556769

research-article2014
JIVXXX10.1177/0886260514556769Journal of Interpersonal ViolenceAmmerman et al.

Article
Journal of Interpersonal Violence
2016, Vol. 31(5) 774­–791
Child Maltreatment © The Author(s) 2014
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DOI: 10.1177/0886260514556769
to CBT Treatment in jiv.sagepub.com

Depressed Mothers
Participating in Home
Visiting

Robert T. Ammerman, PhD,1

James L. Peugh, PhD,1
Angelique R. Teeters, PsyD,1
Frank W. Putnam, MD,2
and Judith B. Van Ginkel, PhD1

Abstract
Child maltreatment contributes to depression in adults. Evidence indicates
that such experiences are associated with poorer outcomes in treatment.
Mothers in home visiting programs display high rates of depression and child
maltreatment histories. In-Home Cognitive Behavioral Therapy (IH-CBT)
was developed to treat maternal depression in home visiting. The purpose
of this study was to examine the moderating effects of child maltreatment
history on depression, social functioning, and parenting in mothers
participating in a clinical trial of IH-CBT. Ninety-three depressed mothers in
home visiting between 2 and 10 months postpartum were randomly assigned
to IH-CBT (n = 47) plus home visiting or standard home visiting (SHV;

1Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine,

OH, USA
2University of North Carolina School of Medicine, Chapel Hill, NC, USA

Corresponding Author:
Robert T. Ammerman, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue,
ML3015, Cincinnati, OH 45229, USA.
Email: robert.ammerman@cchmc.org
Ammerman et al. 775

n = 46). Mothers were identified via screening and then confirmation of

major depressive disorder diagnosis. Measures of child maltreatment history,
depression, social functioning, and parenting were administered at pre-
treatment, post-treatment, and 3-month follow-up. Results indicated high
rates of maltreatment in both conditions relative to the general population.
Mixed model analyses found a number of main effects in which experiences of
different types of trauma were associated with poorer functioning regardless
of treatment condition. Evidence of a moderating effect of maltreatment
on treatment outcomes was found for physical abuse and parenting and
emotional abuse and social network size. Future research should focus on
increasing the effectiveness of IH-CBT with depressed mothers who have
experienced child maltreatment.

Keywords
postpartum depression, cognitive behavioral therapy, child maltreatment,
low income population, home visiting

Maternal depression is prevalent postpartum. In a meta-analysis, Bennett,

Einarson, Taddio, Koren, and Einarson (2004) found that between 7.4% and
12.8% of pregnant women reported significant levels of depression across
each trimester. Between 13% and 19% of new mothers develop major depres-
sive disorder (MDD) postpartum, a rate that at least doubles among mothers
at high risk due to poverty (O’Hara & McCabe, 2013). The public health
implications of maternal depression are profound given its negative impact
on maternal life course and child development, especially during the first
years of life during which foundational biological and psychological pro-
cesses occur (Goodman et al., 2011). Mayberry, Horowitz, and Declercq
(2007) found that financial hardship, age, unemployment, and educational
underachievement predicted elevated depressive symptoms over the first 2
years postpartum. Trauma history and violence are also strongly associated
with the occurrence and persistence of depression (Ammerman et al., 2009).
Child maltreatment undermines the development of emotional and behav-
ioral regulatory systems and contributes to the emergence of MDD in young
adulthood (Institute of Medicine and National Research Council, 2014).
The insidious impact of violence and maltreatment on functioning in
depressed mothers has implications for treatment. Among depressed adults,
there is a diminished response to antidepressants in those who have experi-
enced trauma (Klein et al., 2009). There is also evidence that depressed adults
who have experienced maltreatment in childhood do not benefit to the same
776 Journal of Interpersonal Violence 31(5)

