Accepted Manuscript

Benefits of maternal education for mental health trajectories across childhood and
adolescence

Ann-Katrin Meyrose, Fionna Klasen, Christiane Otto, Gabriela Gniewosz, Thomas

Lampert, Ulrike Ravens-Sieberer

PII: S0277-9536(18)30082-0
DOI: 10.1016/j.socscimed.2018.02.026
Reference: SSM 11634

To appear in: Social Science & Medicine

Received Date: 24 August 2017

Revised Date: 13 February 2018
Accepted Date: 23 February 2018

Please cite this article as: Meyrose, A.-K., Klasen, F., Otto, C., Gniewosz, G., Lampert, T., Ravens-
Sieberer, U., Benefits of maternal education for mental health trajectories across childhood and
adolescence, Social Science & Medicine (2018), doi: 10.1016/j.socscimed.2018.02.026.

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Running head: MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 1
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Benefits of maternal education for mental health trajectories

across childhood and adolescence

Social Science & Medicine

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Ann-Katrin Meyrose1, Fionna Klasen1, Christiane Otto1, Gabriela Gniewosz2, Thomas

Lampert3, Ulrike Ravens-Sieberer1

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1
Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical

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Center Hamburg-Eppendorf, Hamburg, Germany
2
Department of Social Monitoring and Methodology, German Youth Institute, Munich,

Germany
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3
Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
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Acknowledgements: The authors thank all children, adolescents, their parents and young
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adults who participated in the BELLA study. We are very grateful to all experts who
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supported our project, especially to Prof. Dr. Walper and Prof. Dr. Brüderl as well as the

advisory board of the EBWo project and the BELLA study group. Further, we would like to
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thank the Robert Koch Institute for their ongoing support and cooperation.
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Correspondence concerning this article should be addressed to

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1. Ann-Katrin Meyrose, Department of Child and Adolescent Psychiatry and

Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistraße 52

(Building W29), 20246 Hamburg, Germany. E-mail: a.meyrose@uke.de

2. Ulrike Ravens-Sieberer, Department of Child and Adolescent Psychiatry and

Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistraße 52

(Building W29), 20246 Hamburg, Germany. E-mail: ravens-sieberer@uke.de

Running head: MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 1
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Abstract

Rationale: Mental health problems in children and adolescents are widespread and are a

primary public health concern worldwide. During childhood and adolescence different

challenges must be met. Whether the corresponding developmental tasks can be mastered

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successfully and in a psychologically healthy manner depends on the availability of

resources.

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Objective: The aim of the current study was to examine the benefits of maternal education

on the development of mental health in children and adolescents.

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Method: Data from 2,810 participants (48.7% female, 7- to 19-years old) of the longitudinal

BELLA study (mental health module of the representative German KiGGS study) were

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analyzed from up to four measurement points (2003-2012). Individual growth modeling was
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employed to estimate the benefits of maternal education (Comparative Analysis of Social

Mobility in Industrial Nations, CASMIN) for the trajectories of mental health problems (parent-
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reported Strengths and Difficulties Questionnaire, SDQ) in children and adolescents.

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Results: Children of mothers with low education had significantly more mental health
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problems compared to children of mothers with high education. This difference due to

maternal education applied for girls as well as boys and especially for participants who did
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not live with both biological parents. Further, the difference in mental health problems due to

varying maternal education decreased with increasing age of the participants.

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Conclusion: Prevention programs should focus on children of mothers with lower education
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who additionally live in single- or step-parent families as a high-risk group. Knowledge of the

underlying mechanism between education and mental health is highly important.

Keywords: Children, adolescents, mental health, maternal education, trajectories,

longitudinal analyses, Germany

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Introduction

Improving mental health in children and adolescents is crucial for the future of our society.

Notably, mental health problems in children and adolescents are widespread and are a

primary public health concern worldwide (Barkmann & Schulte-Markwort, 2010; Wittchen et

al., 2011; World Health Organization, 2005). Moreover, mental health problems encompass

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individual and familial suffering as well as high societal costs (Olesen et al., 2012; Wittchen

et al., 2011). The onset of mental health problems is early; half of all lifetime mental disorders

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start before the age of fourteen (Kessler et al., 2005). Furthermore, mental health problems

tend to persist into adulthood (Kessler et al., 2010). From childhood and adolescence to

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adulthood different developmental challenges (e.g. puberty, identity formation) must be met.

