchers have contended that although depressive disorder may exist in children, its essential features are “masked” by other nonpsychotic forms of psychopathology (Cytryn & McKnew, 1974; Glaser, 1968).

During the last 5 years, however, each of these positions has been discredited on both theoretical and empirical grounds (e.g., Carlson & Cantwell, 1979, 1980; Costello, 1980; Kashani et al., 1981). In fact, the symptom constellations considered to be hallmarks of depressive disorder in adults have been repeatedly identified in children (e.g., Kashani et al., 1983; Kovacs et al., 1984a; Kovacs et al., j 1984b).

Second, it was not until the publication of DSM-III (American Psychiatric As- sociation, 1980) that widely accepted criteria for diagnosing depression in children were articulated. These criteria are based on the currently popular notion that the core or essential features of depressive disorder are homologous in children and adults (Hodges & Siegel, in press; Kaslow & Rehm, in press; Kazdin et al., in press; Kovacs, in press). Consequently, the DSM-III criteria for major depressive disorder do not vary as a function of age. In addition, the DSM-III criteria for dysthymic disorder vary only with respect to the duration requirement (1 year for children, 2 years for adults). Because there were no generally acknowledged criteria for diagnosing depressive disorders in children until recently, many investigators were discouraged from this area of research.

Methods. Six published studies currently meet the criteria established for inclusion in the present review. These studies are summarized in Table 2.

Five of these studies were conducted with psychiatric patients and are similar with respect to overall sample characteristics. Three of the studies lacked control groups (Poznanski et al., 1976; Poznanski SC Zrull, 1979; Puig-Antich et al., 1978). In addition, these same three studies failed to report interrater reliability data for the diagnosis of depression and the ratings of parent-child relations. Two of the studies included interrater reliability data that had been obtained in previous studies using the same instruments (Puig-Antich et al., 1985a, 1985b). Finally, only one of the studies used raters who were unaware of the diagnoses of the subjects (Puig- Antich et al., 1985a).

The nonclinic study, conducted by Kaslow and her colleagues (1984), used a community sample of school-aged children identified as depressed and nondepressed on the basis of scores obtained on a self-report depression inventory. Test- retest reliability for scores on this inventory was r = .83 after a S-week interval. The psychometric properties of the family relations instrument used in this study were not reported.

Findings. Findings from studies using this methodology were also generally consistent, regardless of the setting from which subjects were selected or the method

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_ ._

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I42 Daniel J. Burbach and Charles M. Borduin

used to identify the subjects. For example, Poznanski and Zrull (1970) found that parents of depressed children were often detached, angry, punitive, and belittling in their relations with their children. In two of the cases, charges were filed against parents for neglect. One case of physical abuse was noted. In contrast with the studies of adult depression that were reviewed earlier, these authors discovered that there was a scarcity of parental overprotection in the families of depressed children.

Six years after the completion of the above study, Poznanski and her associates (Poznanski et al., 1976) conducted a follow-up study of 6 of 14 children from their original sample (the other 8 children could not be located). Four other children, depressed at the time of the initial study but not part of the original sample, were also included in this study. The mean period of follow-up for the 10 children was 6.6 years. The results of this study revealed that five of these children were depressed at the time of follow-up, and that there were continued problems in the parent-child relations of these five children (e.g., parental rejection and deprivation), particularly in father-child relations.

Puig-Antich and his associates (1978) studied 13 families of depressed children and found that 11 of these families evidenced maladaptive parent-child relations. For example, parents in these families were reported to be cruel, abusive, and/or violent toward their children. Four of the depressed children presented histories of sexual molestation. Of these four cases, one was thought to involve a parent.

In a more recent study, Puig-Antich et al. (1985a) found that depressed children and their mothers had poorer communication and less affectionate relations than did normal and nondepressed psychiatric controls and their mothers. Although between-group differences in father-child relations did not emerge, actual differences may have been obfuscated because many of the children were from father- absent homes and almost all data regarding father-child relations were obtained from mothers. In a follow-up of those children who had maintained recovery from depression for 4 months (Puig-Antich et al., 1985b), relations with both the mother and the father were significantly associated with the children’s recovery. Both the quantity and quality of mother-child relations had improved, and there appeared to be less maternal hostility than was evident during the child’s depressive illness. Moreover, the quantity of father-child relations also appeared to increase during recovery. It is unfortunate that the follow-up ratings were conducted by assistants who knew that the children were recovered depressed patients. Furthermore, information was not provided regarding the parent-child relations of depressed children who did not recover or regarding possible changes in the parent-child relations of the control children.