extent as their counterparts when receiving cognitive behavioral therapy

(CBT; Nanni, Uher, & Danese, 2012). Yet, other research has found that child
maltreatment history does not moderate response to treatment (Harkness,
Bagby, & Kennedy, 2012).
There are few studies of child maltreatment history and treatment in peri-
natally depressed women. Grote et al. (2012) reported that child maltreat-
ment history did not moderate response to treatment in a clinical trial of
interpersonal psychotherapy in perinatally depressed women. Moreover,
much of the research on child maltreatment history and response to treatment
in depressed women has conceptualized maltreatment as a general construct,
using summative indicators rather than breaking out specific types of abuse
and neglect. Here, too, findings are mixed, with some studies showing that
adversity broadly contributes to poorer outcomes (L. R. Cohen, Hien, &
Batchelder, 2008), and others suggesting differential outcomes based on
types of maltreatment (Putnam, Harris, & Putnam, 2013).
Mothers participating in home visiting are an especially important popula-
tion in which to examine depression. Home visiting is a voluntary early pre-
vention program for mothers and children designed to optimize child outcomes
and prevent child abuse and neglect. There is increasing interest in home visit-
ing models that target demographically at risk mothers, seek to enroll mothers
during pregnancy or shortly after birth, and provide frequent services over the
first years of the child’s life (Adirim & Supplee, 2013). Mothers participating
in home visiting have high rates of depression and trauma (Ammerman,
Putnam, Bosse, Teeters, & Van Ginkel, 2010). Depression undermines home
visiting outcomes. For example, Easterbrooks et al. (2013) found that
depressed mothers failed to receive the benefits of lowered rates of abuse and
neglect relative to their nondepressed counterparts.
Ammerman et al. (2011) adapted cognitive behavioral therapy to address
depression in mothers receiving home visiting. In-Home Cognitive Behavioral
Therapy (IH-CBT) is implemented concurrently with home visiting. IH-CBT
combines the principles and techniques of CBT with strategies that promote
engagement, make content relevant to the needs of mothers in home visiting,
facilitate delivery in the home, and engender a collaborative relationship
between the therapist and home visitor. Empirical support for IH-CBT was
obtained in a clinical trial comparing mothers who received IH-CBT and con-
current home visiting with those who received home visiting alone
(Ammerman, Putnam, Altaye, Stevens, et al., 2013; Ammerman, Putnam,
Altaye, Teeters, et al., 2013). Results indicated that mothers receiving
IH-CBT were less likely to meet diagnostic criteria for MDD at post-treat-
ment, reported fewer depressive symptoms, and obtained lower scores on
clinician ratings of depression severity. Additional improvements were noted
Ammerman et al. 777

in social support and overall psychological distress. While these findings

demonstrate the benefits of treatment to mood and social functioning in
mothers in home visiting, it is unclear whether impacts were moderated by
maternal histories of child maltreatment.
The purpose of this study was to examine the moderating effects of child
maltreatment history on depression, social functioning, and parenting in
depressed mothers participating in home visiting and receiving IH-CBT treat-
ment. Specifically, new mothers enrolled in a community-based home visiting
program were identified using a two-step process comprising a screen and
subsequent confirmation of MDD diagnosis. Mothers were 16 years of age or
older and were identified at 3 months postpartum. Mothers were randomly
assigned to IH-CBT + home visiting or standard home visiting (SHV). Child
maltreatment history was measured using the Childhood Trauma Questionnaire
(CTQ; Bernstein et al., 2003). Measures of depression, social functioning, and
parenting were administered at pre-treatment, post-treatment, and 3-month
follow-up. It was hypothesized that child maltreatment history would adversely
affect depression, social functioning, and parenting over time in the control
condition but not in mothers receiving IH-CBT.

Method
Sample
Participants were 93 new mothers aged 16 or older who participated in a
home visiting program and were diagnosed with MDD. Mothers were
enrolled in Every Child Succeeds, a community-based home visiting pro-
gram serving Southwestern Ohio and Northern Kentucky (USA). Two mod-
els of home visiting were used: Nurse–Family Partnership (NFP; Olds, 2010)
and Healthy Families America (HFA; Holton & Harding, 2007). Eligibility
for the home visiting program required at least one of the following risk char-
acteristics: unmarried, low income, ≤18 years of age, inadequate prenatal
care. Mothers were enrolled in home visiting prior to 28 weeks gestation in
NFP as per model parameters and from 20 weeks gestation through the child
reaching 3 months of age for HFA. In the NFP, home visits were provided by
nurses, while in HFA, home visits were provided by social workers, related
professionals and paraprofessionals.