Whether children and adolescents cope with these challenges successfully depends on the

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availability of resources. Moreover, resources can support a healthy development in children
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and adolescents even under extreme conditions such as experiencing stressful life events

(e.g,. parents’ divorce: Masten et al., 2009; Rutter, 2000). To this end, it is important to
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identify relevant resources that foster children’s and adolescents’ mental health.
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Bronfenbrenner emphasizes in his bioecological approach the important impact of the

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environment (different, complex as well as interacting contexts) on the development of

individuals across their life-span (Bronfenbrenner, 1979; Bronfenbrenner & Morris, 2006).
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Every context comprises risk as well as protective factors, which affect individual

development (Feinstein et al., 2006). Consequently, children’s development depends on their

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family environment (i.e.,family context) and on the bi-directional interaction between parents
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and their child as an important part of children’s microsystem. This interaction between the

individual (child) and the context (family) influences the health development of children

directly and indirectly. High education could be one protective aspect of the family context,

which is related to other positive family characteristics and could function as a moderator in

reducing the influence of risks (Gniewosz et al., 2018). This relationship between familiar

(educational) resources and health in children and adolescents can be described through

distal (e.g. family income, parental occupation/employment) and proximal (e.g. health
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 3
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literacy, health behavior, social resources) influencing factors (Feinstein et al, 2006;

Gniewosz et al., 2018). According to Bronfenbrenner’s bioecological approach (1979)

contexts and therefore also families, are not static but continuously developing, which is in

line with a model discussed in the research field of social inequalities under a life-course

perspective: The childhood-limited model states that the relationship between socioeconomic

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status (SES) and health is strongest in early childhood followed by a decrease in this

relationship (Chen, 2004; Chen et al., 2002). Therefore, the influence of education may

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change across childhood and adolescence. In adolescence, other contexts (e.g. peers,

school) increase their importance, so the influence of parental education (as part of the

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family context) may then decrease.

Past research mainly focused on social inequalities and monetary benefits of education

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for people’s life courses, but the benefits of child and parental education for mental health
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across childhood and adolescence remain unclear (Gniewosz et al., 2018; Oreopoulos &

Salvanes, 2011), although different meta-analyses emphasized large spill-over effects

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between education and (mental) health (e.g. Furnee et al., 2008; Hale et al., 2015). Cross-
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sectional studies concerning children’s and adolescents’ mental health problems were
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conducted comprising large samples in different European countries (Rajmil et al., 2014). All

studies consistently reported inequalities in child and adolescent mental health problems in
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regard to the degree of parental education. Children of parents with low education (a

maximum of lower secondary level) had more mental health problems compared to children
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of parents with medium (upper secondary level) and high education (university degree;
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Rajmil et al., 2014); mental health problems in children and adolescents were measured

using the parent-reported Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997).

In line with these results, further studies confirmed lower rates of mental health problems in

children and adolescents of parents with higher education. This relationship of parental

education and their children’s mental health remained even when other socioeconomic

factors (e.g. income) were taken into account (e.g. Bøe et al., 2012; Harper et al., 2002;

Reiss, 2013). In addition, low parental education (high school education or less) was related
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to the persistence of behavior disorders such as intermittent explosive-, attention-

deficit/hyperactivity-, oppositional-defiant- or conduct disorders (retrospectively assessed),

whereas other socioeconomic indicators (e.g. parental occupation, financial hardship) were

not associated with the persistence of behavior disorders (McLaughlin et al., 2011). Overall,

low SES has an impact on mental health in children and adolescents of all age groups, but

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this impact is stronger in early childhood compared to adolescence (McLaughlin et al., 2011;

Reiss, 2013). Finally, little is known about the impact of parental education on the

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development of mental health from childhood to adolescence. Several studies (e.g. Bøe et

al., 2012; McLaughlin et al., 2011; Rajmil et al., 2014) focused on the cross-sectional or

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retrospective assessment of mental health problems and parental education. To our

knowledge, large longitudinal studies on the benefit of parental education for the

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development of child and adolescent mental health over time are needed.
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The comparison of maternal and paternal education (categories from no qualification to

degree) highlights that especially lower maternal education was associated with a higher
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prevalence of mental health problems (Lewis et al., 2014). Offspring aged 12- to 24-years old
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of mothers with less than secondary education had higher risks to show a past-year
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depressive episode, whereas paternal education was not related (Park et al., 2013).

Moreover, Huisman et al. (2010) only described an association of lower maternal education
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(using a relative index) and internalizing problems in children and adolescents. For paternal

education, no association with internalizing problems in children and adolescents was found.
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Hence, it remains unclear how maternal education influences the individual development of
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mental health in children and adolescents over time.

Besides exclusive influences of maternal education on offspring’s mental health, the

combined influence of maternal education and family structure must not be ignored. Children

and adolescents in single- or step-parent families had more mental health problems

compared to children living with both biological parents (e.g. Barrett & Turner, 2005; Bramlett

& Blumberg, 2007; Carlson & Corcoran, 2001; Hölling & Schlack, 2008). Importantly, the

same studies demonstrated that more mental health problems occurred in children and
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adolescents in single- or step-parent families, especially in combination with socioeconomic

disadvantages (i.e.,low financial, occupational or educational resources). The benefits of

maternal education for the development of mental health in childhood and adolescence and

its protective role in single- or step-parent families remain unclear.

