ARTICLE

Association Between Parental Depression and

Children’s Health Care Use
Marion R. Sills, MD, MPHa, Susan Shetterly, MSPHb, Stanley Xu, PhDb, David Magid, MD, MPHb, Allison Kempe, MD, MPHa,c

aDepartment of Pediatrics and cPrimary Care Research Unit, University of Colorado at Denver and Health Sciences Center, Denver, Colorado; bClinical Research Unit,
Kaiser Permanente, Denver, Colorado

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. The objective of this study was to determine the association between
parental depression and pediatric health care use patterns.
www.pediatrics.org/cgi/doi/10.1542/
METHODS. We selected all children who were 0 to 17 years of age, enrolled in Kaiser peds.2006-2399
Permanente of Colorado during the study period July 1997 to December 2002, and doi:10.1542/peds.2006-2399
linked to at least 1 parent/subscriber who was enrolled for at least 6 months during Key Words
health services research, health care
that period. Unexposed children were selected from a pool of children whose provider/services, depression, parental
parents did not have a depression diagnosis. Outcome measures were derived from influence, maternal mental health
the child’s payment files and electronic medical charts and included 5 categories of Abbreviations
use: well-child-care visits, sick visits to primary care departments, specialty clinic WCC—well-child care
ED— emergency department
visits, emergency department visits, and inpatient visits. We compared the rate of HMO— health maintenance organization
use per enrollment month for these 5 categories between exposed and unexposed KPCO—Kaiser Permanente of Colorado
ICD-9 —International Classification of
children within each of the 5 age strata. Diseases, Ninth Revision
RxRisk—risk score
RESULTS. Our study population had 24 391 exposed and 45 274 age-matched, un-
Accepted for publication Oct 20, 2006
exposed children. For the outcome of well-child-care visits, teenagers showed Address correspondence to Marion R. Sills,
decreased rates of visits among exposed children. The rate of specialty department MD, MPH, University of Colorado Health
Sciences Center–Pediatrics, Children’s Hospital
visits was higher in exposed children in the 4 oldest age groups. The rates of both of Denver, 1056 E 19th Ave B251, Denver, CO
emergency department visits and sick visits to primary care departments were 80218. E-mail: sills.marion@tchden.org
higher for exposed children across all 5 age categories. The rate of inpatient visits PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2007 by the
was higher among exposed children in 2 of the 5 age groups. American Academy of Pediatrics

CONCLUSIONS. Overall, having at least 1 depressed parent is associated with greater

rate of emergency department and sick visits across all age groups, greater use of
inpatient and specialty services in some age groups, and a lower rate of well-child-
care visits among 13- to 17-year-olds. This pattern of increased use of expensive
resources and decreased use of preventive services represents one of the hidden
costs of adult depression.