Design
A randomized clinical trial design was used with assessments at pre-treatment,
post-treatment, and 3-month follow-up. Participants were randomized to
778 Journal of Interpersonal Violence 31(5)

IH-CBT (IH-CBT + home visiting) or SHV (home visiting alone) following

the pre-treatment assessment. Randomization was stratified by race and
home visiting model (HFA, NFP). There were no differences in the rate and
type of maltreatment between models and the model was not significant in
the statistical models and as a result these are not shown.
Of 151 referred mothers, 115 subsequently received a pre-treatment
assessment (more detailed information about recruitment can be found in
Ammerman, Putnam, Altaye, Stevens, et al., 2013). Twenty-seven mothers
were not interested in participating after referral, and 9 mothers were unreach-
able. There were no differences between assessed and nonassessed partici-
pants on demographics or baseline clinical features. Ninety-four of 115
participants were found to be eligible. One mother was disinterested in par-
ticipating following the assessment but prior to randomization. The remain-
ing 93 mothers were randomized to IH-CBT (n = 47) or SHV (n = 46) and
comprised the intent-to-treat sample. Thirteen mothers dropped out of the
study between assessment points. There were no differences in dropout rate
between conditions, and dropout was unrelated to initial demographic and
clinical features.

IH-CBT.  Mothers in the IH-CBT condition received IH-CBT + home visiting

(see SHV condition for description). IH-CBT was implemented by two
licensed master’s level social workers. Treatment consisted of 15 sessions
that were scheduled weekly and lasted 60 min plus a booster session 1-month
post-treatment. Adaptations to CBT were made to address setting, popula-
tion, and context to maximize engagement and outcomes. First, IH-CBT was
delivered in the home. The second adaptation involved addressing the pri-
mary concerns of young, low income, new mothers who were socially iso-
lated (Levy & O’Hara, 2010). The third adaptation sought to facilitate close
collaboration with home visitors through written communication, telephone
contact, and a joint 15th session with the mother, home visitor, and
therapist.

SHV.  In SHV, mothers received services from home visitors as per the
HFA and NFP model directives. Both models call for regular home visits
during the intervals covered during the trial, and home visitors were given
discretion to increase frequency of visits if needed. Curricula for both
models are distinct but emphasize child health and development, nurturing
mother–child relationship, maternal health and self-sufficiency, and link-
age to other community services. Consistent with standard of care, moth-
ers in the SHV condition were permitted to receive treatment for depression
in the community.
Ammerman et al. 779

Measures.  The Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden,

& Sagovsky, 1987) is a 10-item self-report measure of depressive symptoms.
Items are endorsed on a four-point scale indicating occurrence and severity
over the past week, yielding a total score. The EPDS was used to screen
mothers for referral to the study using a cutoff of ≥11.
The Structured Clinical Interview for DSM-IV Axis 1 Disorders (4th ed.;
DSM-IV; American Psychiatric Association, 1994) Axis 1 Disorders (SCID,
January 2007 Version; Spitzer et al., 1992) is a semistructured psychiatric
interview that is widely used in research and clinical practice. Interviews
were audio-recorded and 25% were rated by a second rater yielding a kappa
coefficient of .89. The SCID was administered at pre-treatment to confirm
MDD diagnosis.
The CTQ (Bernstein et al., 2003) is a 28-item version of the larger CTQ.
Items describe maltreatment experiences in childhood and are endorsed on a
5-item Likert-type scale reflecting how true they are. Raw scores are derived
and these were also used to categorize (none, mild, moderate, severe) sever-
ity of physical abuse, sexual abuse, emotional abuse, physical neglect, and
emotional neglect for descriptive purposes. The CTQ was administered at
pre-treatment.
The Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown,
1996) is one of the most widely used self-report screens of depressive
symptoms, with strong reliability and validity properties. It consists of 21
items indicating presence and severity of symptoms over the past 2 weeks
by endorsing one of four statements reflecting severity, yielding a total
score. The BDI-II was administered at pre-treatment, post-treatment, and
follow-up.
The Interpersonal Support Evaluation List (ISEL; S. Cohen & Hoberman,
1983) is a widely used self-report of social support that has been utilized with
multiple clinical and nonclinical populations. This 40-item measure consists
of statements regarding the availability and use of tangible and emotional
support from others that are endorsed using a 4-point scale reflecting the
degree to which they are true. The total score was used as the primary indica-
tor in the current study and was administered at pre-treatment, post-treat-
ment, and follow-up.
The Social Network Index (SNI; S. Cohen, Doyle, Skoner, Rabin, &
Gwaltney, 1997) consists of 12 items that document the size of the moth-
er’s social network and this was used as the study variable. The social
network number (SNN) reflects the number of people (e.g., parents, close
friends, coworkers) with whom the mother has had contact in the prior 2
weeks. The SNI was administered at pre-treatment, post-treatment, and
follow-up.
780 Journal of Interpersonal Violence 31(5)