In addition, it is important to consider potential influences of sociodemographic variables

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of the child (e.g. age, gender) as well as characteristics of the family (e.g. maternal age,

maternal mental health problems) on child and adolescent mental health and/or maternal

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education. Concerning gender- and age-specific differences, two studies compared

trajectories of mental health problems in girls and boys over time. First, Costello et al. (2011)

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reviewed both longitudinal and cross-sectional studies reporting prevalence rates of

psychiatric disorders in childhood, adolescence, and early adulthood. Recently, Klasen et al.

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(2016) investigated four specific psychiatric disorders using questionnaire data of the
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German longitudinal BELLA study. Both studies demonstrated similar trajectories: Roughly

summarized, most externalizing mental health problems decreased from childhood through
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adolescence and early adulthood for both girls and boys. On average, boys had higher
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externalizing mental health problems compared to girls. In contrast, most internalizing mental
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health problems increased from childhood to adolescence, particularly for girls (Costello et

al., 2011; Klasen et al., 2016). The association with education was not investigated.
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Additionally, it is important to keep other family-characteristics in mind, which are at least

partly associated with both maternal education and mental health problems in children and
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adolescents, to investigate the independent effect of maternal education on offspring’s

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mental health. For this reason, family income (e.g. Bøe et al., 2012; Rajmil et al., 2014;

Reiss, 2013), maternal employment (e.g. Reiss, 2013) , maternal age (e.g. Fergusson et al.,

2008; Plass-Christl et al., 2017), maternal mental health problems (e.g. Plass-Christl et al.,

2017; Siegenthaler et al., 2012), the ethnic group/migration background (e.g. Luo & Waite,

2005; Nguyen et al., 2007) as well as the community size/urbanity (e.g. Peen et al., 2010;

Zijlema et al., 2015) should be considered in such analyses.

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In summary, there is a paucity of systematic longitudinal analyses investigating the

benefits of maternal education for the trajectories of mental health problems across the entire

childhood and adolescent period. Whilst some research has been carried out on the

development of mental health problems in children and adolescents as well as on the

benefits of parental education separately, the interdisciplinary investigation (medicine,

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psychology, educational science, life course research) of both is still lacking. Therefore, we

address the following three research questions: (i) Do children and adolescents benefit from

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maternal education in terms of the trajectories of their mental health problems? (ii) Do

trajectories grouped by maternal education differ between girls and boys as well as between

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different age groups? (iii) Does high maternal education reduce the disadvantages in step-

and single-parent families in terms of children’s and adolescents’ mental health problems

compared to two-biological-parent families?

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Method
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Study Design and Sample

The presented analyses are part of a German governmental initiative to promote research
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about education and its potentially non-monetary benefits. Within this framework the
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collaborative research project Benefits of education for the well-being of parents, children,

adolescents and young adults (EBWo) is supported by the German Federal Ministry of
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Education and Research and directed by the German Youth Institute in cooperation with the

University Medical Center Hamburg-Eppendorf and the Ludwig Maximilian University of

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Munich. The EBWo project focusses systematically on the non-monetary benefits of

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education, such as the various aspects of health and well-being in children, adolescents, and

young adults taking into account the life-courses and key transition stages. Research issues

are investigated by means of secondary analyses of longitudinal data from large panel

studies. For further information about the project EBWo, see Gniewosz et al. (2018) and

www.dji.de/ebwo.

The analyses presented in this study are based on the longitudinal BELLA study as the

mental health module of the representative German National Health Interview and
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 7
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Examination Survey among children and adolescents (KiGGS; Kamtsiuris et al., 2007; Lange

et al., 2014). Data from 2,810 participants of the population-based BELLA study aged

between 7 and 19 years from up to four measurement points were analyzed to estimate the

benefits of maternal education for the trajectories of mental health problems in children and

adolescents. Parent-reports on their children’s mental health were chosen due to the

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availability for the total baseline sample and the coverage of the maximum age range. Data

were collected by computer-assisted telephone interviews and subsequent questionnaires at

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the baseline assessment (2003-2006), 1-year follow-up (2004-2007), 2-year follow-up (2005-

2008) and 6-year follow-up (2009-2012). All participants were recruited at the baseline

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assessment (aged 7-17 years) and participated in up to three additional measurement points.