PEDIATRICS Volume 119, Number 4, April 2007 e829

Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
N UMEROUS STUDIES HAVE shown a high prevalence
of depression among parents, ranging as high as
47% in some pediatric settings.1–6 Prevalence is highest
in parents who care for a chronically ill family mem-
ber.7–9 Studies of the impact of parental depression on
child health outcomes have found positive associations
with adverse child behavioral,10–19 developmental,20–23
psychological,14,24–28 and physiologic outcomes.29
Studies that have examined the association be-
tween parental depression and child health care use
outcomes have been inconsistent in their findings. Two
studies found lower rates of well-child-care (WCC) visits
among children of depressed parents31; other studies
found no association with WCC indicators.32–35 Studies
have found an association between parental depression
and child acute-care use indicators, including hospital-
ization,29,32,34,36,37 and emergency department (ED) vis-
its.35,36,38 Only 2 studies found no association between a
parent’s depression and ED visits.33,37
Most of these previous studies were limited by small
sample sizes, by studying only 1 type of use, by studying
use in only 1 type of setting (eg, clinic, nursery), or by
relying on the parent’s report of use to measure out-
comes. No previous studies combined a wide array of use
outcomes in the context of a large sample size, and none
did this in the context of a closed-model health mainte-
nance organization (HMO) setting, which allows nearly
total capture of all health care use.
Closing these literature gaps has important implica-
tions for families and their health care providers. By
strengthening and broadening our understanding of the
association between parental depression and child
health care outcomes, we can improve clinicians’ assess-
ment and management of the pediatric patient in the
context of the child–parent dyad. By demonstrating the
magnitude of this association, we provide additional im-
petus to improve mental health services for parents and
help policy-makers understand more about the hidden
costs of adult depression. The objective of this study was
to assess the association between parental depression
and pediatric health care use. We hypothesized that
children of depressed parents would have lower use of
preventive care and higher use of emergent services
than children of nondepressed parents. This association
was hypothesized to be present for both maternal and
paternal depression and across all age strata of children.
METHODS
Data Source
The data for this study were drawn from the Kaiser
Permanente of Colorado (KPCO) membership system.
The study period for these analyses was July 1997 to
December 2002. Our study design was a retrospective,
matched-cohort design.
e830 SILLS et al
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
Subjects
We identified all children who were 0 to 17 years of age
and enrollees of KPCO during the study period July
1997 to December 2002. Children were linked to “par-
ents” by identifying subscribers through whom the child
received eligible care. Over time, many children had ⬎1
subscriber. We considered any subscriber who was
linked to a child’s record to be a “parent.” This method
missed parents who were not primary subscribers to
KPCO, such as spouses who consistently were depen-
dents during the entire study period, and may have
included nonparents, including grandparents or unre-
lated subscribers. We included only those children who
were linked to at least 1 parent/subscriber who had been
a member for at least 6 continuous months during this
time. Only 1 child was randomly selected from each
family within each predefined age group (3–11 months,
1–2 years, 3–5 years, 6 –12 years, and 13–17 years).
Children who had any parent with a depression di-
agnosis were classified as exposed for these analyses.
Parents’ diagnoses were obtained from the visit records
and outside claim records. A parent was considered to
have depression when their records contained any of the
International Classification of Diseases, Ninth Revision
(ICD-9) depression codes in Table 1.
Unexposed children were selected from a pool of
children whose parents did not have a depression diag-
nosis and whose parents also did not have any other
mental health condition or prescription antidepressant
use. Other mental health conditions were identified us-
ing the ICD-9 codes between 290 and 316. Excluded
codes were the depression codes listed in Table 1 and
codes that commonly are used in primary care for non–
mental health issues: 302.7 psychosexual dysfunction
(impotence), 305 nondependent drug use (includes to-
bacco use), 307.81 tension headache, and 315 develop-
mental disorders. Pharmacy records provided informa-
tion on prescription antidepressant use.
For each child, we defined an index date indicating
the start of the period of captured use data. For exposed
children, we defined this starting point as the latter of 2
dates: (1) the first captured parental depression date or
(2) the 90th day after the child’s KPCO enrollment date.
TABLE 1 ICD-9 Code–Based Definition of Depression
ICD-9 Code Description
296.2 Major depression, single episode
296.3 Major depression, recurrent episode
296.82 Atypical depression disorder
298.0 Depressive type psychosis
300.4 Neurotic depression
308.0 Predominant disturbance of emotions
309.0 Adjustment reaction, brief depressive
309.1 Adjustment reaction, prolonged depressive
309.4 Adjustment reaction, with mixed disturbance emotions
311 Depressive disorder not otherwise classified
Children were required to be members for at least 3
months before the index date to avoid capturing use
during initial months when a new member’s use often is
inflated. This matching requirement resulted in exclu-
sion of all children who were 0 to 3 months from our
sample. We excluded children whose membership du-
ration was ⬍1 month after the index date; this was a
relatively rare finding (⬍3%). A total of 24 413 exposed
children met these eligibility criteria.
Up to 2 unexposed children were matched to each
exposed child by age and membership eligibility criteria.
We chose to match by age because of the great age-
related variability in health care use, fostered, in part, by
nationally endorsed childhood immunization and WCC
visit schedules. We chose to match by enrollment period
to align the timing of use data capture for exposed and
unexposed children, to minimize problems that changes
in administrative data elements over time might intro-
duce. First, we selected unexposed children with birth
dates within a 2-week window of the exposed child’s
birth date. We then set the index dates for the unex-
posed children to the date for the matched exposed child
and applied the same membership eligibility minimum
requirements of 3 months before and 1 month after the
index date.
Of the 24 413 exposed children, 24 391 were matched
to at least 1 unexposed child by age and membership
eligibility criteria. Two control matches were found for
85.6% (20 883). This produced a total N of 69 665 for these
analyses.
Measures
Outcome measures were derived from the KPCO use
database and included 5 categories of use: WCC visits,
