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Journal of Abnormal Child Psychology

, Volume 43, Issue 1, pp 177–187 | Cite as

The Impact of Chronic Physical Illness, Maternal Depressive Symptoms, Family Functioning, and Self-esteem on Symptoms of Anxiety and Depression in Children

  • Mark A. FerroEmail author
  • Michael H. Boyle
Article

Abstract

The present study extends earlier research identifying an increased risk of anxiety among children with chronic physical illness (CwCPI) by examining a more complete model that explains how physical illness leads to increased symptoms of anxiety and depression. We tested a stress-generation model linking chronic physical illness to symptoms of anxiety and depression in a population-based sample of children aged 10 to 15 years. We hypothesized that having a chronic physical illness would be associated with more symptoms of anxiety and depression, increased levels of maternal depressive symptoms, more family dysfunction, and lower self-esteem; and, that maternal depressive symptoms, family dysfunction, and child self-esteem would mediate the influence of chronic physical illness on symptoms of anxiety and depression. Data came from the National Longitudinal Survey of Children and Youth (N = 10,646). Mediating processes were analyzed using latent growth curve modeling. Childhood chronic physical illness was associated with increases in symptoms of anxiety and depression, β = 0.20, p < 0.001. Mediating effects were also observed such that chronic physical illness resulted in increases in symptoms of maternal depression and family dysfunction, leading to declines in child self-esteem, and in turn, increases in symptoms of anxiety and depression. CwCPI are at-risk for symptoms of anxiety and depression. Some of this elevated risk appears to work through family processes and child self-esteem. This study supports the use of family-centered care approaches among CwCPI to minimize burden on families and promote healthy psychological development for children.

Keywords

Anxiety Behavior Chronic illness Cohort study Depression Growth modeling Mediation Stress-generation 

Notes

Conflict of Interest

Dr. Ferro was the recipient of a Banting Postdoctoral Fellowship from the Government of Canada and is currently supported by a Research Early Career Award from Hamilton Health Sciences. Dr. Boyle holds a Canada Research Chair (Tier I) in the Social Determinants of Child Health from the Canadian Institutes of Health Research. While the research and analyses are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada.