The Parenting Stress Index–Short Form (PSI-SF; Abidin, 1995) is a

36-item parent report measure of child and parent functioning/coping. This
widely used measure yields a standardized score for Total Stress. The PSI-SF
was administered at pre-treatment, post-treatment, and follow-up.
The Home Observation for Measurement of the Environment Inventory
(HOME; Caldwell & Bradley, 1984) is a standardized observational measure
of features in the home consistent with a stimulating, nurturing, and safe
environment. It yields a Total Score and was administered at pre-treatment,
post-treatment, and follow-up.

Results
Overview of Analyses
The SPSS MIXED procedure was used to examine the moderating rela-
tionship of each of the five child maltreatment categories for IH-CBT and
SHV groups across three time points. Mixed model analyses first esti-
mated fixed and random effects to determine the best descriptive form of
change over time. Analyses then estimated main effects (M) of emotional
abuse, physical abuse, sexual abuse, emotional neglect and physical
neglect, followed by the two-way interaction of maltreatment type by
time (M × T) interaction and the three-way interaction of maltreatment
type by time by condition (IH-CBT or SHV). An intent-to-treat approach
was used such that all participants were included in analyses. Missing
data were minimal (range: 0.39%-3.15%) and were handled with multiple
imputation using all analysis variables, plus an additional 185 auxiliary
correlate variables in the imputation model to produce I = 100 imputed
data sets (Enders, 2010). The False Discovery Rate (FDR; Benjamini &
Hochberg, 1995) was used to control for Type 1 error inflation across all
analyses.

Sample Characteristics and Child Maltreatment Experiences

Table 1 shows the demographics of the two groups. No differences were
found between treatment and control groups on these variables. There were
no differences between groups on the risk variables used to determine eligi-
bility for the home visiting program. In terms of home visiting model, 81
mothers were in the HFA model and 12 in the NFP model. Eighty-five moth-
ers were primiparous and 8 had more than one child (all of these were in the
HFA model). No differences were found on number of children or number of
home visits received (p > .05).
Ammerman et al. 781

Table 1.  Demographic Characteristics of IH-CBT (n = 47) and SHV (n = 46)

Participants.

IH-CBT
Condition SHV Condition

Variable M (SD) or n (%) M (SD) or n (%) t or χ2 p Value

Mother age (years) 22.4 (5.2) 21.5 (3.9) 0.9 ns
Mother race
 White 30 (63.8%) 28 (60.8%) 1.2 ns
  African American 14 (29.9%) 16 (34.8%)  
  Native American 1 (2.1%) 0 (0.0%)  
  Native Hawaiian or 1 (2.1%) 1 (2.2%)  
other Pacific Islander
 Biracial 1 (2.1%) 1 (2.2%)  
Mother ethnicity
 Latina 3 (6.4%) 4 (8.7%) 0.5 ns
 None 44 (93.6%) 42 (91.3%)  
Marital status
  Single, never married 41 (87.2%) 39 (84.8%) 1.0 ns
 Married 6 (12.8%) 6 (13.0%)  
 Separated 0 (0.0%) 1 (2.2%)  
Education (years) 11.6 (2.0) 11.3 (1.7) 1.0 ns
Income
  US$0-$9, 999 27 (58.7%) 25 (54.3%) 7.5 ns
  US$10, 000-$19,999 6 (13.0%) 13 (28.3%)  
  US$20, 000-$29, 999 10 (21.7%) 5 (10.9%)  
  US$30, 000-$39, 999 2 (4.3%) 1 (2.2%)  
  US$40, 000-$49, 999 0 (0.0%) 2 (4.3%)  
  >US$50, 000 1 (2.2%) 1 (2.2%)  
Child’s age (days) 159.8 (73.7) 146.1 (74.4) 0.9 ns

Note. IH-CBT = In-Home Cognitive Behavioral Therapy; SHV = standard home visiting.

