ISSN: 2455-5460
Archives of Depression and Anxiety
Research Article       Open Access      Peer-Reviewed

Maternal health problems such as depression and anxiety and parent-child interaction

Sarah Liliane Goergen*, Margarete Bolten, Martin Schröder, Marc Schmid and Christina Stadler

Department of Psychiatric University Clinics of Basel, Department of Child and Adolescent Psychiatry, University of Basel, Switzerland
*Corresponding author: Sarah Liliane Goergen, Department of Psychiatric University Clinics of Basel, Department of Child and Adolescent Psychiatry, University of Basel, Switzerland, Tel: +41 78 897 17 04, E-mail: Sarah.Goergen@stud.unibas.ch
Received: 01 August, 2018 | Accepted: 12 September, 2018 | Published: 14 September, 2018
Keywords: Child psychopathology; Expressed emotion; Mother-child interaction; Maternal psychopathology

Cite this as

Goergen SL, Bolten M, Schröder M, Schmid M, Stadler C (2018) Maternal health problems such as depression and anxiety and parent-child interaction. Arch Depress Anxiety 4(2): 034-039. DOI: 10.17352/2455-5460.000032

Background: The emotional climate between mothers and their children is known to be a significant indicator for the development of childhood psychopathology. One index that allows measuring family-emotional climate is the expressed emotion measure (EE). Maternal mental strain is known to affect maternal EE, as it can shape the way a mother thinks about, and interacts with her child.

Context and purpose of the study: The main objective of our study was to highlight the links between maternal EE, mother-child interaction and maternal mental problems on behavior problems in children.

Data were examined from 49 children aged 5 to 7 and their mothers. The Five-Minute Speech Sample (FMSS) was used to evaluate maternal EE. Behavioral disorders have been assessed with the German version of the Child Behavior Checklist (CBCL-4/18). To evaluate maternal symptoms of psychopathology, we used the German version of the Brief Symptoms Inventory (BSI). The quality of the mother–child interaction was observed during a standardized problem-solving task.

Results: High maternal criticism was linked to more child psychopathology, more maternal mental health problems, less maternal sensitivity and less responsiveness in children during the interactional task. The effect of maternal mental problems on externalizing problems in children was mediated by high criticism in mothers.

Conclusions: The results highlight noteworthy links between mother’s criticism, child psychopathology and mother-child interactional patterns. According to our results, intervention programs focusing on children, mother-child-interaction and maternal psychopathology seem to be of major importance.

Background

There is convincing evidence indicating that parental mental problems substantially raise the risk for emotional and behavioral problems in their children [1]. In addition, it was shown that parental mental health problems negatively impact parenting and parent-child interaction [2]. Whereas proactive parenting characterized by clear instruction, limit setting and supportive presence longitudinally predicted fewer behavior problems over time in children with disruptive behavior disorder, parental anger predicted a continuation of problem behavior [3]. Thus, parental-driven factors, especially mental illness and negative parenting seem to be one of the most important risk factors in the development of childhood mental health problems.

However, up to now it is not sufficiently investigated whether parental mental health problems are associated directly with child mental problems or whether this association might be mediated by parental expressed emotion towards the child [4-6]. The assumption underlying the concept of expressed emotion (EE) is that the way parents talk about their child is indicative of the way they treat their child in daily-life and thus is an index of the emotional quality of the parent-child relationship and -interaction [7]. According to Brown et al. (1962) EE includes a critical (EE CRIT) and an emotional over-involvement dimension (EOI). EE CRIT comprises possible negative comments from the parent talking about their child and is indicative for possible negative relationship structure. EOI refers to the level of emotional over-involvement between parent and child, including self-sacrificing and overprotective behavior. High levels of parental EE have consistently been associated with externalizing behavior, ADHD and conduct disorders [8-11]. Additionally, high rates of EE have also been found in parents of children with internalizing disorders, e.g. depression [12-14], anxiety disorders [15] and self-injurious thoughts or behaviors [16]. Moreover, there is evidence indicating that EE is associated with depression in mothers [4, 17]. Whereas EE might be a key mechanism of risk transmission, it was not yet investigated whether EE directly impacts parental-child interaction. Thus, the main objective of this study was to investigate whether in mothers with high EE the mother-child interaction is negatively affected and whether EE is associated to other mental problems in mothers besides depression. In order to assess objective indices of the mother-child interaction (e. g. maternal sensitivity, child responsiveness) a structured problem-solving task was used. Second, based on previous literature we further investigated whether maternal EE is associated both with externalizing and internalizing behavior symptoms. Moreover, we examined if mothers with high EE differ in mental health problems. Finally, we tested whether the association between maternal and child mental health problems is mediated by maternal EE towards the child.