Of the 2,810 participants in the presented analyses, 2,803 had valid data at baseline

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(99.8%), 2,157 at the 1-year follow-up (76.8%), 2,089 at the 2-year follow-up (74.3%) and
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775 at the 6-year follow up (56.1% of the potentially eligible sample due to the age

restriction). The reduced sample size at the 6-year follow-up is caused by the fact that
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parent-reports of the SDQ were only collected for participants aged 7 to 17 years; moreover,
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participants had to consent twice to participate in the last measurement point for the first time
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(for KiGGS and BELLA each) due to new German data protection regulations (for more

information see Ravens-Sieberer et al. 2015). In total, 7,824 measurements could be

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included across all measurement points. Previous drop-out analyses revealed that at all

measurement points, participants with lower SES or migration background were significantly
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less likely to follow-up compared to participants with higher SES or non-migrants. However,
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drop-out status (at any follow-up) was neither significantly associated with gender,

community size, region, nor parent-reported general health or parent-reported mental health

problems in children and adolescents at baseline (Ravens-Sieberer et al., 2015). Prior to

study inclusion, families had to give their written informed consent to participate in the BELLA

study. The approval for the BELLA study was obtained from the Federal Commissioner for

Data Protection in Germany. For further details on the design and methods (e.g. sampling

procedure, response analyses, and incentives) of the BELLA study, see Ravens-Sieberer et
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al. (2015). In the current analyses, data of children and adolescents were included if

participants met four criteria: i) participated in the baseline assessment, ii) were 7 to 17 years

old at baseline, iii) lived together with at least one biological parent and iv) had valid data on

mental health problems on at least one measurement point of the BELLA study.

Consequently, more than 98% of the original baseline survey sample could be analyzed.

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Measures

Mental health problems in children and adolescents were measured with the parent-

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reported Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997). The SDQ provides

the Total Difficulties score that ranges from 0 to 40 and is calculated by gathering all 20 items

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of the subscales emotional symptoms, peer related problems, conduct problems and

hyperactivity/inattention (www.sdq.org). All items refer to the last six months and three

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response options are offered (0 = not true to 2 = certainly true). Higher scores indicate more
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severe mental health problems. In the current sample, internal consistencies for all

measurement points were between Cronbach’s α = 0.68 and α = 0.73. In general, the SDQ is
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an established, reliable, and valid measure (Goodman, 2001). Additionally, an item response
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theory approach confirmed the psychometric properties of the Total Difficulties Score using
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parent-reported data and recommended its application for screening purposes in particular

(Keller & Langmeyer, 2017).

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Maternal education was operationalized by the CASMIN (Comparative Analysis of Social

Mobility in Industrial Nations) classification of education (Brauns et al., 2003) indicated by

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parent-reports at the baseline assessment. The CASMIN classification is an international

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comparable measurement instrument and one of the most widely used tools for educational

attainment. It enables the differentiation of the three levels of education: low (primary),

medium (secondary), and high (tertiary).

Further, the following information assessed at baseline are included: children’s and

adolescents’ gender, age at baseline (in years), family structure, maternal age (in years),

maternal employment, family income (in Euro), migration background as well as community

size (rural, small-town, medium-sized town, metropolitan). Maternal mental health problems
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were measured at all measurement points. Family structure was dichotomized into living with

both biological parents versus not. The latter category includes all children living in single-

parent-families (with their mother or father only) or in step-parent families (with their mother

and partner or father and partner). Maternal employment was categorized into the three

groups unemployed, released from work (e.g. due to parental leave, retirement, study), and

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employed (reference category). Family income was determined by families’ approximate

monthly net equivalent income. For the purpose of this study, the net income was adjusted

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for household size and age-specific needs of household members (Organisation for

Economic Cooperation and Development, OECD-modified equivalence scale: head of

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household = 1, additional adult household members = 0.5, children = 0.3). Maternal mental

health problems were measured with the German translation of the Symptom-Checklist Short

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version (SCL-S-9), a short form of the Symptom-Checklist-90-R (Klaghofer & Braehler, 2001;
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Prinz et al., 2013). The SCL-S-9 is a frequently applied screening instrument that covers

different dimensions of mental health problems in adults (i.e., somatization, obsessive-

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compulsive, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety,

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paranoid ideation, psychoticism). All items refer to the previous week and five response
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options are offered (0 = none at all to 4 = very severe). Higher total scores over all nine items

of the SCL-S-9 indicate more severe psychopathological symptoms. In the current sample,
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internal consistencies for all measurement points were between Cronbach’s α = 0.82 and α =

0.87. Migration background was assessed taking into account the child’s and both parents’
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countries of birth and the citizenship of the parents. Migration background was given, if i) the
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child or adolescent him- or herself immigrated from another country to Germany and had at

least one parent who was not born in Germany, or if ii) at least one of his or her parents

immigrated from another country and did not hold German citizenship.