In a study primarily concerned with the social-cognitive correlates of depression, Kaslow et al. (1984) examined the parent-child relations of 23 depressed and 85 nondepressed children. These authors found that depressed children perceived their family relations as significantly more dysfunctional (e.g., less psychological availability of parents, poorer relations) than nondepressed children.

In addition to the six empirical studies cited above, numerous authors have presented anecdotal data suggesting a variety of disturbances in the parent-child relations of depressed children (e.g., Blumberg, 1981; Connel, 1972; McKnew & Cytryn, 1973; Fabian & Donahue, 1956; Grossman et al., 1983; Perris, 1966). Until these data are collected in a more systematic fashion, however, using measures that


inquire directly about parent-child relations, their reliability and validity remain

questionable. Simply knowing that a depressed child is from a “broken” marriage (e.g., Perris, 1966) or feels “rejected by others” (e.g., Connel, 1972) does not provide clear evidence of maladaptive parent-child relations.

Relations between Depressed Parents and Their Offspring

The potential impact of parental depression on the offspring of affected probands has been studied in at least three different ways. For example, one group of studies has focused on the diagnostic presentation of children whose parents are depressed (e.g., Weissman et al., 1984b). Although there are numerous methodological problems with existing familial aggregation studies, the available evidence suggests that the prevalence of depressive disorder ranges from 7% (Weissman et al., 1984b) to 13% (Welner et al., 1977) in the offspring of depressed parents, in contrast to a prevalence rate of - 2% in community samples of children (Kashani & Simonds, 1979).

A second group of studies has assessed the social and cognitive difficulties exhibited by the offspring of depressed parents (e.g., Neale SC Weintraub, 1975). As noted by Beardslee et al. (1983) in their review of these studies, the offspring of depressed parents seem to manifest significantly more social and cognitive problems than do the offspring of normal parents. These problems include excessive rivalry with siblings and peers, feelings of social isolation, frequent classroom disturbances, inattentiveness/withdrawal, and poor comprehension. However, because there are still so little empirical data concerning the social and cognitive difficulties exhibited by children at risk for depression, it is too early to determine whether these difficulties are similar to those exhibited by other populations of at-risk children (e.g., children with a schizophrenic parent).

A third group of studies has investigated the relations between depressed parents and their offspring. To date, there have been four such studies. Each of these studies is outlined in Table 3. Two additional studies (Billings & Moos, 1983; Hirsch et al., 1985), which also examined the relations of families containing a depressed parent, could not be included in the present review because these studies did not report parent-child relationship data separately from other family relationship data.

Methods. Three of the four studies outlined in Table 3 were conducted by Weiss- man and her colleagues using the same core sample of patients (Weissman et al., 1972; Weissman et al., 1971; Weissman & Siegel, 1972). These researchers reported an acceptable level of interrater reliability for their measurement of parent.-child relations (mean Pearson r = .80). The study by Deykin and her associates (1966) did not include interrater reliability coefficients for any of the measures. None of the four studies reported test-retest reliability coefficients or used raters who were unaware of the subjects’ diagnostic status.

Findings. Deykin et al. (1966) focused on the depressed mothers of young adult offspring who had recently left home. Of the 16 depressed mothers examined by these investigators, 7 were judged to have “latent” conflict with their adult offspring (i.e., conflict evident to the clinician but not to the mother or adult child) and 7

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were judged to have “overt” conflict with their adult offspring (i.e., conflict evident to, and reported by, either the mother or adult child). Two depressed mothers exhibited no conflict in their relations with their adult offspring. According to these authors, all 14 mothers in the conflict groups exhibited an inability to cope with the departure of their grown children. This was referred to as the “empty nest syndrome.” A vague, undefined dissatisfaction with parent-child relations was expressed by mothers in the latent conflict group. Verbal and physical violence were manifested by mothers in the overt conflict group.