References

  1. Auerbach, R. P., Bigda-Peyton, J. S., Eberhart, N. K., Webb, C. A., & Ho, M. R. (2011). Conceptualizing the prospective relationship between social support, stress, and depressive symptoms among adolescents. J Abnorm Child Psychol, 39, 475–487.PubMedCrossRefGoogle Scholar
  2. Bahreinian, S., Ball, G. D., Vander Leek, T. K., Colman, I., McNeil, B. J., Becker, A. B., & Kozyrskyj, A. L. (2013). Allostatic load biomarkers and asthma in adolescents. Am J Respir Crit Care Med, 187, 144–152.PubMedCrossRefGoogle Scholar
  3. Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Guildford PressGoogle Scholar
  4. Beebe, A., Gelfand, E. W., & Bender, B. (2010). A randomized trial to test the effectiveness of art therapy for children with asthma. J Allergy Clin Immunol, 126, 263–266.PubMedCrossRefGoogle Scholar
  5. Blackman, J. A., Gurka, M. J., Gurka, K. K., & Oliver, M. N. (2011). Emotional, developmental and behavioural co-morbidities of children with chronic health conditions. J Pediatr Child Health, 47, 742–747.CrossRefGoogle Scholar
  6. Boyle, M. H., Offord, D. R., Racine, Y., Fleming, J. E., Szatmari, P., & Sanford, M. (1993). Evaluation of the revised Ontario child health study scales. J Child Psychol Psychiatry, 34, 189–213.PubMedCrossRefGoogle Scholar
  7. Brehaut, J. C., Kohen, D. E., Garner, R. E., Miller, A. R., Lach, L. M., Klassen, A. F., & Rosenbaum, P. L. (2009). Health among caregivers of children with health problems: findings from a Canadian population-based study. Am J Public Health, 99, 1254–1262.PubMedCrossRefPubMedCentralGoogle Scholar
  8. Brehaut, J. C., Garner, R. E., Miller, A. R., Lach, L. M., Klassen, A. F., Rosenbaum, P. L., & Kohen, D. E. (2011). Changes over time in the health of caregivers of children with health problems: growth-curve findings from a 10-year Canadian population-based study. Am J Public Health, 101, 2308–2316.PubMedCrossRefPubMedCentralGoogle Scholar
  9. Burton, P., & Phipps, S. (2009). Economic costs of caring for children with disabilities in Canada. Can Public Policy, 35, 269–290.CrossRefGoogle Scholar
  10. Byles, J., Byrne, C., Boyle, M. H., & Offord, D. R. (1988). Ontario child health study: reliability and validity of the general functioning subscale of the mcmaster family assessment device. Fam Process, 27, 97–104.PubMedCrossRefGoogle Scholar
  11. Cartwright-Hatton, S. (2006). Anxiety of childhood and adolescence: challenges and opportunities. Clin Psychol Rev, 26, 813–816.PubMedCrossRefGoogle Scholar
  12. Celano, M., Bakeman, R., Gaytan, O., Smith, C. O., Koci, A., & Henderson, S. (2008). Caregiver depressive symptoms and observed family interaction in low-income children with persistent asthma. Fam Process, 47, 7–20.PubMedCrossRefGoogle Scholar
  13. Chaney, J. M., Mullins, L. L., Uretsky, D. L., Pace, T. M., Werden, D., & Hartman, V. L. (1999). An experimental examination of learned helplessness in older adolescents and young adults with long-standing asthma. J Pediatr Psychol, 24, 259–270.PubMedCrossRefGoogle Scholar
  14. Chiang, L. C., Ma, W. F., Huang, J. L., Tseng, L. F., & Hsueh, K. C. (2009). Effect of relaxation-breathing training on anxiety and asthma signs/symptoms of children with moderate-to-severe asthma: a randomized controlled trial. Int J Nurs Stud, 46, 1061–1070.PubMedCrossRefGoogle Scholar
  15. Class, Q. A., D’Onofrio, B. M., Singh, A. L., Ganiban, J. M., Spotts, E. L., Lichtenstein, P., & Neiderhiser, J. M. (2012). Current parental depression and offspring perceived self-competence: a quasi-experimental examination. Behav Genet, 42, 787–797.PubMedCrossRefPubMedCentralGoogle Scholar
  16. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Lawrence Erlbaum AssociatesGoogle Scholar
  17. Cole, D. A., Martin, J. M., & Powers, B. (1997). A competency-based model of child depression: a longitudinal study of peer, parent, teacher, and self-evaluations. J Child Psychol Psychiatry, 38, 505–514.PubMedCrossRefGoogle Scholar
  18. Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. methods and public health burden. J Am Acad Child Adolesc Psychiatry, 44, 972–986.PubMedCrossRefGoogle Scholar