Statistical Analyses

Data were analyzed by means of individual growth modeling. A linear mixed model served

to investigate effects of predictors on the course of mental health problems in our sample

over time (Field, 2013; Heck et al., 2013; Raudenbush & Bryk, 2002). In the main analyses,
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 10
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we followed a four-stage approach. First, we calculated the null-model (which includes no

predictors and therefore, only intercepts) to determine an estimate of the intra-class

correlation (ICC), the Akaike information criterion (AIC) and the -2 log-likelihood statistic. The

ICC indicates the variance in the outcome, which can be explained by differences between

the investigated subjects. The AIC and the -2 log-likelihood statistics describe the model fit.

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Second, we added a linear time variable (individual information about the intervals between

measurement points) as level-1-predictors to the null-model representing the outcome

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changes. Third, the level-2-predictors (only assessed at baseline) gender, age, maternal

education, and family structure (living with vs. without both biological parents) were included

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in the model. Simultaneously, we controlled for maternal mental health problems (assessed

over time), maternal age, maternal employment (unemployed, released from work,

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employed), equivalent family income (in 100€), migration background, and community size
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(rural, small-town, medium-sized town, metropolitan). Fourth, we added interaction terms to

our model in order to consider gender-, age-, and maternal education-specific trajectories
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and to investigate moderator effects concerning maternal education (time × gender, time ×
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age, time × gender × age, time × maternal education, gender × age, gender × maternal
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education, age × maternal education, family structure × maternal education).

All predictors and interactions were included as fixed effects, which describe the
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corresponding averaged effects of the total sample. The time variable served additionally as

a random effect to represent differences between individuals (variances of fixed effect). The
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metric predictors age, maternal age, and equivalent family income were centered using the
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sample’s grand mean. Prior to model calculations, we replaced missing data of predictors

and control variables using the Expectation-Maximization (EM) algorithm to include all cases

(N = 2,810). Missing values were below 2% for all predictors. Individual growth modeling

uses full information maximum likelihood; therefore, the outcome variable could be kept

unchanged (Field, 2013; Heck et al., 2013). To evaluate the model fit, the AIC (smaller

values indicate better model fit) as well as the difference in the -2 log-likelihood of the null

and the final model (χ2 Difference Test) were compared. We roughly evaluated the strength
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of significant effects by using McFadden’s R2 (McFadden, 1974) based on the log-likelihood

estimates of the final model and the final model without the predictor in question. In addition,

sensitivity analyses were computed to test the robustness of results (i. with vs. without

missing imputation; ii. parent- vs. self-reported mental health problems; iii. living together with

both biological parents vs. living in single-parent-families vs. living in step-parent-families).

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Graphic representations visualize the trajectories of mental health problems across the four

measurement points for groups according to levels of maternal education using the

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estimated marginal means of the final mixed model. Graphs were smoothed by local

polynomial regression. All analyses were computed using IBM SPSS Version 22 and R

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Version 2.15.3 (package ggplot2).

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ANResults

To investigate the benefits of maternal education for the trajectories of mental health

problems in children and adolescents, we analyzed longitudinal data of 2,810 participants

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(48.7% female) of the BELLA study from up to four measurement points. At the baseline

assessment, participants were between 7 and 17 years old (M = 12.23, SD = 3.15). Overall,
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most participants lived together with both biological parents (76.7%), the remaining
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participants lived together with their mother only (12.2%), with their father only (0.9%), with

their mother and her partner (9.6%) or with their father and his partner (0.5%). Further
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descriptive statistics of baseline sample characteristics and predictors are displayed in Table

1. Additionally, Table 2 contains information on the mental health problems in children and
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adolescents as well as in mothers for all measurement points. In general, missing values
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were below 2% for all baseline predictors.

>> Please insert Table 1 and Table 2 here. <<

Trajectories of Mental Health Problems Differ Between Individuals

Following our stepwise approach, the estimation of the null-model (AIC = 43,993) revealed

an ICC of .71 indicating that 71% of the variance in the outcomes could be explained by

differences between the investigated subjects. The calculation of a mixed model was

necessary. The model fit of the final model (AIC = 42,419) was significantly improved
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compared to the null model by adding the level-1- and level-2-predictors as well as

interaction terms; ∆χ2(29, 2,810) = 1,631.61, p ≤ .01.

The final model of the individual growth trajectories of parent-reported mental health

problems in children and adolescents (see Table 3 for all estimates and 95% confidence

intervals) revealed a significant fixed intercept but no main linear time effect. Besides fixed

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effects, our model includes a significant random intercept as well as a significant random

linear slope. In addition, the random intercept and the random linear slope interacted: as the

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intercept increased, the slope decreased. Consequently, the starting points as well as the

development of mental health problems over time differed between individuals.