Table 2 presents the breakout of severity of child maltreatment experience

in each group for each type of maltreatment using the four categories (none,
mild, moderate, severe). The CTQ was missing for one participant in the
SHV condition so the table reflects n = 92. Results indicate a high proportion
of child maltreatment experiences in both groups. Emotional abuse was the
most commonly reported experience, endorsed as at least mild in 80.4% of
the sample. Mothers reported high rates of severe levels of maltreatment in
both the IH-CBT (range: 14.9%-48.9%) and SHV (range: 22.2%-44.4%)
conditions.
782 Journal of Interpersonal Violence 31(5)

Table 2.  Number and Percentage in Maltreatment History Categories From

the Childhood Trauma Questionnaire in IH-CBT (n = 47) and SHV (n = 45)
Participants.

IH-CBT Condition SHV Condition

Category n (%) n (%) χ2

Emotional abuse
 None 6 (12.8%) 12 (26.7%) 3.5
 Low 12 (25.5%) 7 (15.6%)  
 Moderate 6 (12.8%) 6 (13.3%)  
 Severe 23 (48.9%) 20 (44.4%)  
Physical abuse
 None 17 (36.2%) 20 (44.4%) 0.8
 Low 8 (17.0%) 7 (15.6%)  
 Moderate 6 (12.8%) 4 (8.9%)  
 Severe 16 (34.0%) 14 (31.1%)  
Sexual abuse
 None 23 (48.9%) 21 (46.7%) 2.7
 Low 5 (10.6%) 3 (6.7%)  
 Moderate 2 (4.3%) 6 (13.3%)  
 Severe 17 (36.2%) 15 (33.3%)  
Emotional neglect
 None 7 (14.9%) 16 (35.5%) 6.3
 Low 16 (34.0%) 12 (26.7%)  
 Moderate 11 (23.4%) 5 (11.1%)  
 Severe 13 (27.7%) 12 (26.7%)  
Physical neglect
 None 21 (44.7%) 24 (53.3%) 3.0
 Low 12 (25.5%) 6 (13.3%)  
 Moderate 7 (14.9%) 5 (11.1%)  
 Severe 7 (14.9%) 10 (22.2%)  

Note. ps > .05. IH-CBT = In-Home Cognitive Behavioral Therapy; SHV = standard home
visiting.

Mixed Model Analyses

Fixed effect analysis results (not shown) showed that linear growth best
described the average form of change across participants for the HOME,
PSI-SF, and SNN response variables, while quadratic change best described
the average form of change across participants for the BDI-II and ISEL
response variables. Furthermore, the PSI-SF, ISEL, and SNN response
Ammerman et al. 783

Table 3.  Mixed Model Analyses of Types of Childhood Maltreatment From the
Childhood Trauma Questionnaire on Maternal Depression, Social Functioning, and
Parenting.
BDI-II ISEL SNN HOME PSI-SF