sick visits to primary care departments, specialty clinic
visits, ED visits, and inpatient visits. Primary care de-
partment providers include Family medicine, internal
medicine, pediatrics, and obstetrics/gynecology practi-
tioners. All visits to other departments were classified as
“specialty” visits.
We included a risk adjustment variable to control for
possible morbidity differences between exposed and un-
exposed children. We used a pharmacy-based disease
score that was developed by Fishman and Shay39 and
applied this to pharmacy dispensings during the 12
months after the index date. The 33 disease indicator
groups include both physical and mental health cate-
gories. We evaluated several different variables for pos-
sible morbidity adjustment: (1) the risk score (RxRisk) as
it was originally developed and weighted to predict costs
in the following year; (2) a summed count of the 33
disease indicators used in the score; (3) a summed count
of the disease indicators excluding (a) sickle cell disease,
which needed reprogramming to capture appropriately
only penicillin use with concurrent folic acid use and
which is low prevalence in our region, and (b) the liver
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
disease indicator, which contained a drug that often is
used to treat pediatric constipation at KPCO; and (4)
selected individual disease indicators entered as separate
variables. The count of diseases excluding the 2 ques-
tionable indicators (modified RxRisk count) provided
the most consistent adjustment across the various use
outcomes in this study and also decreased exposed ver-
sus unexposed differences to the greatest degree. We
selected this morbidity adjustment as the best and most
conservative adjustment for the analyses presented here.
Analysis
Frequencies of categorical variables were contrasted by
␹2 statistics. Wilcoxon rank sum tests were used for the
chronic disease score and membership months variables
because of the skewness of their distributions. We per-
formed bivariate comparisons of characteristics of ex-
posed and unexposed children within each age group.
We calculated a visit rate for each group by dividing
the total number of each type of visit during the chil-
dren’s captured use period by the duration of that pe-
riod. We compared rates of use for each of the 5 visit
categories between exposed and unexposed children
within each of the 5 age strata, yielding 25 comparisons.
We estimated confidence intervals for these person-time
rates using Fisher’s exact method in PEPI software ver-
sion 4.0.40 These rate contrasts provide magnitudes of
visit differences between exposed and unexposed chil-
dren while accounting for varying enrollment periods in
the denominator calculations but do not adjust for
matching.
Incidence rate ratios were estimated using conditional
Poisson models. These models used counts of visits over
time as the primary outcome, adjusted for varying en-
rollments by an offset variable and additionally ac-
counted for matching with a stratum identifier. Both
ratios of the descriptive rates and the incidence rate
ratios from univariate conditional Poisson models were
presented. Adjusted incidence rate ratios also are pre-
sented controlling for the child’s gender, number of
parents, and the pediatric RxRisk risk-adjustment vari-
able described.
We estimated the excess visit rate that was attribut-
able to having depressed parent(s) by multiplying the
adjusted rate ratio by the unadjusted visit rate for unex-
posed children. For example, for infants, the exposed
versus unexposed sick visit adjusted rate ratio is 1.14.
This suggests that exposed infants have 14% more sick
visits than unexposed infants, so the excess would be
0.14 ⫻ 487.1 (the unadjusted rate of sick visits for un-
exposed infants), which equals 68.2 visits per 100 per-
son-years.
Analyses were completed using SAS 9.1.41 This study
was approved by the institutional review boards of the
Children’s Hospital of Denver and KPCO.
PEDIATRICS Volume 119, Number 4, April 2007 e831
RESULTS
Our study population had 24 391 exposed and 45 274
unexposed children. Table 2 shows the comparison of
gender, number of linked parents, number of chronic
diseases, and membership duration between exposed
and unexposed children within each age group. There
were slightly more girls in the unexposed group, al-
though this difference was not significant. The number
of parents who were linked to the child’s KPCO record
was higher among exposed than unexposed children.
Exposed children had longer periods of enrollment after
the index date. The differing enrollment times are ac-
counted for in the Poisson models. As expected, exposed
children had a higher mean number of chronic diseases.8
Of the exposed children, 88.2% had 1 depressed par-
ent, 11.7% had 2, and 0.1% had 3. Gender of depressed
parents was 79.7% female and 31.7% male; these fig-
ures include the 11.4% of children with depressed par-
ents of both genders. Of all depressed parents, 83.9%
were on antidepressant medications.
Unadjusted use rates are presented in Table 3, which
presents the visit rate for exposed and unexposed chil-
dren. Sick visits to primary care sites were the most
common visit type across all age groups, even in the
infant age category, when frequent WCC visits are the
standard of care. ED visit rates were higher than spe-
cialty visit numbers in the youngest ages, but this pattern
reversed among older children.
The most common departments in the specialty visits,
by percentage of all subspecialty visits, were mental health
(23.9%), optometry (18.6%), orthopedics (10.7%), head
and neck surgery (9.6%), ophthalmology (6.6%), derma-
tology (5.6%), and allergy (5.5%). Mental health, optom-
etry, and orthopedics visits increased with increasing age,
with ⬎80% of visits in each of these 3 categories among 6-
to 17-year-olds.
Differences in visit counts for exposed and unexposed
children were apparent for several types of visits in these
unadjusted numbers (Table 3). WCC visit rates for ex-
posed children were either similar to or slightly lower
than those of unexposed children, although none of
these differences was significant. In contrast, exposed
children had higher rates of sick visits and ED visits in all
ages. Univariate rates of specialty visits also generally
were higher among exposed children, although confi-
dence intervals were nonoverlapping only for children
who were 3 years or older. Hospital rates were higher for
exposed children who were 6 years and older.
Table 4 improves the statistical comparison of ex-
posed and unexposed children through the use of con-
ditional Poisson models to add control of matching as
well as adjusting for possible confounders, including
gender, number of parents, and disease history counts.
In Table 4, univariate rate ratios showed patterns of
significance and direction that generally mirrored those
seen in Table 3. Adding adjustment for possible con-
founders generally lowered the exposed versus unex-
posed differences primarily as a result of adjustment for
the higher disease counts among exposed children.
For the outcome of WCC visits, our adjusted model
showed a decreased rate of WCC visits among exposed
children in the teenage category. The rates of both ED