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Trajectories of Mental Health Problems Differ between Girls and Boys

Overall, trajectories of mental health problems differed between girls and boys. Parents

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reported for boys higher mean SDQ Total scores at baseline (∆1.51 points) and a stronger
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linear decrease over time (∆0.24 points per year) than for girls. In addition, boys showed

(compared to girls) a smaller linear decrease of mental health problems over time the older
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they were, however, this threefold interaction of gender, age and linear slope did not reach
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significance (p = .061).
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Children and Adolescents Benefit from High Maternal Education

Mean trajectories of children’s and adolescents’ parent-reported SDQ Total scores

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differed depending on their mother’s level of education (see Table 3 and Figure 1 for mean

trajectories across the four measurement points). Our results demonstrate that children of
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mothers with low education had significantly higher mean SDQ Total scores compared to
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children of mothers with high education (∆1.02 points). In contrast, the development over

time did not depend on their mother’s education (interaction of time and maternal education).

Moreover, girls as well as boys seem to benefit equally from maternal education according to

the evaluation of their mental health by their parents. Regarding an age-specific effect of

maternal education, an interaction was found: The difference in SDQ Total scores between

children and adolescents with varying maternal education decreased the older the children

and adolescents were (see Table 3; for the interested reader see Figure A in the supplement
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material). The inclusion of time invariant and variant control variables, which might be

associated with maternal education and mental health problems in children and adolescents,

allowed the identification of an independent influence of maternal education on children’s and

adolescents’ mental health. Overall, the model fit improved most by including maternal

mental health problems (McFadden’s R2 = .02) and less by including the other predictors

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(McFadden’s R2 ≤ .01).

Children’s and Adolescents’ Mental Health Problems Depend on Maternal Education

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and Family Structure Interaction

The varying amount of mental health problems due to maternal education applied

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especially for children and adolescents who did not live with both biological parents. In our

final model, no disadvantage existed for children who lived in single- or step-parent families,

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but in combination with low maternal education parent-reports revealed considerably higher
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mean SDQ Total scores for those children compared to children of mothers with high

education (∆2.94 points). The same was shown for children of mothers with medium
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compared to high education (∆1.82 points).

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>> Please insert Table 3 here. <<

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>> Please insert Figure 1 here. <<

Sensitivity Analyses
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To test the robustness of our presented results three deepening sensitivity analyses were

computed (results not presented in detail). First, the comparison of analyses with and without
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missing data imputation confirmed our results. The effects of maternal education on
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trajectories of mental health problems in children and adolescents remained significant and

roughly equal.

Second, self-reported SDQ Total scores (available for 11- to 19-year-olds) were used

instead of parent-reported SDQ Total scores to operationalize mental health problems in

children and adolescents. In line with the results of our main analyses, children of mothers

with low education had significantly higher mean self-reported SDQ Total scores compared

to children of mothers with high education (∆1.42 points, 95% confidence intervals
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 14
ACCEPTED MANUSCRIPT
[0.44;2.39]). The interaction of maternal education and family structure also revealed similar

effects and significance using self- instead of parent-reported mental health problems (∆1.88,

[0.61;3.15] and ∆1.30 points [0.22;2.38] for low vs. high and medium vs. high education,

respectively).

Third, we compared children living with both biological parents to those living in single-

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parent-families and to those in step-parent families. Both children living in single- as well as

in step-parent families had higher mean parent-reported SDQ Total Scores in combination

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with low maternal education compared to high maternal education. In step-parent families,

children of mothers with low compared to high education had the highest mean SDQ Total

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scores (∆3.65 points, [1.80;5.50]), followed by children of mothers with medium compared to

high education (∆2.05 points, [0.44;3.66]). In single-parent families, also children of mother

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with low compared to high education had increased mean SDQ Total scores (∆2.39 points,
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[0.81;3.97]), followed by children of mothers with medium compared to high education (∆1.61

points, [0.25;2.97]).
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Further, no cohort effects existed for the total sample as well as for girls. However, a
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cohort effect was found for boys (η = .016; F(20) = 2.156, p = .002) but these differences
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between cohorts were small, according to Cohen (1988).

Discussion
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The present study aimed to investigate the benefit of maternal education on mental health

trajectories in girls and boys across childhood and adolescence. Overall, maternal education
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was positively associated with mental health in both girls and boys. Children of mothers with
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high education had less mental health problems compared to children of mothers with low

education. Consequently, we understand decreased mental health problems in children and

adolescents as a non-monetary benefit of maternal education. Maternal education seems

especially important for children’s and adolescents’ mental health in single- and step-parent

families.

In general, boys showed more mental health problems compared to girls. However, boys

experienced a decrease in mental health problems over time, whereas girls did not. These
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 15
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results are in line with previous studies using data on specific mental health problems in the

BELLA study (Klasen et al., 2016) as well as in the large review by Costello et al. (2011).