  19. Datta, S. S., Premkumar, T. S., Chandy, S., Kumar, S., Kirubakaran, C., Gnanamuthu, C., & Cherian, A. (2005). Behaviour problems in children and adolescents with seizure disorder: associations and risk factors. Seizure, 14, 190–197.PubMedCrossRefGoogle Scholar
  20. Elgar, F. J., Curtis, L. J., McGrath, P. J., Waschbusch, D. A., & Stewart, S. H. (2003). Antecedent-consequence conditions in maternal mood and child adjustment: a four-year cross-lagged study. J Clin Child Adolesc Psychol, 32, 362–374.PubMedCrossRefGoogle Scholar
  21. Ferro, M. A., & Boyle, M. H. (2013a). Brief report: Testing measurement invariance and differences in self-concept between adolescents with and without physical illness or developmental disability. J Adolesc, 36, 947–951.PubMedCrossRefGoogle Scholar
  22. Ferro, M. A., & Boyle, M. H. (2013b). Longitudinal invariance of measurement and structure of global self-concept: a population-based study examining trajectories among adolescents with and without chronic illness. J Pediatr Psychol, 38, 425–437.PubMedCrossRefGoogle Scholar
  23. Ferro, M. A., & Boyle, M. H. (2013c). Self-concept among children and adolescents with a chronic illness: a meta-analytic review. Health Psychol, 32, 839–848.PubMedCrossRefGoogle Scholar
  24. Ferro, M. A., & Speechley, K. N. (2009). Depressive symptoms among mothers of children with epilepsy: a review of prevalence, associated factors, and impact on children. Epilepsia, 50, 2344–2354.PubMedCrossRefGoogle Scholar
  25. Ferro, M. A., & Speechley, K. N. (2012). Examining clinically relevant levels of depressive symptoms in mothers following a diagnosis of epilepsy in their children: a prospective analysis. Soc Psychiatry Psychiatr Epidemiol, 47, 1419–1428.PubMedCrossRefGoogle Scholar
  26. Ferro, M. A., Avison, W. R., Campbell, M. K., & Speechley, K. N. (2011). The impact of maternal depressive symptoms on health-related quality of life in children with epilepsy: a prospective study of family environment as mediators and moderators. Epilepsia, 52, 316–325.PubMedGoogle Scholar
  27. Gannoni, A. F., & Shute, R. H. (2010). Parental and child perspectives on adaptation to childhood chronic illness: a qualitative study. Clin Child Psychol Psychiatry, 15, 39–53.PubMedCrossRefGoogle Scholar
  28. Gartstein, M. A., & Sheeber, L. (2004). Child behavior problems and maternal symptoms of depression: a mediational model. J Child Adolesc Psychiatr Nurs, 17, 141–150.PubMedCrossRefGoogle Scholar
  29. Ge, X., Conger, R. D., & Elder, G. H., Jr. (2001). Pubertal transition, stressful life events, and the emergence of gender differences in adolescent depressive symptoms. Dev Psychol, 37, 404–417.PubMedCrossRefGoogle Scholar
  30. Ginsburg, G. S., La Greca, A. M., & Silverman, W. K. (1998). Social anxiety in children with anxiety disorders: relation with social and emotional functioning. J Abnorm Child Psychol, 26, 175–185.PubMedCrossRefGoogle Scholar
  31. Graham, J. W. (2009). Missing data analysis: making it work in the real world. Annu Rev Psychol, 60, 549–576.PubMedCrossRefGoogle Scholar
  32. Gray, K. M., Piccinin, A. M., Hofer, S. M., Mackinnon, A., Bontempo, D. E., Einfeld, S. L., & Tonge, B. J. (2011). The longitudinal relationship between behavior and emotional disturbance in young people with intellectual disability and maternal mental health. Res Dev Disabil, 32, 1194–1204.PubMedCrossRefPubMedCentralGoogle Scholar
  33. Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R., & Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry, 60, 427–435.PubMedCrossRefGoogle Scholar
  34. Hammen, C. (1991). Generation of stress in the course of unipolar depression. J Abnorm Psychol, 100, 555–561.PubMedCrossRefGoogle Scholar
  35. Haney, P., & Durlak, J. A. (1998). Changing self-esteem in children and adolescents: a meta-analytic review. J Clin Child Psychol, 27, 423–433.PubMedCrossRefGoogle Scholar
  36. Hankin, B. L., Mermelstein, R., & Roesch, L. (2007). Sex differences in adolescent depression: stress exposure and reactivity models. Child Dev, 78, 279–295.PubMedCrossRefGoogle Scholar