Materials and Methods

Procedure

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee. The study protocol was approved by the ethics committee of Basel (EKBB) and is consistent with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. No funding was received.

In order to recruit children varying in the level of emotional and behavioral problems, recruitment was conducted both in community and clinical settings via newspapers and flyers. Subjects were included if the mother could communicate in German sufficiently, and the child was 5 to 7 years of age. To ensure comparability and understanding of tasks, children with a history of a pervasive developmental disorder were not included.

After giving informed consent, mothers and their children were asked to participate in a structured problem-solving task to assess the quality of dyadic interaction. EE was assessed by the Five-Minute Speech Sample (FMSS). Questionnaires on maternal and child mental health problems were provided to the mothers after completing the FMSS.

Sample description

The participants included a total of 49 children and their mothers. The mean age of the children was 6.5 (SD = 1.2) years, 66.7% were boys and had primarily (70%) Swiss or European Union citizenship. The mean age of the mothers was 37.5 (SD = 5.6) years. About 67% of mothers were married or lived with their partner and 85% had 10 or more years of schooling.

The data of participants was excluded when screening data on maternal or child mental health problems was missing or incomplete. Furthermore, some FMSS videos could not be rated because of technical problems during recording. Finally, 49 mother-child interaction dyads could be included in the analyses.

In a preliminary analysis, we examined whether EE categories (EE CRIT / EOI) were related to the socioeconomic patterns of the family (financial situation, apartment size, number of siblings in household, years of schooling, etc.), demographic characteristics (sex, age, nationality, etc.) or any child or mother variables of the study, to address the need for potential control variables in subsequent analyses. Child age, gender, and nationality were not significantly associated with any of the study variables.

Children’s behavioral and emotional problems regarding externalizing behavior symptoms ranged from T=50 to T=83 (M=57, SD=10) and internalizing behavior symptoms from T= 50 to T= 78 (M=55, SD=11). Of the 49 dyads, 37 (75.5%) mothers were rated as having low EE CRIT and 12 (24.5%) mothers were rated as having high EE CRIT. EE CRIT was unrelated to demographic variables, including family structure (single vs. dual parent family), child sex or age, mother’s age or mother’s level of education. All ratings were based on EE CRIT. No mother in our sample displayed EOI during the FMSS.

Measures

Behavioral and Emotional Problems of the children (CBCL).

Behavioral disorders were assessed using the German version of the Child Behavior Checklist (CBCL-4/18) [18]. The CBCL-4/18 allows an assessment to be made of behavioral and emotional abnormalities, as well as somatic complaints using eight symptom scales: Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, Rule-breaking Behavior and Aggressive Behavior. From these scales, an Internalizing Problems Index, an Externalizing Problems Index and a Total Score can be derived. The CBCL scales showed good internal consistencies (α ≥ .93).

Mental problems of the mother (BSI)

To evaluate a broad range of psychological problems in mothers, we used the German version of the Brief Symptoms Inventory (BSI) [19]. The BSI is the short version of the Symptom Checklist-90-R (SCL-R-90) [20], which consists of 53 items, covering nine symptom dimensions: Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism and a Global Severity Index.

Expressed Emotion (EE)

EE was measured using the Five-Minute Speech Sample (FMSS) [21]. Trained interviewers asked the mothers to describe their relationship with the child and what their child is like in a five-minute monologue (e.g., “For the next 5 minutes, I would like you to describe [name of child] to me; what is he/she like?”, “How would you describe your relationship with each other?”). The mother was encouraged to talk freely with no interruptions. However, if the mother found this difficult, the interviewer could aid the mother with a series of semi-structured probes.

According to the most updated FMSS coding manual [22], high expressed emotion criticism (EE CRIT) was scored as present if there was a negative relationship rating or if there were one or more critical statements/negative tone of voice about the child. A negative relationship was rated if there was a statement indicating that the mother and the child did not get along (e.g., if the mother said, “My child is impossible to deal with”). Critical comments are negative comments about the child’s behavior or personality and they were scored on the basis of critical content and/or critical tone. Criticisms based on the content were scored, when the child’s behavior or characteristics were described by the mother with a critical phrase (e.g., “ I don’t like the way he dresses”) or in a negative manner (e.g., “she is very self-centered”). Similarly, criticisms were scored if there was harsh voice even in the absence of critical content.