TABLE 2 Characteristics of Exposed and Unexposed Children by Age Groups

Characteristic Age Group
3–11 mo (2445 1–2 y (2678 关34.5%兴 3–5 y (3872 关36.0%兴 6–12 y (8440 关35.8%兴 13–17 y (6956
关34.6%兴 of 7072) of 7771) of 10 767) of 23 544) 关33.9%兴 of 20 511)
Estimatea Pb Estimatea Pb Estimatea Pb Estimatea Pb Estimatea Pb
Girls, %
Exposed 47.0 .08 50.2 .88 48.3 .33 48.3 .11 49.0 .76
Unexposed 49.2 50.4 49.3 49.4 49.2
No. of parents, % with 1, 2, or 3
Exposed
1 13.4 ⬍.0001 11.7 ⬍.0001 11.4 ⬍.0001 12.6 ⬍.0001 14.4 ⬍.0001
2 78.7 82.2 81.7 79.9 77.9
3 8.0 6.1 6.8 7.4 7.7
Unexposed
1 20.8 23.1 23.5 25.2 16.7
2 77.8 75.0 74.1 71.8 79.6
3 1.4 2.0 2.4 3.0 3.7
Mean No. of chronic diseases
Exposed 0.32 ⬍.0001 0.15 ⬍.0001 0.16 ⬍.0001 0.31 ⬍.0001 0.54 ⬍.0001
Unexposed 0.19 0.10 0.10 0.16 0.32
Mean No. of membership months
Exposed 9.59 ⬍.0001 9.91 ⬍.0001 10.05 ⬍.0001 10.25 ⬍.0001 10.45 ⬍.0001
Unexposed 8.34 8.39 8.54 8.91 9.82
a Estimates are percentages for % girls and number of parents and means for number of chronic disease and membership months.
bP value from ␹2 test for % girls and number of parents and from Wilcoxon rank sum test for number of chronic disease and membership months.

e832 SILLS et al
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
 TABLE 3 Estimated Visit Rates Per 100 Person-Years for Exposed and Unexposed Children by Age, With Excess Visits Among Exposed Children
Use Outcome Age Group
3–11 mo (n ⫽ 7072), 1–2 y (n ⫽ 7771), 3–5 y (n ⫽ 10 767), 6–12 y (n ⫽ 23 544), 13–17 y (n ⫽ 20 511),
Rate (95% CI)a Rate (95% CI)a Rate (95% CI)a Rate (95% CI)a Rate (95% CI)a
WCC visits
Exposed 204.1 (197.8–210.5) 72.0 (68.5–75.6) 45.7 (43.4–48.1) 24.5 (23.4–25.7) 16.5 (15.5–17.6)
Unexposed 210.3 (205.3–215.4) 76.1 (73.3–79.0) 45.3 (43.4–47.2) 24.0 (23.1–24.9) 17.2 (16.5–18.0)
Sick visits: primary care departments
Exposed 563.2 (552.8–573.9) 331.6 (324.1–339.3) 214.4 (209.4–219.5) 189.1 (185.9–192.3) 214.3 (210.6–218.0)
Unexposed 487.1 (479.5–494.8) 277.7 (272.3–283.2) 173.6 (170.0–177.4) 140.9 (138.7–143.1) 157.0 (154.7–159.4)
Specialty department visits
Exposed 39.5 (36.7–42.3) 34.8 (32.4–37.3) 35.7 (33.7–37.8) 64.7 (62.8–66.6) 103.3 (101–106)
Unexposed 36.4 (34.3–38.5) 28.6 (26.8–30.4) 26.2 (24.8–27.7) 35.6 (34.5–36.7) 59.3 (57.8–60.7)
ED visits
Exposed 50.4 (47.3–53.6) 34.1 (31.7–36.7) 17.6 (16.2–19.2) 14.4 (13.5–15.3) 20.9 (19.7–22.0)
Unexposed 41.4 (39.3–43.7) 26.4 (24.8–28.2) 14.6 (13.6–15.8) 10.0 (9.4–10.6) 13.5 (12.8–14.2)
Inpatient visits
Exposed 4.5 (3.6–5.5) 2.4 (1.7–3.1) 1.1 (0.7–1.5) 2.3 (1.9–2.6) 4.8 (4.3–5.4)
Unexposed 3.7 (3.1–4.4) 1.5 (1.1–1.9) 1.0 (0.7–1.3) 0.7 (0.5–0.9) 2.5 (2.2–2.8)
CI indicates confidence interval.
a Visit rate, in visits per 100 person-years, was derived from univariate conditional Poisson models.