  b t b t b t b t b t

SA
 M 0.18 0.74 −0.67 −1.56 −0.07 −0.62 0.09 0.82 −0.15 −0.40
  M×T 0.17 1.13 0.10 0.36 −0.01 −0.19 −0.11 −1.72† 0.26 0.93
  M×T×G −0.27 −1.29 −0.01 −0.04 0.12 1.04 0.07 0.76 −0.23 −0.59
PA
 M 0.61 1.86† −1.07 −1.86† −0.38 −2.57** −0.53 −3.63** 0.20 0.38
  M×T −0.01 −0.01 0.18 0.49 0.01 0.08 0.17 1.96† −0.10 −0.28
  M×T×G −0.12 −0.47 −0.06 −0.13 0.21 1.56 −0.24 −2.06* 0.19 0.40
EA
 M 0.76 2.66** −1.31 −2.63** −0.24 −1.82† −0.34 −2.60** 0.01 0.01
  M×T −0.07 −0.39 0.17 0.55 −0.09 −0.97 0.11 1.40 −0.18 −0.55
  M×T×G −0.10 −0.40 0.20 0.45 0.29 2.22* −0.10 −0.90 0.28 0.60
EN
 M 0.41 1.34 −1.88 −3.77** −0.40 −3.00** −0.33 −2.44** 0.06 0.13
  M×T −0.06 −0.32 0.47 1.42 −0.02 −0.25 0.09 1.09 −0.33 −0.96
  M×T×G −0.09 −0.33 −0.01 −0.01 0.25 1.79† −0.03 −0.28 0.37 0.73
PN
 M 0.38 1.05 −1.66 −2.69** −0.44 −2.74** −0.33 −2.05* −0.09 −0.16
  M×T 0.08 0.35 0.67 1.72† 0.02 0.19 0.11 1.12 0.24 0.61
  M×T×G −0.63 −1.77† −0.19 −0.30 0.19 1.01 −0.04 −0.25 −0.81 −1.21

Note. BDI-II = Beck Depression Inventory–II, ISEL = Interpersonal Support Evaluation List, SNN = social
network number from Social Network Index, HOME = Home Observation for Measurement of the
Environment Inventory, PSI-SF = Parenting Stress Index–Short Form; SA = sexual abuse; PA = physical
abuse; EA = emotional abuse; EN = emotional neglect; PN = physical neglect; M = maltreatment main
effect; T = effect of time; G = group (1 = IH-CBT, 0 = SHV)
†p < .10. *p < .05. **p < .01.

variables showed significant intercept (T = 1) and linear slope variation

across participants, while the BDI and HOME response variables showed
significant intercept variation only.
Results from adding the main effects (M) for each maltreatment type, the
maltreatment by time interactions (M × T), and the maltreatment by time by
group three-way interactions (M × T × G) to each longitudinal mixed model
are summarized in Table 3. Statistically significant effects (p < .05 or .01) and
effects that approached significance (p < .10) are shown.
For sexual abuse, there were no significant main effects. There was a trend
(p < .10) for a two-way interaction between time and sexual abuse for the
HOME such that scores on this measure decreased over time across groups.
No significant three-way interactions were found.
784 Journal of Interpersonal Violence 31(5)

Main effects for physical abuse were observed with the SNN and HOME.
Mothers reporting childhood physical abuse had smaller social networks and
had lower scores reflecting nurturing and stimulating parenting. A trend (p <
.10) was found for the main effects of physical abuse on the BDI-II and ISEL.
These were in the direction of increased depressive symptoms and lower lev-
els of social support for mothers reporting higher levels of physical abuse. A
three-way interaction was observed between physical abuse, time, and group
with the HOME. Mothers in the SHV group who reported higher levels of
physical abuse had lower HOME scores at pre-treatment, and these increased
over time to reach equivalent levels as their counterparts at follow-up.
Three main effects were found for emotional abuse: BDI-II, HOME, and
ISEL. Mothers reporting histories of emotional abuse had higher levels of
depression, lower HOME scores, and reported less social support that those
without these experiences. A trend (p < .10) was found for the main effect of
emotional abuse and the SNN, reflecting decreased network size in mothers
experiencing more emotional abuse. This was further elucidated by a three-
way interaction between emotional abuse, time, and group and the SNN. This
finding is presented in Figure 1. Mothers in the IH-CBT group reporting
emotional abuse started the trial with the smallest level of social network
size, increasing over time to be equivalent to those in the treatment group
with lower levels of emotional abuse.
Significant main effects were found for emotional neglect for the ISEL,
SNN, and HOME. Mothers’ report of experiencing emotional neglect was
associated with lower levels of social support, smaller social networks, and
less nurturing and stimulating parenting. A trend (p < .10) emerged for the
three-way interaction with social network number.
For physical neglect, main effects were found for the HOME, ISEL, and
SNN. Mothers reporting this type of maltreatment had lower HOME scores,
less social support, and smaller social networks than their counterparts with
lower levels of physical neglect. A trend (p < .10) was found for the two-way
interaction between time and physical neglect on the ISEL and the three-way
interaction between physical neglect, time, and group on the BDI-II.