The studies by Weissman and her colleagues also demonstrated an association between maternal depression and disrupted mother-offspring relations. For example, semistructured interviews with depressed mothers indicated that they exhibited less involvement, poorer communication, more friction, and less affection in their relations with their prepubertal children (Weissman et al., 1971) and adolescent children (Weissman & Siegel, 1972) than normal mothers. Similar problems were found in depressed mothers’ relations with their infant and adult offspring (Weissman et al., 1972).

The percentage of offspring who were adversely affected by maternal depression appeared to decrease as a function of age (Weissman et al., 1972). Among the infants of depressed mothers, all exhibited some developmental disturbance (e.g., “tyrannical behavior,” separation anxiety). In contrast, < 40% of the adults manifested any behavioral problems (e.g., rebellion, guilt). However, there were no reports of depressive disorder in the offspring of these depressed mothers. Fur- thermore, because there were no direct studies of offspring, the extent to which the rates of behavioral disturbance in the offspring of depressed mothers actually differ from the rates of disturbance occurring in the offspring of normal or nondepressed psychiatric control mothers is not known.

Several years ago, Reiss (1976) delineated two scientific requirements necessary to establish an etiolgic link between family relations and schizophrenia. These requirements are equally applicable for researchers attempting to identify a similar link between parent-child relations and depressive disorder.

First, Reiss argued that the hypothesized family variable(s) must be clearly de- fined and measured by reliable and objective methods. However, only six studies included data relevant to the interrater reliability of parent-child relations measures, most of which were collected prior to, not during, the study of interest (Blatt et al., 1976; Weissman et al., 1972; Weissman et al., 1971; Weissman & Siegel, 1972). Furthermore, only two sets of studies included data pertinent to the test-retest reliability of these measures (Parker, 1981; Puig-Antich et al., 1985a, 1985b). In addition, none of the studies presented interrater reliability data concerning the diagnosis of depression in the study of interest, and only one study reported diagnostic test-retest reliability (Blatt et al., 1978). With respect to the objectivity of ratings, there were only two attempts to use raters of parent-child relations who were unaware of the diagnostic status of subjects (Blatt et al., 1978; Puig-Antich et al., 1985a).

Second, Reiss proposed that the etiologic significance of any family variable must be assessed by demonstrating that this variable: (a) is specifically linked to the


disorder of interest as opposed to other conditions and states,’ (b) has an impact on the individual prior to t.he onset of the disorder, and (c) is not confounded by a covarying or concomitant variable that is the true etiologic variable. Each of these points will now be used to evaluate existing research in the depression literature.

The first point of this second requirement necessitates the use of normal and nondepressed psychiatric control groups. As Tables 1 through 3 illustrate, only 11 of the 24 studies reviewed here used a normal control group and only five included a nondepressed psychiatric control group. Only one irlvestigative team attempted to use both types of control groups in the design of a study (Puig-Antich et al., 1985a, 1985b).

The second point of this requirement necessitates the use of prospective, longitudinal research designs. To date, all studies concerning the potential association between parent-child relations and depressive disorder have been cross-sectional and retrospective in design. This fact is problematic for a number of reasons. First, when cross-sectional designs are used, one of the family members has already been identified as depressed. Thus, any inferences made about the parent-child relations of depressed patients are made only after the onset of the disorder. In such instances, it is just as plausible to conclude that depression in a family member precedes, causes, and/or maintains specific patterns of parent-child relations. Sec- ond, even when a disn~rbance in parent-child relations is retrospectively determined to precede the onset of depressive disorder, it cannot be immediately concluded that this disturbance caused the depression. To prove this etiologic link in part requires a demonstration that this disturbance is a necessary and sufficient component of depressive disorder. That is, the disturbance must occur in the parent-child relations of all depressed patients and moreover, must not occur in the parent-child relations of nondepressed ill~lividuaIs. Third, the validity of retrospective data obtained from depressed patients and their families is questionable at best. Indeed, it has been demonstrated that parents are frequently unable to recall their child-rearing practices accurately (Maccoby, 1980). Furthermore, and most important, numerous researchers have reported data which suggest that depression can severely distort perception and memory (for a review, see Rehm, 1982). It should be noted, however, that Parker (1981) failed to find any influence of self-reported levels of depression on ratings of parent-child relations, and that mothers and children rated their relations in similar ways. This latter finding is based on a sample that was not entirely composed of depressed patients, Although we do not wish to imply that the perceptions of depressed patients are unimportant, it is suggested that such data be considered together with more objective data whenever possible.