Both demonstrated that boys show more externalizing mental health problems, which

decrease as they get older, whereas girls suffer increasingly from internalizing mental health

problems as they get older. Furthermore, not only were gender-specific differences in

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trajectories of mental health problems demonstrated in our analyses, but also differences

between individuals. Children and adolescents differed from each other concerning their

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starting points as well as their development of mental health problems over time. Mean

values are insufficient to describe children’s and adolescents’ mental health and the use of

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mixed models is necessary to allow fluctuations in individual trajectories.

Our finding demonstrates that children and adolescents benefit from maternal education in

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regard to their mental health and strengthens the results of previous cross-sectional studies
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(e.g. McLaughlin et al., 2011; Rajmil et al., 2014). In addition, to the best of our knowledge,

this study presents the first evidence of benefits of maternal education for trajectories of
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mental health problems across childhood and adolescence based on longitudinal data.
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These benefits of maternal education apply for both parent- as well as self-reported mental
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health problems in children and adolescents. To investigate the independent benefit of

maternal education for offspring’s mental health we considered important family-

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characteristics related to maternal education in our analyses (Table 3). Hence, we controlled

the influences of maternal mental health problems, maternal age, maternal employment,
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family income, migration background as well as community size and demonstrated an

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independent benefit of maternal education for girls’ and boys’ mental health over time.

Overall, maternal mental health problems were the most important influencing factor to

predict children’s and adolescents’ mental health problems over time.

Our results indicate a stronger influence of maternal education on children’s compared to

adolescents’ mental health problems (Supplement Material, Figure A). In the presented

analyses, parent-reports on their children’s mental health problems in relation to the levels of

maternal education seem to converge with increasing age of children and adolescents. This
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 16
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age-trend has already been discussed for the influence of a low SES (McLaughlin et al.,

2011; Reiss, 2013) and fits well to the childhood-limited model proposed by Chen et al.

(2002). Authors suggested that factors during early childhood (e.g. attachment to the mother,

housing conditions) play an important role in explaining the relationship between maternal

education and mental health problems (Chen, 2004). Another explanation could be that

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children’s and adolescents’ own education becomes more important with increasing age,

whereas maternal education becomes less important. In this regard, Ditton (2013) described

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that parental education predicts children’s education due to an accumulation of educational

resources. Similarly, other studies investigating benefits of education in different

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developmental phases offer evidence for this shift (Bauldry et al., 2012; Heckman, 2006;

Sheikh et al., 2014). According to Bronfenbrenner’s bioecological approach (1979) the

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transition from childhood to adolescence is accompanied by changing contexts. School and
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peers become more important (Steinberg, 2005), which potentially results in the decreasing

influence of maternal education.

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The investigated sample of children and adolescents covered a wide age range (7- to 19-
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years old). This allowed us to investigate associations between maternal education and
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mental health problems across the whole period of childhood and adolescence. However, we

did not explicitly consider the measurement invariance of the analyzed measures across age
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or gender in our study. Findings and focus of investigations in studies on measurement

invariance of the parent-reported SDQ are heterogeneous so far (e.g. He et al., 2013;
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Niclasen et al., 2013). For 9- to 12-year-olds, Stone et al. (2013) found configural, scalar, and
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metric invariance across gender and maternal education. For 13- to 18-year-olds He et al.

(2013) showed a satisfactory fit of the factor structure provided and evidence that the parent-

report of the SDQ was invariant across gender, age, race/ethnicity, and groups with different

family income. However, Niclasen et al. (2013) could not conform measurement invariance of

parent-reported SDQ scores across age for 5- to 7- versus 10- to 12-year-olds. Future

research should focus more on the investigation of measurement invariance across relevant
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 17
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subgroups for well-established measures, especially to support longitudinal analyses based

on large survey data.

Concerning the interaction of maternal education and family structure our sensitivity

analyses imply that high maternal education protects children’s and adolescents’ mental

health in single- as well as step-parent families. In step-parent families this protective role

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seems to be most important. Thus, maternal education functions as a moderator. It is

possible that mothers with high education handle challenges in single and step-parent

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families superiorly due to higher competences (e.g. coping strategies, communication skills)

and better living conditions (e.g. larger networks, financial resources). In general, previous

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research showed that children and adolescents living in single- or step-parent families had

more mental health problems compared to children living with both biological parents (e.g.,

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Barrett & Turner, 2005; Bramlett & Blumberg, 2007; Carlson & Corcoran, 2001; Hölling &
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Schlack, 2008). Our results highlight the important interaction of maternal education and

stressful life circumstances (i.e.,parental divorce, loss of a parent, single parenthood) across
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the entire childhood and adolescent period. Children and adolescents of mothers with only
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low education and who are living without both biological parents have a special need for
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prevention.