Discussion
This study examined the moderating influence of child maltreatment history
on response to an adapted CBT treatment for depressed mothers in home visit-
ing programs. Each type of maltreatment occurred at elevated levels relative
to the general population (Centers for Disease Control and Prevention, 2010),
especially emotional abuse, emotional neglect, and physical abuse. For a siz-
able proportion of mothers reporting child maltreatment, their experiences
Ammerman et al. 785

Figure 1.  Three-way interaction between emotional abuse, time, and condition.
Note. SNN = social network number; SHV = standard home visiting; IH-CBT = In-Home
Cognitive Behavioral Therapy.

were in the moderate and severe ranges of severity. These findings underscore
the prevalence of maternal maltreatment history in home visiting populations
(Ammerman et al., 2009), and the strong association between maltreatment
history and depression (Blackmore et al., 2013). The prominence of maltreat-
ment experiences in childhood in this population of mothers is relevant to the
presentation and course of depression and associated clinical features.
Maltreatment history was associated with depression and impaired social
functioning and parenting regardless of time or treatment condition. These
findings mirror Grote et al. (2012) who also found that maltreatment histories
did not differentiate outcomes between interpersonal psychotherapy and
untreated controls in mothers with perinatal depression. Grote et al. speculated
that their findings might be partly attributable to the lesser severity of maltreat-
ment in their sample. In the present study, however, severity levels were high,
suggesting that this aspect of maltreatment is not driving findings. Two three-
way interactions were found between maltreatment history type, time, and
786 Journal of Interpersonal Violence 31(5)

condition. One of these, involving emotional abuse, revealed that mothers

experiencing this form of abuse in childhood had greater improvements in
social network size in the IH-CBT condition relative to controls. The synergis-
tic influences of IH-CBT treatment and concurrent home visiting may have
facilitated accelerated growth of network size in these mothers. Larger social
networks provide more resources for emotional and tangible support and may
be an important buffer against recurrence of MDD (Balaji et al., 2007).
A number of main effects for maltreatment type were identified for social
support and social network. Each measure of these constructs yielded signifi-
cant coefficients for three different types of maltreatment. A fourth coeffi-
cient for each approached but did not reach statistical significance (p < .10).
The negative impact of child maltreatment in adult social functioning is well
documented (Institute of Medicine and National Research Council, 2014),
and is evident in this sample of depressed mothers. There was only one sig-
nificant main effect for depression, involving emotional abuse. In contrast,
maltreatment histories were associated with parenting deficits as measured
by the HOME Inventory. This measure reflects nurturing and stimulating par-
enting. Main effects were found for all types of maltreatment except sexual
abuse indicating that physical abuse and neglect were associated with overall
parenting deficits. No significant findings emerged for parenting stress. It
should be noted that all of the outcome variables have been found to be
related to maltreatment, and that the analytic strategy in this study sought to
characterize the influence of maltreatment on mothers already presenting
with depression. Time was not statistically significant (except in the three-
way interactions), suggesting that maltreatment history was unrelated to
course of functioning during treatment.
In terms of maltreatment type, emotional abuse, emotional neglect, and
physical abuse were most associated with impairment. The pattern of find-
ings supports the interrelatedness of maltreatment (Dong et al., 2004). Yet,
the lack of significant associations with sexual abuse and differential patterns
of results for other types of maltreatment support the value of separating
types of maltreatment. As noted by the Institute of Medicine and National
Research Council (2014), findings are mixed regarding the utility of defining
maltreatment as a global construct versus breaking out specific types of abuse
and neglect. Until this becomes more definitive, it is suggested that specific
types of maltreatment be considered separately.
IH-CBT is a promising treatment approach with a strong evidence-base
(Ammerman, Putnam, Teeters, & Van Ginkel, 2014) that joins other success-
ful efforts to treat low income, perinatally depressed women using cognitive
behavioral therapy (O’Mahen, Himle, Fedock, Henshaw, & Flynn, 2013).
However, maltreatment history in this population is associated with increased
Ammerman et al. 787