visits and sick visits to primary care departments were DISCUSSION

higher for exposed children in the adjusted models
across all 5 age categories, and the rate of specialty
department visits was higher in exposed children in the
4 oldest age groups. The rate of inpatient visits was
higher among exposed children in the 2 oldest age
groups.
Table 5 shows the excess visit rate, in visits per 100
person-years, that was attributable to having a depressed
parent. The difference is greatest for sick visits to primary
care departments, particularly in the youngest age
group, in which exposed infants had 68 more visits per
100 person-years than did unexposed infants. For both
sick visits and ED visits, the age-related trend was simi-
lar, with greater excesses in the youngest age groups. In
contrast, the greatest excesses in specialty visit rates
were among the older age groups.
In this study, children with at least 1 depressed parent
had higher use of costlier forms of health care— using
more ED, sick visit, specialty department, and inpatient
services—than did children of parents without depres-
sion. Findings from our study, in general, support pre-
vious studies, although our study strengthens the evi-
dence for these findings, because no previous studies
combined a wide array of use outcomes in the context of
a large sample size, and none did this in the context of a
closed-model HMO setting. Ours also is only the second
study to consider paternal as well as maternal depression
as a predictor of health care use.
Our finding of no association between parental de-
pression and a child’s WCC visits in the 4 youngest age
groups is consistent with previous findings. However,
our finding that 13- to 17-year-olds had fewer WCC

TABLE 4 Use Rate Ratios from Conditional Poisson Models Comparing Exposed and Unexposed Children
Use Outcome Model Age Group
3–11 mo 1–2 y 3–5 y 6–12 y 13–17 y
(n ⫽ 7072) (n ⫽ 7771) (n ⫽ 10 767) (n ⫽ 23 544) (n ⫽ 20 511)
Rate Ratio P Rate Ratio P Rate Ratio P Rate Ratio P Rate Ratio P
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
WCC visits Univariatea 0.97 (0.93–1.01) .12 0.95 (0.89–1.01) .10 1.01 (0.95–1.08) .76 1.03 (0.97–1.10) .35 0.96 (0.89–1.04) .27
Adjustedb 0.96 (0.92–1.00) .07 0.94 (0.88–1.01) .07 0.99 (0.93–1.06) .82 0.99 (0.93–1.06) .75 0.92 (0.85–0.99) .04
Sick visits c Univariatea 1.15 (1.12–1.18) ⬍.0001 1.19 (1.16–1.23) ⬍.0001 1.22 (1.18–1.26) ⬍.0001 1.36 (1.33–1.39) ⬍.0001 1.36 (1.33–1.39) ⬍.0001
Adjustedb 1.14 (1.11–1.17) ⬍.0001 1.16 (1.12–1.20) ⬍.0001 1.19 (1.15–1.23) ⬍.0001 1.24 (1.21–1.27) ⬍.0001 1.21 (1.18–1.24) ⬍.0001
ED visits Univariatea 1.22 (1.12–1.33) ⬍.0001 1.29 (1.17–1.43) ⬍.0001 1.18 (1.05–1.32) .005 1.41 (1.29–1.54) ⬍.0001 1.55 (1.44–1.68) ⬍.0001
Adjustedb 1.23 (1.12–1.34) ⬍.0001 1.31 (1.18–1.46) ⬍.0001 1.15 (1.02–1.30) .02 1.28 (1.16–1.41) ⬍.0001 1.35 (1.24–1.46) ⬍.0001
Inpatient visits Univariatea 1.21 (0.91–1.61) .19 1.65 (1.11–2.45) .013 1.19 (0.75–1.89) .45 3.55 (2.69–4.69) ⬍.0001 1.99 (1.68–2.35) ⬍.0001
Adjustedb 1.18 (0.84–1.66) .33 1.35 (0.81–2.25) .25 0.87 (0.47–1.61) .66 2.02 (1.22–3.34) .006 1.51 (1.22–1.85) ⬍.0001
CI indicates confidence interval.
a Visit rate ratio (exposed/unexposed) from univariate conditional Poisson model.

b Adjusted visit rate ratio from conditional Poisson model controlling for the child’s gender, number of parents, and the pediatric RxRisk risk-adjustment variable.

c Sick visits to primary care department.