The last point of Reiss’ second requirement necessitates an analysis and control of covarying or concomitant variables that may confound the results of these studies. For instance, four of the studies reviewed here used samples of medical patients to control for factors associated with the “patient role.” Because none of these studies included the other necessary control groups, their value is equivocal.

Other methodological limitations exist that are unique to studies in which the relations between depressed parents and their offspring have been investigated.

‘Such a requirement does not ruIe out the possibility that the same family variable may interact with other unique non-family variables (e.g., a genetic diathesis) to cause specific types of psycho~thol[~~y.


For example, because these children are already at-risk for depressive disorder by virtue of their genetic relatedness to the depressed parent(s), it is almost impossible to disentangle the respective contributions of heredity and environment in such families. Furthermore, even when the offspring of depressed parents are discordant for depressive disorder at a particular time, the risk period for this disorder extends into adulthood (American Psychiatric Association, 1980). Thus, offspring must be assessed through their entire risk period to obtain the most valid epidemiological data.

Because all existing studies of relations between depressed parent probands and their offspring use only depressed mothers, they are problematic. The precise implications of this form of sample bias are not yet clear. One obvious implication is that nothing is known about the relations of depressed fathers and their offspring or about parent-child relations when both parents are depressed. In addition, the offspring of depressed mothers may be quite different from the offspring of depressed fathers with respect to the variables of interest in parent-child relations studies. Therefore, attempts to generalize existing data to the relations between depressed fathers and their offspring should be done cautiously.

The last two problems to be discussed here concern all three methodologies currently used to identify an association between parent-child relations and depressive disorder. The first problem concerns the lack of attention that has been given to the clinical state of both children and parents at the time parent-child relations are assessed. Knowing the clinical state of each member of the dyad at the time parent-child relations are measured is important since the psychological functioning of each person may have impact on these relations. This is a notable shortcoming of most existing research, considering the increased likelihood that parents of depressed patients may be depressed themselves, particularly when the proband has an early age of onset of depression (Weissman et al., 1984c).

The second problem involves the assumption that various parental behaviors (e.g., low parental care, high parental overprotection) operate in a unidirectional fashion to place a child at risk for depressive disorder. As Bell (1968) and others (Brofenbrenner, 1979; Thomas & Chess, 1984) have demonstrated, parent-child interactions are reciprocal in nature. That is, the characteristics and behaviors of the child influence the parents’ behavior, and in turn, the characteristics and behaviors of the parents influence the child’s behavior. Thus, while the parents of depressed adults may have exhibited low care and overprotection, these behaviors may have arisen as responses to specific types of child characteristics and behaviors.

RECOMMENDATIONS FOR FUTURE RESEARCH

The value of future research in this area can be substantially increased if the methodological weaknesses outlined above are corrected. Several recommendations that may help to accomplish this task are described below.

Research Designs

Although expensive and time-consuming, prospective and longitudinal research designs will be necessary to resolve many of the questions that remain in this area. Subjects in these studies should be followed-up through their entire risk period


may mediate the and depressive disorder (e.g.,

more restricted stages of the life-cycle (e.g., infancy, toddlerhood, preadolescence, adolescence) could be made. Findings from such studies would only be generalizable to age-matched populations, however.

Prospective and longitudinal research designs could also be used to help identify the respective influences of heredity and environment in the etiology of depression. Investigations of parent-child relations in families of adopted children whose biological parents received a diagnosis of depression should be initiated. Samples of nongenetic risk children adopted into the home of a depressed parent could be examined in a similar fashion. Such research would also help to clarify factors that appear to “protect” children, especially at-risk children, from depressive disorder.

Assessment and Diagnosis

Samples of depressed patients should meet generally accepted diagnostic criteria for depressive disorder, such as the DSM-III criteria (American Psychiatric Asso- ciation, 1980) or the Research Diagnostic Criteria (Spitzer et al., 1978). Moreover, these diagnoses should be based on psychometrically sound, structured diagnostic interviews. Examples include the Schedule for Affective Disorders and Schizo- phrenia (Endicott & Spitzer, 1978) for adults, and the Kiddie-SADS (Puig-Antich SC Chambers, 1978) or the Child Assessment Schedule (Hodges et al., 1982) for children. Interrator reliability for diagnoses should always be reported, even if this reliability coefficient is calculated on a small percentage of the sample studied.