EOI rating refers to the level of emotional over-involvement between mother and child. High EOI was rated as present, if there was self-sacrificing/overprotective behavior or emotional display during the interview. Self-sacrificing/overprotective behavior was scored as present, when the mother reported extreme or unusual sacrifice (e.g., “I don’t spend that much money on things for myself so that I can give it to my son”), examples of extreme enmeshment (e.g., “ We’re so close, I just don’t want her to grow up”) or extreme or unusual over-protection (e.g., “Even though he is ten years old, I like him to be in front of my eyes all the time, even when he is playing with his friends”). Next, emotional display was rated as present when the mother cried or was unable to speak during the interview due to emotional sentiment.

To ensure reliability, every videotaped EE interview was scored independently by two well-trained raters. Inter-rater reliability was moderate (Kappa = 0.42).

Mother-Child Interaction

According to Wolke, Rios and Unzer [23], the quality of the mother–child interaction was observed during a standardized problem-solving task. We used an Etch-a-Sketch, a toy that allows for the sketching of pictures by turning two buttons: one allows horizontal lines and the other vertical lines to be drawn. We asked each mother-child dyad to copy a house according to a template. Each interaction partner was allowed to use only one of the buttons. This should induce coordinative communication between mother and child. All interactions were videotaped and were stopped by the experimenter after 5 minutes.

To assess the quality of parent-child interactions a coding system developed on the concept of emotional availability [24] and Bowlby´ s attachment theory [25] comprising three maternal dimensions (sensitivity, structuring and intrusiveness), one child dimension (child responsiveness) and one dimension concerning the quality of interaction (harmony and warmth) was applied (Table 1). To ensure reliability, every videotaped mother-child interaction was scored independently by two well-trained raters. Inter-rater-reliability was very good (Kappa 0.78 to 0.92.).

Data analysis

The data was analyzed using SPSS statistical software for Windows, release 22 (SPSS Inc., Chicago, Illinois).

First, in order to investigate whether mother and child interactional behaviors differ in high and low maternal EE CRIT, we performed a one-way analysis of variance between groups (ANOVA). Using the same statistical procedures, we examined the association between child emotional and behavioral problems (CBCL) and maternal mental health problems (BSI) on maternal EE occurrence. Investigating the link between child problems and EE CRIT, we controlled for maternal mental problems (ANCOVA). Finally, to determine the mediating effect of EE CRIT on the association between maternal psychopathology and children´s behavioral problems, we ran a linear regression analysis.

Results

Association between maternal expressed emotion criticism and mother-child interactional behaviors.

Result of the conducted ANOVA indicate that children of mothers expressing high levels of EE CRIT were less responsive (F = 5.20, p = 0.03, d = 0.37) to their mothers and that there was significantly less harmony and warmth during the interaction (F = 4.55, p = 0.038, d = 0.71). In addition, there was a trend showing that mothers expressing high rates of criticism were rated as acting less sensitively (F = 4.18; p = 0.05; d = 0.56) towards their children (Figure 1).

There was no significant group difference regarding maternal structuring behavior or maternal intrusiveness.

Association between maternal expressed emotion criticism and internalizing and externalizing problems of the child.

Results further indicate that children of mothers who showed high levels of EE CRIT had significantly more behavioral problems than children of mothers showing less criticism (Withdrawn: F = 5.44, p = 0.24, d = 0.78; Anxious/Depressed: F = 13.61, p = 0.001, d = 1.23; Social problems: F = 17.43, p = 0.001, d = 1.39; Attention problems: F = 6.10, p = 0.017, d = 0.08; Rule-breaking behavior: F = 7.20, p = 0.010, d = 0.89; Aggressive behavior: F = 9.04, p = 0.004, d = 1; Internalizing problems: F = 12.13, p = 0.001, d = 1.16; Externalizing problems: F = 8.23, p = 0.006, d = 0.95; Global strain: F = 12.95, p = 0.001, d = 1.19) (Figure 2).