PEDIATRICS Volume 119, Number 4, April 2007 e833

Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
 TABLE 5 Excess Number of Visits per 100 Person-Years Among Exposed Children
Use Outcome
3–11 mo
(n ⫽ 7072)
WCC visits NS
Sick visits to primary care departments 68.2
Specialty department visits NS
ED visits 9.5
Inpatient visits NS
We estimated the excess visit rate that was attributable to having depressed parent(s) by multiplying the adjusted rate ratio (Table 4) by the
unadjusted visit rate (Table 3) for unexposed children. NS indicates nonsignificant.
visits when they had a depressed parent is the first report
that we could find of a significant association between
parental depression and WCC visit rates in adolescents.
This does not contradict previous studies, because all 4
previous analyses of the association between parental
depression and WCC visits studied infants32,34,35 or pre-
school children only.33
Our finding of an association between parental de-
pression and higher rates of sick visits to the primary
care site is consistent with the 1 previous study of this
association, authored by Mandl et al.35 That study found
that women were twice as likely to exhibit depressive
symptoms when their infant had ⬎1 sick visit. We found
no comparison studies that assessed the association be-
tween specialty visits and parental depression.
Regarding ED visits, previous literature is mixed, with
some studies showing increased ED visits among chil-
dren of depressed parents36 and others showing no as-
sociation.33,37 By showing a strong association between
ED visits and parental depression across all age groups
and in a large patient population, our study greatly
strengthens the evidence for this association.
The literature is more consistent regarding the asso-
ciation between parental depression and the child’s like-
lihood of inpatient visit, with previous studies finding an
odds ratio of 1.5 to 3.0.32,34,36–38 Our study found an
association only in the 2 oldest age groups. Of the pre-
vious 5 analyses, 3 studied children who were younger
than 2 years.32,34,36 Our finding of no association in the 3
youngest age groups is inconsistent with these previous
findings and may be related to selection bias: the 2 US
studies selected their subjects from families who at-
tended primary care clinics, which may select for a pop-
ulation with a greater tendency to use services.32,36 Of the
2 previous analyses that involved older children, 1 stud-
ied 4- to 9-year-old children with asthma,38 and the
other studied 6- to 23-year-olds; the latter study found
higher rates of surgery-related inpatient visit among
children of depressed parents but no difference in the
rate of nonsurgical inpatient visits.37
The finding of higher excess visit rates for ED and sick
visits among the youngest age groups may reflect the
greater difficulty that depressed parents encounter con-
e834 SILLS et al
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
Age Group
1–2 y 3–5 y 6–12 y 13–17 y
(n ⫽ 7771) (n ⫽ 10 767) (n ⫽ 23 544) (n ⫽ 20 511)
NS NS NS ⫺1.4
44.4 33.0 33.8 33.0
3.7 6.3 19.9 25.5
8.2 2.2 2.8 4.7
NS NS 1.4 1.3
fronting the challenge that is presented by figuring out
the anatomic site and the severity of distress among
preverbal children. It also may reflect the influence of
ongoing postpartum depression, which can last up to 1
year after delivery. Because we used the adjusted rate
ratio in calculating excess visits, we accounted for the
effect of chronic illness; this is corroborated further by
the finding that no excess inpatient visits were noted in
these youngest age groups despite their higher excesses
of emergent and urgent visit rates.
The clinical significance of the excess bed days de-
pends to some degree on perspective. None of our rates
exceeded 1 extra visit per patient per year, so the aver-
age impact of excess visits on families may not be clini-
cally significant. However, even the smallest significant
excess in visits—an excess of 1.3 inpatient visits per 100
patients in the 13- to 17-year age group—is significant
from a health care financing standpoint.
The limitations of this study are related to limitations
that are inherent in using medical chart databases. Sev-
eral factors limit the accuracy of medical charts for dis-
ease identification in general, including incomplete or
erroneous charts submitted by providers and limited
clinical detail in the ICD-9 system. The use of adminis-
trative data for depression identification in particular
presents additional challenges.42 Social stigma may dis-
courage individuals from reporting mental health diag-
noses, and suboptimal health care screening practices by
providers may limit further individuals’ ability to know
and report mental illness.43,44 These limitations would
result in misclassification of exposed children as unex-
posed children and would be expected to dilute the
effect reported. The identification of “parents” by sub-
scriber match also led to inexact linking of parents and
children. This, too, likely would result in misclassifica-
tion of exposed children as unexposed, which would
bias our results to the null. Another set of limitations are
related to dissimilarities between the exposed and unex-
posed groups. We found a higher number of parents
linked to the child’s KPCO record among exposed chil-
dren than unexposed. This finding may result, in part,
from the fact that having more parents gives a child
more opportunity to have at least 1 depressed parent.
We also found longer enrollment periods among ex-