Depression In Nonclinical Samples

Several of the studies reviewed here focused on parent-child relations in nonclinical samples of individuals who self-reported various levels of depressive symptomatology. Whether the findings of such studies generalize to clinic samples of patients meeting standardized diagnostic criteria for depressive disorder is unclear (Lew- insohn & Teri, 1982). Future research is needed to determine the generalizability of findings from these analog studies.

Parent-Child Relations Measures

Researchers must begin to assess the psychometric properties of the parent-child relations measures that they use. Interrater and test-retest reliabilities should be routinely reported. The validity of these instruments must also be assessed. In addition, ratings of parent-child relations should be made by raters who are unaware of the diagnostic status of subjects. Finally, direct observation studies of parent-child relations, such as those reported by Cytryn et al. (1984) in their research on bipolar illness, are clearly needed. Observational measures permit sequential analyses of family interaction data and assess reciprocal parent-child influences more adequately than do self-report measures. Again, we do not wish to suggest that family members’ perceptions of their relations should be ignored by researchers. Because self-report and observational methods provide different


vantage points for the study of current family relations, researchers should use both types of methods whenever possible.

Researchers should indicate the clinical state of the informant and/or each member of the parent-child dyad at the time that parent-child relations are assessed. This information is essential because data obtained from subjects may vary as a function of their clinical state. In addition, parent-child relations may vary as a function of the clinical state of each member of the parent-child dyad.

Control Groups

To evaluate the specificity of findings, normal control groups as well as nondepressed psychiatric control groups should be included in the design of these studies. The composition (i.e., diagnostic breakdown) of the nondepressed psychiatric control group(s) should be clearly specified.

Increased attention must also be given to those variables that may confound the results of parent-child relations studies. Examples of such variables include the premorbid adjustment, past psychiatric history, age of onset, chronicity of disorder, severity of disorder, and treatment status of the depressed patient at the time of the study. Various demographic variables must also be controlled, since such factors might influence findings (e.g., age of parents, marital status of parents, number of offspring; see Jacob, 1975). These potential confounds can be controlled through the selection of appropriate control groups and/or through proper statistical analyses.

Depression Subtypes and Symptomatology

Existing research in this area appears to be based on the assumption that depressive disorder is a unitary phenomenon. More attention should be paid to the various types of depressive disorders (e.g., major depressive disorder, dysthymic disorder) as well as to the specific depressive symptoms or syndromal patterns present in the patient, since each may be associated with parent-child relations in different ways. Such an approach has been found to be especially useful in the study of parent- child relations in the families of delinquent children (e.g., Hetherington et al., 1971).

Father- Child Relations

Future research should-begin to assess the relations between depressed fathers and their offspring. During the past decade, there has been growing evidence that fathers make significant contributions to the psychosocial functioning of their children (e.g., Lamb, 1976; Lynn, 1974). For example, there is an increasing recog- nition that a father contributes importantly to his child’s psychosocial adjustment through emotional support of his wife (Clarke-Stewart, 1978). Hence, future en- deavors to assess relations between depressed fathers and their children may profit from focusing on the entire family context. Contributions in this area will be made not by simply describing these relations but by explaining how these relations may protect children or place them at risk for depression.


Toward a Conceptual Framework

The discovery of reciprocity between parental and child behavior seriously un- dercuts the value of simplistic unidirectional theories that link specific patterns of parental behaviors to the etiology of depressive disorder. Future breakthroughs in parent-child relations studies will likely require not only an understanding of parent-child reciprocity but also an awareness of the complex interactions between familial and extrafamilial systems. It is suggested that an ecological systems model (Bronfenbrenner, 1979; Henggeler, 1982) may be useful for this purpose. This approach not only emphasizes the reciprocity of behavior but also provides a theoretical framework for conceptualizing the unique and interactive influences of various systems (e.g., biological, family, peer group, neighborhood, community) upon behavior.

Acknowledgment-The authors wish to thank Scott W. Henggeler and two anonymous re-

viewers for comments on an earlier draft of this article, as well as the many individuals who

provided us with unpublished manuscripts.

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Parent-child relations and the etiology of depression