  37. Harter, S. (1982). The perceived competence scale for children. Child Dev, 53, 87–97.CrossRefGoogle Scholar
  38. Hedges, L. V., & Olkin, I. (1984). Nonparametric estimators of effect size in meta-analysis. Psychol Bull, 96, 573–580.CrossRefGoogle Scholar
  39. Hoare, P., & Mann, H. (1994). Self-esteem and behavioural adjustment in children with epilepsy and children with diabetes. J Psychosom Res, 38, 859–869.PubMedCrossRefGoogle Scholar
  40. Hobdell, E. F., Grant, M. L., Valencia, I., Mare, J., Kothare, S. V., Legido, A., & Khurana, D. S. (2007). Chronic sorrow and coping in families of children with epilepsy. J Neurosci Nurs, 39, 76–82.PubMedCrossRefGoogle Scholar
  41. Hodes, M., Garralda, M. E., Rose, G., & Schwartz, R. (1999). Maternal expressed emotion and adjustment in children with epilepsy. J Child Psychol Psychiatry, 40, 1083–1093.PubMedCrossRefGoogle Scholar
  42. Holmes, A. M., & Deb, P. (2003). The effect of chronic illness on the psychological health of family members. J Ment Health Policy Econ, 6, 13–22.PubMedGoogle Scholar
  43. Hoppe, C., & Elger, C. E. (2011). Depression in epilepsy: a critical review from a clinical perspective. Nat Rev Neurol, 7, 462–472.PubMedCrossRefGoogle Scholar
  44. Hoyert, D. L., Mathews, T. J., Menacker, F., Strobino, D. M., & Guyer, B. (2006). Annual summary of vital statistics: 2004. Pediatrics, 117, 168–183.PubMedCrossRefGoogle Scholar
  45. Hughes, A. A., Hedtke, K. A., & Kendall, P. C. (2008). Family functioning in families of children with anxiety disorders. J Fam Psychol, 22, 325–328.PubMedCrossRefGoogle Scholar
  46. Ialongo, N., Edelsohn, G., Werthamer-Larsson, L., Crokettn, L., & Kellam, S. (1996). Social and cognitive impairment in first-grade children with anxious and depressive symptoms. J Clin Child Psychol, 25, 15–24.CrossRefGoogle Scholar
  47. Jacquez, F., Cole, D. A., & Searle, B. (2004). Self-perceived competence as a mediator between maternal feedback and depressive symptoms in adolescents. J Abnorm Child Psychol, 32, 355–367.PubMedCrossRefGoogle Scholar
  48. Kercher, A., & Rapee, R. M. (2009). A test of a cognitive diathesis-stress generation pathway in early adolescent depression. J Abnorm Child Psychol, 37, 845–855.PubMedCrossRefGoogle Scholar
  49. Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003). Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Genernal Psychiatry, 60, 709–717.CrossRefGoogle Scholar
  50. Law, M., Hanna, S., King, G., Hurley, P., King, S., Kertoy, M., & Rosenbaum, P. (2003). Factors affecting family-centred service delivery for children with disabilities. Child Care Health Dev, 29, 357–366.PubMedCrossRefGoogle Scholar
  51. Lim, J., Wood, B. L., Miller, B. D., & Simmens, S. J. (2011). Effects of paternal and maternal depressive symptoms on child internalizing symptoms and asthma disease activity: mediation by interparental negativity and parenting. J Fam Psychol, 25, 137–146.PubMedCrossRefPubMedCentralGoogle Scholar
  52. MacKinnon, D. P. (2008). Introduction to statistical mediation analysis. Hoboken: Erlbaum Psych PressGoogle Scholar
  53. Marsh, H. W. (1992). Self Description Questionnaire (SDQ) I: A theoretical and empirical basis for the measurement of multiple dimensions of preadolescent self-concept. An interim test manual and research monograph. University of Western Sydney, MacarthurGoogle Scholar
  54. Marshall, K. (2006). Converging gender roles. Perspect Labour Income, 7, 5–17.Google Scholar
  55. McCaffery, J. M., Marsland, A. L., Strohacker, K., Muldoon, M. F., & Manuck, S. B. (2012). Factor structure underlying components of allostatic load. PLoS One, 7, e47246.PubMedCrossRefPubMedCentralGoogle Scholar
  56. McClellan, C. B., & Cohen, L. L. (2007). Family functioning in children with chronic illness compared with healthy controls: a critical review. J Pediatr, 150, 221–223. 223 e221-222.PubMedCrossRefGoogle Scholar
  57. McEwen, B. S. (1998). Stress, adaptation, and disease. allostasis and allostatic load. Ann N Y Acad Sci, 840, 33–44.PubMedCrossRefGoogle Scholar