impairments in affective, social, and parental functioning relative to those

who have not experienced such childhood adversity. It is possible that
depressed mothers with significant trauma histories need more sessions,
more booster sessions, or specific treatment approaches that target trauma-
related clinical features to obtain the full benefits of treatment. Cuijpers,
Huibers, Ebert, Koole, and Andersson (2013) found that, in a meta-analysis,
more frequent sessions each week was associated with improved depression
outcomes in adults. Such an approach may also be beneficial to perinatally
depressed mothers in home visiting who have experienced maltreatment in
childhood.
The study had a number of strengths. First, the design provided a rigorous
framework within which to examine IH-CBT and the moderating impacts of
child maltreatment history. Second, depressed mothers were identified using
a standardized diagnostic interview in contrast to reliance on self-report mea-
sures that characterize much of the research on maternal depression generally
and home visiting in particular. Third, an intent-to-treat strategy was used and
retention of the sample was good. Fourth, both maternal functioning and par-
enting were considered. Fifth, two widely disseminated models of home vis-
iting were represented in the sample. Findings are generalizable to low
income, socially isolated mothers, who in turn reflect the largest population
enrolled in home visiting programs.
The study also has several limitations that warrant caution in interpreting
findings. First, the sample size was relatively small, limiting power. Second,
there was no long-term follow-up. Third, child maltreatment histories were
determined using retrospective recall. This is subject to bias, although recent
research supports the validity of such reports (Fergusson, Horwood, &
Boden, 2011). Fourth, although child maltreatment history was documented,
more recent experiences of violence were not measured. Fifth, findings may
not be generalizable to mothers with higher levels of social resources.

Conclusion
Research has documented high rates of depression in mothers participating in
home visiting, although until recently few treatment options were available.
Given the sizable public investment in home visiting, and evidence that
depression undermines important outcomes sought in these programs, identi-
fying effective treatments is imperative. IH-CBT is an adapted version of cog-
nitive behavioral therapy that is specifically designed for depressed mothers in
home visiting. Although IH-CBT is effective in ameliorating depression and
associated clinical features, this study revealed that depressed mothers who
have experienced child maltreatment display greater impairment in social
788 Journal of Interpersonal Violence 31(5)

functioning and parenting over the course of treatment when compared with
those without such experiences. Emotional abuse, emotional neglect, and
physical abuse were most related to impairments in functioning. Future
research should focus on enhancing IH-CBT to more systematically address
trauma experiences to optimize outcomes for these mothers.

Acknowledgment
The authors acknowledge the participation and support of Interact for Health, United
Way of Greater Cincinnati, Kentucky H.A.N.D.S., Ohio Help Me Grow, and www.
OhioCanDo4Kids.org.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was supported by Grant
R34MH073867 from the National Institute of Mental Health.

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Author Biographies
Robert T. Ammerman is professor of pediatrics at Cincinnati Children’s Hospital
Medical Center, University of Cincinnati College of Medicine, and scientific director,
Every Child Succeeds. His research interests include elucidating the impact of mater-
nal depression and its treatment on mother and child outcomes, and engaging fathers
in home visiting.
James L. Peugh is an assistant professor of pediatrics and quantitative psychology
with joint appointments in the Divisions of Behavioral Medicine and Clinical
Psychology and Biostatistics and Epidemiology. His primary area of research involves
the Monte Carlo testing of various cross-sectional, longitudinal, and multilevel latent
variable mixture models.
Angelique R. Teeters is a postdoctoral fellow at Cincinnati Children’s Hospital
Medical Center. Her research interests include enhancing early childhood home visit-
ing programs with a focus on maternal and infant mental health. She received an Early
Career Home Visiting Research Scholar awarded by the Home Visiting Research
Network.
Frank W. Putnam is professor of psychiatry at the University of North Carolina at
Chapel Hill. He is the former director of the Center for Safe and Healthy Children at
Cincinnati Children’s Hospital Medical Center. His current research interests include
the dissemination of prevention and treatment programs for child abuse.
Judith B. Van Ginkel is president, Every Child Succeeds, and professor of pediatrics
at Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of
Medicine. Her interests include the development of public policy to support initiatives
for women and children and the application of social enterprise in the public sector.