posed children. This may reflect a phenomenon that is
similar to the effect of having more parents linked to
one’s file; namely, children with longer enrollments had
more opportunity to have a parent receive a diagnosis of
depression. Finally, because this is a retrospective anal-
ysis, we cannot make assumptions about causality. De-
spite adjusting for chronic illness, we cannot assume that
causality starts with the parent’s depression; perhaps it is
the child’s genuine need for more visits that has contrib-
uted to the parent’s depression. In either causality sce-
nario, efforts that are directed at improving the parent’s
depression are likely to be associated with improved
outcomes for the parent– child dyad.
This study confirms previously reported associations
in a large, closed-model HMO setting. The costlier pat-
terns of health care use that are associated with parental
depression raise important issues both for pediatric
health care providers and for health care policy-makers.
For pediatric providers, our study supports the conclu-
sions of previous reports, which have called for increased
screening for and treatment of depression in the parents
of pediatric patients.45 Conducting routine, brief, mater-
nal depression screening during WCC visits has been
found to be feasible, successful, and well accepted and
has resulted in specific pediatrician actions.46 For policy-
makers, our findings suggest that interventions that are
directed at improving rates of detection and treatment of
parental depression will result in less costly health care
use patterns for children of depressed parents.
ACKNOWLEDGMENTS
This study was funded by grants D14HP00153 and
D54HP00054 from the Health Resources and Services
Administration and grant G06807 from the Children’s
Hospital Research Institute.
REFERENCES
1. Olson AL, DiBrigida LA. Depressive symptoms and work role
satisfaction in mothers of toddlers. Pediatrics. 1994;94:363–367
2. Hall LA, Williams CA, Greenberg RS. Supports, stressors, and
depressive symptoms in low-income mothers of young chil-
dren. Am J Public Health. 1985;75:518 –522
3. Orr ST, James S. Maternal depression in an urban pediatric
practice: implications for health care delivery. Am J Public
Health. 1984;74:363–365
4. Reis J. Correlates of depression according to maternal age.
J Genet Psychol. 1988;149:535–545
5. Kemper K, Babonis T. Screening for maternal depression in
pediatric clinics. Am J Dis Child. 1992;146:876 – 878
6. Kemper KJ. Self-administered questionnaire for structured
psychosocial screening in pediatrics. Pediatrics. 1992;89:
433– 436
7. Orr ST, James SA, Burns BJ, Thompson B. Chronic stressors
and maternal depression: implications for prevention. Am J
Public Health. 1989;79:1295–1296
8. Jessop DJ, Riessman CX, Stein RE. Chronic childhood illness
and maternal mental health. J Dev Behav Pediatr. 1988;9:
147–156
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
9. Ilfeld FW. Current social stressors and symptoms of depression.
Am J Psychiatry. 1977;134:161–166
10. Beardslee WR, Bemporad J, Keller MB, Klerman GL. Children
of parents with major affective disorder: a review. Am J Psychi-
atry. 1983;140:825– 832
11. Weissman MM, Prusoff BA, Gammon GD, Merikangas KR,
Leckman JF, Kidd KK. Psychopathology in the children (ages
6 –18) of depressed and normal parents. J Am Acad Child Psy-
chiatry. 1984;23:78 – 84
12. Weissman MM, John K, Merikangas KR. Depressed parents
and their children: general health, social, and psychiatric prob-
lems. Am J Dis Child. 1986;140:801– 805
13. Weissman MM, Gammon GD, John K. Children of depressed
parents: increased psychopathology and early onset of major
depression. Arch Gen Psychiatry. 1987;44:847– 853
14. Weissman MM, Warner V, Wickramaratne P, Moreau D, Olf-
son M. Offspring of depressed parents. 10 Years later. Arch Gen
Psychiatry. 1997;54:932–940
15. Leadbeater B, Bishop S, Raver C. Quality of mother-toddler
interactions, maternal depressive symptoms, and behavior
problems in preschoolers of adolescent mothers. Dev Psychol.
1996;32:280 –288
16. Civic D, Holt VL. Maternal depressive symptoms and child
behavior problems in a nationally representative normal birth-
weight sample. Matern Child Health J. 2000;4:215–221
17. Field T, Healy B, Goldstein S. Infants of depressed mothers
show depressed behavior even with non-depressed adults.
Child Dev. 1988;59:1569 –1579
18. Leadbeater BJ, Bishop SJ. Predictors of behavior problems in
preschool children of inner-city Afro-American and Puerto
Rican adolescent mothers. Child Dev. 1994;65:638 – 648
19. Kim-Cohen J, Moffitt TE, Taylor A, Pawlby SJ, Caspi A. Ma-
ternal depression and children’s antisocial behavior: nature
and nurture effects. Arch Gen Psychiatry. 2005;62:173–181
20. Alpern L, Lyons-Ruth K. Preschool children at social risk:
chronicity and timing of maternal depressive symptoms and
child behavior problems at school and at home. Dev Psycho-
pathol. 1993;5:371–387
21. Cummings E, Davies P. Maternal depression and child devel-
opment. J Child Psychol Psychiatry. 1994;35:73–112
22. Breznitz Z, Friedman S. Speech patterning of natural discourse
of well and depressed mothers and their young children. Child
Dev. 1987;58:395– 400
23. Coghill SR, Caplan HL, Alexandra H, Robson K, Kumar R.
Impact of maternal post-natal depression on cognitive devel-
opment of young children. Br Med J. 1986;292:1165–1167
24. Olfson M, Marcus SC, Druss B, Alan Pincus H, Weissman MM.
Parental depression, child mental health problems, and health