  58. McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examining the association between parenting and childhood anxiety: a meta-analysis. Clin Psychol Rev, 27, 155–172.PubMedCrossRefGoogle Scholar
  59. Merikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci, 11, 7–20.PubMedPubMedCentralGoogle Scholar
  60. Msall, M. E., Avery, R. C., Tremont, M. R., Lima, J. C., Rogers, M. L., & Hogan, D. P. (2003). Functional disability and school activity limitations in 41,300 school-age children: relationship to medical impairments. Pediatrics, 111, 548–553.PubMedCrossRefGoogle Scholar
  61. Mullick, M. S., Nahar, J. S., & Haq, S. A. (2005). Psychiatric morbidity, stressors, impact, and burden in juvenile idiopathic arthritis. J Health Popul Nutr, 23, 142–149.PubMedGoogle Scholar
  62. Muthén, L. K., & Muthén, B. O. (2010). Mplus user’s guide (6th ed.). Los Angeles: Muthén & MuthénGoogle Scholar
  63. Newacheck, P. W., & Kim, S. E. (2005). A national profile of health care utilization and expenditures for children with special health care needs. Arch Pediatr Adolesc Med, 159, 10–17.PubMedCrossRefGoogle Scholar
  64. O’Mara, A. J., Marsh, H. W., Craven, R. G., & Debus, R. L. (2006). Do self-concept interventions make a difference? a synergistic blend of construct validation and meta-analysis. Educ Psychol, 41, 181–206.CrossRefGoogle Scholar
  65. Pai, A. L., Patino-Fernandez, A. M., McSherry, M., Beele, D., Alderfer, M. A., Reilly, A. T., & Kazak, A. E. (2008). The Psychosocial assessment Tool (PAT2.0): psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with cancer. J Pediatr Psychol, 33, 50–62.PubMedCrossRefPubMedCentralGoogle Scholar
  66. Patterson, J., & Blum, R. W. (1996). Risk and resilience among children and youth with disabilities. Arch Pediatric Adolesc Medicine, 150, 692–698.CrossRefGoogle Scholar
  67. Pelkonen, M., Marttunen, M., Kaprio, J., Huurre, T., & Aro, H. (2008). Adolescent risk factors for episodic and persistent depression in adulthood. a 16-year prospective follow-up study of adolescents. J Affect Disord, 106, 123–131.PubMedCrossRefGoogle Scholar
  68. Pinquart, M., & Shen, Y. (2011a). Anxiety in children and adolescents with chronic physical illnesses: a meta-analysis. Acta Paediatr, 100, 1069–1076.PubMedCrossRefGoogle Scholar
  69. Pinquart, M., & Shen, Y. (2011b). Behavior problems in children and adolescents with chronic physical illness: a meta-analysis. J Pediatr Psychol, 36, 1003–1016.PubMedCrossRefGoogle Scholar
  70. Poulin, C., Hand, D., & Boudreau, B. (2005). Validity of a 12-item version of the CES-D used in the national longitudinal study of children and youth. Chron Dis Can, 26, 65–72.Google Scholar
  71. Radloff, L. S. (1977). The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measures, 1, 385–401.CrossRefGoogle Scholar
  72. Reichman, N. E., Corman, H., & Noonan, K. (2004). Effects of child health on parents’ relationship status. Demography, 41, 569–584.PubMedCrossRefGoogle Scholar
  73. Rolland, J. S., & Walsh, F. (2006). Facilitating family resilience with childhood illness and disability. Curr Opin Pediatr, 18, 527–538.PubMedCrossRefGoogle Scholar
  74. Roustit, C., Campoy, E., Chaix, B., & Chauvin, P. (2010). Exploring mediating factors in the association between parental psychological distress and psychosocial maladjustment in adolescence. Eur Child Adolesc Psychiatry, 19, 597–604.PubMedCrossRefPubMedCentralGoogle Scholar
  75. Sassmann, H., de Hair, M., Danne, T., & Lange, K. (2012). Reducing stress and supporting positive relations in families of young children with type 1 diabetes: a randomized controlled study for evaluating the effects of the DELFIN parenting program. BMC Pediatr, 12, 152.PubMedCrossRefPubMedCentralGoogle Scholar
  76. Settipani, C. A., & Kendall, P. C. (2013). Social functioning in youth with anxiety disorders: association with anxiety severity and outcomes from cognitive-behavioral therapy. Child Psychiatry Hum Dev, 44, 1–18.PubMedCrossRefGoogle Scholar
  77. Singer, G. H. (2006). Meta-analysis of comparative studies of depression in mothers of children with and without developmental disabilities. Am J Ment Retard, 111, 155–169.PubMedCrossRefGoogle Scholar