When controlling for maternal psychopathology by using the global severity index of BSI (GSI) as a covariate, the difference in child behavioral and emotional problems (total CBCL score) between those with mothers with high compared to low EE CRIT was still significant (F = 4.48, p = 0.04, d = 3.7).

Association between maternal expressed emotion criticism and maternal psychiatric symptoms.

Except for the subscales somatization and phobia, all subscales differed significantly in low and high EE CRIT rates. Mothers with high EE CRIT showed significantly more mental health problems in the GSI compared to mothers expressing low rates of EE CRIT (Obsessive-compulsive: F = 8.70, p = 0.005, d = 1.13; Interpersonal sensitivity: F = 13.31, p = 0.001, d = 1.35; Depression: F = 10.85, p = 0.002, d = 1.33; Anxiety: F = 8.01, p = 0.007, d = 1.12; Hostility: F = 11.39, p = 0.001, d = 1.15; Paranoia: F = 13.16, p = 0.001, d = 1.25; Psychoticism: F = 8.99, p= 0.004, d = 0.91; Global severity index: F = 12.70, p =. 0001, d = 1.61) (Figure 3).

Mediating effect

Results of the linear regression analyses revealed that children of mothers who scored higher on the GSI had a significantly higher probability of being classified as having clinically relevant externalizing behavioral problems (corrected R2 = 0.112, F = 7.04, β = 0.361, p = 0.011, d = 0.54). The direct effect of this association decreased to a statistically non-significant level (β = 0.218, p = 0.147) while accounting for EE CRIT as a mediator (corrected R2 = 0.171, F = 5.96, β = 0.310, p = 0.04, d = 0.50) (Figure 4).

Discussion

Our first study goal was to investigate whether in mothers expressing high expressed emotion criticism (EE CRIT) the mother-child interaction is negatively affected. Our data partially supported our first hypothesis, as high rates of EE CRIT were associated with more negative mother-child interactional patterns. We found that high maternal EE CRIT is related to less responsive children, indicating that these children show less willingness to touch upon communication signals sent by their mothers. This is consistent with the finding of McCarty, Lau, Valeri and Weisz [26]. In addition, overall maternal harmony and warmth was significantly lower during mother-child interactions when the mother belonged to the high EE CRIT group. Moreover, we found a trend that high rates of maternal EE CRIT have a negative effect on mothers’ sensitivity towards their children. We could not find any differences between low/high maternal EE CRIT on maternal structuring behavior or intrusiveness.

Second, we investigated whether higher rates of expressed criticism in mothers are associated with both higher rates of internalizing and externalizing child mental problems. Our second hypothesis was also supported. Children with elevated internalizing and externalizing symptoms had mothers who expressed significantly more criticism towards them. These associations are consistent with the literature on the subject [8, 9, 27, 28], and remained significant after controlling for maternal metal problems.

Additionally, we investigated whether higher rates of expressed criticism in mothers are associated with higher rates of mental problems in mothers. Our third hypothesis could also be supported by our data, as mothers with elevated psychiatric symptoms expressed significantly more criticism towards their children. Most studies examining the influence of maternal depression on EE found that high levels of maternal depression predicted high EE ratings [5, 17]. In our study, we assessed a whole range of maternal psychiatric symptoms, including symptoms of depression. Except for two subscales, all other maternal psychiatric symptoms (psychoticism, paranoia, hostility, anxiety, interpersonal sensitivity, obsessive-compulsive behavior, and psychiatric global strain) had as much influence on EE CRIT as depression symptoms did and showed large effect sizes.

Finally, our hypothesis that the association between maternal and children’s mental health problems is mediated by EE CRIT was supported only for externalizing problems, not for internalizing ones. This result is consistent with a previous finding of Nelson, Hammen, Brennan and Ullman [5]. Thus, our results also indicate that EE CRIT is more important when it comes to the extent to which children exhibit under-controlled, impulsive, rule-breaking and aggressive behavior than it is regarding internalizing problem behavior. As there is convincing evidence that a harsh and negative parenting style is a risk factor for externalizing problem behavior in children, e.g. conduct disorder [3], our results indicate that even already parental expressed emotion criticism might be considered as a risk factor for the development of externalizing behavior disorders. One possible explanation might be that the development of social norms, prosocial behavior and impulse/behavioral control in children is presumed to rather develop in social contexts of emotional learning in daily interactions. The development of internalizing symptoms might have other roots, e.g. temperamental factors as behavioral inhibition and anxious models have been discussed as main risk factors [29].