care utilization. Med Care. 2003;41:716 –721
25. Beardslee WR, Keller MB, Seifer R, et al. Prediction of adoles-
cent affective disorder: effects of prior parental affective disor-
ders and child psychopathology. J Am Acad Child Adolesc Psychi-
atry. 1996;35:279 –288
26. Schwartz CE, Dorer DJ, Beardslee WR, Lavori PW, Keller MB.
Maternal expressed emotion and parental affective disorder:
risk for childhood depressive disorder, substance abuse, or
conduct disorder. J Psychiatr Res. 1990;24:231–250
27. Hammen C, Burge D, Burney E, Adrian C. Longitudinal study
of diagnoses in children of women with unipolar and bipolar
affective disorder. Arch Gen Psychiatry. 1990;47:1112–1117
28. Hipwell AE, Murray L, Ducournau P, Stein A. The effects of
maternal depression and parental conflict on children’s peer
play. Child Care Health Dev. 2005;31:11–23
29. Shalowitz MU, Berry CA, Quinn KA, Wolf RL. The relationship
of life stressors and maternal depression to pediatric asthma
morbidity in a subspecialty practice. Ambul Pediatr. 2001;1:
185–193
PEDIATRICS Volume 119, Number 4, April 2007 e835
30. Jhanjee I, Saxeena D, Arora J, Gjerdingen DK. Parents’ health
and demographic characteristics predict noncompliance with
well-child visits. J Am Board Fam Pract. 2004;17:324 –331
31. Minkovitz CS, Strobino D, Scharfstein D, et al. Maternal de-
pressive symptoms and children’s receipt of health care in the
first 3 years of life. Pediatrics. 2005;115:306 –314
32. Chung EK, CuCollum KF, Elo IT, Lee HJ, Culhane JF. Maternal
depressive symptoms and infant health practices among low-
income women. Pediatrics. 2004;113(6). Available at:
www.pediatrics.org/cgi/content/full/113/6/e523
33. Watson J, Kemper K. Maternal factors and child’s health care
use. Soc Sci Med. 1995;40:623– 628
34. Bagedahl-Strindlund M, Tunell R, Nilsson B. Children of men-
tally ill mothers: mortality and utilization of paediatric health
services. Acta Paediatr Scand. 1988;77:242–250
35. Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer CJ. In-
fant health care use and maternal depression. Arch Pediatr
Adolesc Med. 1999;153:808 – 813
36. McCarthy P, Freudigman K, Cicchetti D, et al. The mother-
child interaction and clinical judgment during acute pediatric
illnesses. J Pediatr. 2000;136:809 – 817
37. Kramer RA, Warner V, Olfson M, Ebanks CM, Chaput F,
Weissman MM. General medical problems among the offspring
of depressed parents: a 10-year follow-up. J Am Acad Child
Adolesc Psychiatry. 1998;37:602– 611
38. Weil CM, Wade SL, Bauman LJ, Lynn H, Mitchell H, Lavigne J.
The relationship between psychosocial factors and asthma
e836 SILLS et al
Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015
morbidity in inner-city children with asthma. Pediatrics. 1999;
104:1274 –1280
39. Fishman PA, Shay DK. Development and estimation of a pe-
diatric chronic disease score using automated pharmacy data.
Med Care. 1999;37:874 – 883
40. Abramson JH, Gahlinger PM. Computer Programs for Epi-
demiologists: PEPI V. 4.0 [computer program]. Salt Lake City, UT:
Sagebrush Press; 2001
41. SAS Institute. SAS/STAT 9.1 User’s Guide. Cary, NC: SAS
Institute; 2004
42. Spettell C, Wall T, Allison J, et al. Identifying physician-
recognized depression from administrative data: consequences
for quality measurement. Health Serv Res. 2003;38:1081–1102
43. Rost K, Smith R, Matthews D, Guise B. The deliberate misdi-
agnosis of major depression in primary care. Arch Fam Med.
1994;3:333–337
44. Lemelin J, Hotz S, Swensen R, Elmslie T. Depression in primary
care. Why do we miss the diagnosis? Can Fam Physician. 1994;40:
104 –108
45. Pignone M, Gaynes B, Rushton J, et al. Screening for de-
pression in adults: a summary of the evidence for the US
Preventive Services Task Force. Ann Intern Med. 2002;136:
765–776
46. Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief maternal
depression screening at well-child visits. Pediatrics. 2006;118:
207–216
 Association Between Parental Depression and Children's Health Care Use
Marion R. Sills, Susan Shetterly, Stanley Xu, David Magid and Allison Kempe
Pediatrics 2007;119;e829
DOI: 10.1542/peds.2006-2399
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/119/4/e829.full.h
tml
References This article cites 43 articles, 6 of which can be accessed free
at:
http://pediatrics.aappublications.org/content/119/4/e829.full.h
tml#ref-list-1
Citations This article has been cited by 3 HighWire-hosted articles:
http://pediatrics.aappublications.org/content/119/4/e829.full.h
tml#related-urls
Subspecialty Collections This article, along with others on similar topics, appears in
the following collection(s):
Developmental/Behavioral Issues
http://pediatrics.aappublications.org/cgi/collection/developme
nt:behavioral_issues_sub
Growth/Development Milestones
http://pediatrics.aappublications.org/cgi/collection/growth:de
velopment_milestones_sub
Psychosocial Issues
http://pediatrics.aappublications.org/cgi/collection/psychosoci
al_issues_sub
Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xht
ml
Reprints Information about ordering reprints can be found online:
http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015

 Association Between Parental Depression and Children's Health Care Use
Marion R. Sills, Susan Shetterly, Stanley Xu, David Magid and Allison Kempe
Pediatrics 2007;119;e829
DOI: 10.1542/peds.2006-2399

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/119/4/e829.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2007 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at UCLA Biomedical Library on April 4, 2015