  78. Singh, R. (2009). Does my structural model represent the real phenomenon? a review of the appropriate use of structural equation modeling (SEM) model fit indices. Mark Rev, 9, 199–212.CrossRefGoogle Scholar
  79. Sportel, B. E., de Hullu, E., de Jong, P. J., & Nauta, M. H. (2013). Cognitive bias modification versus CBT in reducing adolescent social anxiety: a randomized controlled trial. PLoS One, 8, e64355.PubMedCrossRefPubMedCentralGoogle Scholar
  80. Statistics Canada. (2007). Microdata user guide: National Longitudinal Survey of Children and Youth, cycle 8 September 2008 to July 2009. Retrieved Feb 15, 2013, from http://www23.statcan.gc.ca/imdb-bmdi/document/4450_D4_T9_V8-eng.pdfGoogle Scholar
  81. Stein, R. E., & Silver, E. J. (1999). Operationalizing a conceptually based noncategorical definition: aa first look at US children with chronic conditions. Arch Pediatr Adolesc Med, 153, 68–74.PubMedCrossRefGoogle Scholar
  82. Stein, R. E., Bauman, L. J., Westbrook, L. E., Coupey, S. M., & Ireys, H. T. (1993). Framework for identifying children who have chronic conditions: the case for a new definition. J Pediatr, 122, 342–347.PubMedCrossRefGoogle Scholar
  83. Svavarsdottir, E. K., & Rayens, M. K. (2005). Hardiness in families of young children with asthma. J Adv Nurs, 50, 381–390.PubMedCrossRefGoogle Scholar
  84. Trautwein, U., Ludtke, O., Koller, O., & Baumert, J. (2006). Self-esteem, academic self-concept, and achievement: how the learning environment moderates the dynamics of self-concept. J Pers Soc Psychol, 90, 334–349.PubMedCrossRefGoogle Scholar
  85. van der Lee, J. H., Mokkink, L. B., Grootenhuis, M. A., Heymans, H. S., & Offringa, M. (2007). Definitions and measurement of chronic health conditions in childhood: a systematic review. JAMA, 297, 2741–2751.PubMedCrossRefGoogle Scholar
  86. Vazquez, M. I., & Buceta, J. M. (1993). Effectiveness of self-management programmes and relaxation training in the treatment of bronchial asthma: relationships with trait anxiety and emotional attack triggers. J Psychosom Res, 37, 71–81.PubMedCrossRefGoogle Scholar
  87. Wallander, J. L., & Varni, J. W. (1998). Effects of pediatric chronic physical disorders on child and family adjustment. J Child Psychol Psychiatry, 39, 29–46.PubMedCrossRefGoogle Scholar
  88. Whittemore, R., Jaser, S., Chao, A., Jang, M., & Grey, M. (2012). Psychological experience of parents of children with type 1 diabetes: a systematic mixed-studies review. Diabetes Educ, 38, 562–579.PubMedCrossRefPubMedCentralGoogle Scholar
  89. Witt, W. P., & DeLeire, T. (2009). A family perspective on population health: the case of child health and the family. Wis Med J, 108, 240–245.Google Scholar
  90. Yen, C. F., Yang, P., Wu, Y. Y., & Cheng, C. P. (2013). The relation between family adversity and social anxiety among adolescents in Taiwan: effects of family function and self-esteem. J Nerv Ment Disord, 201, 964–970.CrossRefGoogle Scholar
  91. Zashikhina, A., & Hagglof, B. (2007). Mental health in adolescents with chronic physical illness versus controls in Northern Russia. Acta Paediatr, 96, 890–896.PubMedCrossRefGoogle Scholar
  92. Zimmer, K. P., & Minkovitz, C. S. (2003). Maternal depression: an old problem that merits increased recognition by child healthcare practitioners. Curr Opin Pediatr, 15, 636–640.PubMedCrossRefGoogle Scholar
  93. Zou, G. Y., & Donner, A. (2008). Construction of confidence limits about effect measures: a general approach. Stat Med, 27, 1693–1702.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Offord Centre for Child StudiesMcMaster UniversityHamiltonCanada
  2. 2.Department of PediatricsMcMaster University, Health Sciences CentreHamiltonCanada
  3. 3.Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonCanada
  4. 4.CanChild Centre for Childhood Disability ResearchMcMaster University, Institute for Applied Health SciencesHamiltonCanada
  5. 5.Department of Clinical Epidemiology and BiostatisticsMcMaster University, Health Sciences CentreHamiltonCanada

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