Conclusions

Some study limitations merit acknowledgement. First, the relatively small sample size limited our ability to test some more complex associations or subgroup comparisons. Replications with larger sample sizes are strongly recommended. However, as we included children’s responsiveness in an objective observational task and found significant associations with maternal EE CRIT, we can refute an exclusive maternal bias.

Nevertheless, future studies are strongly encouraged to incorporate multiple measures of child psychopathology symptoms in order to clarify the question on reports by mothers. Prospective longitudinal studies of larger numbers of children will be needed to confirm these conclusions and clarify a possible causal direction of effects.

Despite the limitations, study strengths should get some acknowledgment too. First, our findings provide new knowledge about direct associations between EE and mother-child interactional patterns using a structured and objective instrument to measure quality of mother-child-interaction. Second, we did not only focus on maternal depression but included a broad spectrum of maternal symptoms of psychopathology indicating that other mental health problems have similar associations with EE than depression does.

Finally, the findings of the study have important implications for interventions and clinical practice. Criticism should be a target of interventions, as highly critical mothers might engage in negative interactions with their child, thus contributing to the escalation of negative mother-child interactions. In this regard, results provide important knowledge regarding possible starting points for more tailored intervention programs focusing on mother-child interaction.

This work has been supported by the Young Investigators grant of the University Basel. We are indebted to the families who participated in this study.

  1. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, et al.(2014) Effects of perinatal mental disorders on the fetus and child. The Lancet. 384:1800-1819. Link: https://goo.gl/JvcSgH
  2. Reupert AE, Maybery DJ, Kowalenko NM (2013) Children whose parents have a mental illness: prevalence, need and treatment. The Medical Journal of Australia. 199:7-9. Link: https://goo.gl/HRWmJY
  3. Denham SA, Workman E, Cole PM, Weissbrod C, Kendziora KT, et al. (2000) Prediction of externalizing behavior problems from early to middle childhood: The role of parental socialization and emotion expression. Development and psychopathology. 12:23-45. Link: https://goo.gl/UMyNqm
  4. Gravener JA, Rogosch FA, Oshri A, Narayan AJ, Cicchetti D, et al. (2012) The relations among maternal depressive disorder, maternal expressed emotion, and toddler behavior problems and attachment. Journal of abnormal child psychology. 40:803-813. Link: https://goo.gl/umYMm9
  5. Nelson DR, Hammen C, Brennan PA, Ullman JB (2003) The impact of maternal depression on adolescent adjustment: The role of expressed emotion. Journal of Consulting and Clinical Psychology. 71:935. Link: https://goo.gl/KoyQmw
  6. Bolton C, Calam R, Barrowclough C, Peters S, Roberts J, et al. (2003) Expressed emotion, attributions and depression in mothers of children with problem behaviour. Journal of Child Psychology and Psychiatry. 44:242-254. Link: https://goo.gl/VJ9ZXp
  7. Brown GW, Monck E, Carstairs GM, Wing JK (1962) Influence of family life on the course of schizophrenic illness. British journal of preventive & social medicine. 16:55. Link: https://goo.gl/pSw8Rr
  8. Baker BL, Heller TL, Henker B (2000) Expressed emotion, parenting stress, and adjustment in mothers of young children with behavior problems. The Journal of Child Psychology and Psychiatry and Allied Disciplines. 41:907-915. Link: https://goo.gl/tFovoX
  9. Caspi A, Moffitt TE, Morgan J, Rutter M, Taylor A, et al. (2004) Maternal expressed emotion predicts children's antisocial behavior problems: using monozygotic-twin differences to identify environmental effects on behavioral development. Developmental psychology. 40:149. Link: https://goo.gl/Zs5K9c
  10. Musser ED, Karalunas SL, Dieckmann N, Peris TS, Nigg JT (206) Attention-deficit/hyperactivity disorder developmental trajectories related to parental expressed emotion. Journal of abnormal psychology. 125:182. Link: https://goo.gl/mQmM13
  11. Peris TS, Hinshaw SP (2003) Family dynamics and preadolescent girls with ADHD: the relationship between expressed emotion, ADHD symptomatology, and comorbid disruptive behavior. Journal of Child Psychology and Psychiatry. 44:1177-1190. Link: https://goo.gl/qwyhbp
  12. Asarnow JR, Tompson M, Woo S, Cantwell DP (2001) Is Expressed Emotion a Specific Risk Factor for Depression or a Nonspecific Correlate of Psychopathology? Journal of Abnormal Child Psychology. 29:573-583. Link: https://goo.gl/bFpBdf
  13. Rogosch FA, Cicchetti D, Toth SL (2004) Expressed emotion in multiple subsystems of the families of toddlers with depressed mothers. Development and psychopathology. 16:689-709. Link: https://goo.gl/Buqp3v
  14. Silk JS, Ziegler ML, Whalen DJ, Dahl RE, Ryan ND, et al. (2009) Expressed emotion in mothers of currently depressed, remitted, high-risk, and low-risk youth: Links to child depression status and longitudinal course. Journal of Clinical Child & Adolescent Psychology. 38:36-47. Link: https://goo.gl/WLAJqq
  15. Stern EH (2003) Expressed emotion and interaction patterns in mothers with anxiety disorders and their children. Link: https://goo.gl/sv2jYo
  16. Wedig MM, Nock MK (2007) Parental expressed emotion and adolescent self-injury. Journal of the American Academy of Child & Adolescent Psychiatry. 46:1171-1178. Link: https://goo.gl/bjjwQ8
  17. Tompson MC, Pierre CB, Boger KD, McKowen JW, Chan PT, et al. (2010) Maternal depression, maternal expressed emotion, and youth psychopathology. Journal of abnormal child psychology. 38:105-117. Link: https://goo.gl/NzMssR
  18. Achenbach TM, Rescorla L (2001) ASEBA school-age forms & profiles, Aseba Burlington, VT. Link: https://goo.gl/iCC561
  19. Spitzer C, Hammer S, Löwe B, Grabe H, Barnow S, et al. (2011) Die Kurzform des Brief Symptom Inventory (BSI-18): erste Befunde zu den psychometrischen Kennwerten der deutschen Version. Fortschritte der Neurologie· Psychiatrie. 79:517-523. Link: https://goo.gl/guQsjx
  20. Derogatis LR, Rickels K, Rock AF (1976) The SCL-90 and the MMPI: a step in the validation of a new self-report scale. The British Journal of Psychiatry. 128:280-289. Link: https://goo.gl/KhsdGK
  21. Magaña AB, Goldstein MJ, Karno M, Miklowitz DJ, Jenkins J, et al. (1986) A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry research. 17:203-212. Link: https://goo.gl/bQmGNG
  22. Magana-Amato A (1993) Manual for coding expressed emotion from the five minute speech sample. Unpublished manuscript, University of California at Los Angeles. Link: https://goo.gl/MmStk7
  23. Wolke D, Rios P, Unzer A (1995) AMCIES-Erfassung der Mutter-Kind-Interaktion mit der Zaubertafel AMCIES evaluation of mother–child interaction with the Etch-A-Sketch. Unpublished manuscript, University of Hertfordshire. Link: https://goo.gl/oVXprb
  24. Biringen Z, Robinson J (1991) Emotional availability in mother-child interactions: A reconceptualization for research. American journal of Orthopsychiatry. 61:258. Link: https://goo.gl/oh8XEJ
  25. Bowlby J, Ainsworth M, Boston M, Rosenbluth D (1956) The effects of mother‐child separation: a follow‐up study. Psychology and Psychotherapy: Theory, Research and Practice. 29:211-247. Link: https://goo.gl/To1SQk
  26. McCarty CA, Lau AS, Valeri SM, Weisz JR, (2004) Parent-child interactions in relation to critical and emotionally overinvolved expressed emotion (EE): Is EE a proxy for behavior? Journal of abnormal child psychology. 32:83-93. Link: https://goo.gl/Pj9FzN
  27. Psychogiou L, Daley DM, Thompson MJ, Sonuga-Barke EJ (2007) Mothers’ expressed emotion toward their school-aged sons. European child & adolescent psychiatry. 16:458-464. Link: https://goo.gl/L9B1TS
  28. Nelson DR (2001) Children of depressed mothers: The role of expressed emotion. UCLA. Link: https://goo.gl/9E55ko
  29. Fisak B, Grills-Taquechel AE (2007) Parental modeling, reinforcement, and information transfer: Risk factors in the development of child anxiety? Clinical Child and Family Psychology Review. 10:213-231.  Link: https://goo.gl/wu6Yo4
© 2018 Goergen SL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.