Especially for prevention, the knowledge of underlying mechanisms between parental

EP

education and mental health in children and adolescents is highly promising in order to

promote children’s and adolescents’ mental health. Our results demonstrated the important
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role of maternal education, besides maternal mental health, for children’s and adolescents’
AC

mental health. However, it is not feasible or preferable to conclude that all females have to

reach high education. One of the key questions is which skills, competences, and family

characteristics are strengthened by education and which promote (mental) health in children

and adolescents simultaneously. Initial approaches have already illustrated some potential

mediators, for example parental emotional well-being and parenting practices (Bøe et al.,

2014), health behavior (Bauldry et al., 2012) or parental and own health literacy (Braveman

et al., 2011; Low et al., 2005; Mirowsky & Ross, 2003). Following Oreopoulos and Salvanes
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 18
ACCEPTED MANUSCRIPT
(2011) schooling helps people to make better decisions about health, marriage, and

parenting as well as improves trust and social interaction in general. According to

Bronfenbrenner (1979), it can be assumed that certain mechanisms are important in different

developmental phases. In childhood, the family context (e.g. parental mental health, family

climate) is especially relevant, whereas in adolescence the school and peer contexts (e.g.

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social support) increase in importance. Thus, only general conclusions can be drawn

regarding the underlying mechanisms between parental education and mental health in

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children and adolescents, though this knowledge is substantial for the development of

prevention and intervention programs.

SC
Taken together, our present study investigated for the first time benefits of maternal

education for trajectories of mental health in children and adolescents from Germany across

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the entire childhood and adolescent period. Individual growth modeling was applied in a large
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population-based longitudinal sample representative for children and adolescents resident in

Germany and having a command of the German language. Internationally established

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instruments were used to operationalize our main concepts (i.e., mental health problems in
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children and adolescents as well as maternal education). Our results confirm previous
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findings as well as contribute additional knowledge concerning the connection of education

and mental health and conclusions for clinical practice (e.g., prevention programs).
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Additionally, further research questions have been raised. The knowledge of underlying

mechanisms between maternal education and offspring’s mental health trajectories is

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especially crucial. We will address this issue in our next analyses to investigate a hypothesis-
AC

based explanatory model.

Limitations

Despite these strengths, some limitations should be considered. It is beyond the scope of

this study to examine differentiated information about education. It is a simplified assumption

to operationalize maternal education by school graduation and vocational qualifications.

Future studies may wish to define and analyse this construct in a more detailed fashion and

to differentiate between maternal, paternal, and parental education and its specific
MATERNAL EDUCATION AND OFFSPRING’S MENTAL HEALTH PROBLEMS 19
ACCEPTED MANUSCRIPT
characteristics. The shift of importance from parental to own education should also be

investigated, which was implied by our results as well as by those of previous studies.

Moreover, maternal education may have an impact on the way mothers rate their children’s

mental health. To address this question, we conducted sensitivity analyses and we confirmed

the beneficial effect of maternal education on mental health in children and adolescents

PT
using self-reported mental health data. Future studies may wish to investigate the

association of other maternal characteristics (e.g., intelligence, executive function,

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temperament) with mental health in children and adolescents, which could not be considered

in the current study.

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Conclusions

Prevention programs should strengthen and mobilize educational resources among other

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familial resources, especially in single- or step-parent families with less education as a high-
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risk group - best at an early stage. Special examples focusing on parental education are two-

generation programs helping parents to extend their education to promote their children’s
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healthy development (Kaushal, 2014). Future investigations of underlying mechanisms

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between education and mental health are crucial for the successful development of
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prevention programs as well as for clinical practice. Finally, the connection between

education and (mental) health is not only worthy of improvement in research but also
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concerning politics. Additional to findings of this study, meta-analyses emphasize spill-over

effects between education and (mental) health (e.g., Furnee et al., 2008; Hale et al., 2015),
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but public policies as well as many research strategies tend to be highly compartmentalized.
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A widespread example is the division between the Ministries of Education, which is

responsible for all educational concerns, and the Ministries of Health, which deals with all

questions concerning healthcare and well-being. To conclude, we recommend more

comprehensive and integrated research, policy approaches, and prevention programs to

education and (mental) health to make substantial improvements - especially to foster our

children’s and adolescents’ healthy development.

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Tables and Figures

Table 1

Baseline characteristics of the study population

BELLA sample (N = 2,810)

a
n valid % M (SD)
Gender 2,810
Male 1,441 51.3

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Female 1,369 48.7
Age (years) 2,810 12.23 (3.15)
Maternal education 2,775
Low 616 22.2

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Medium 1,723 62.1
High 436 15.7
Family structure 2,810
With both biological parents 2,156 76.7

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b
Without both biological parents 654 23.3
Maternal age (years) 2,783 39.83 (5.35)
Maternal employment
Unemployed 272 9.8

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Released from work 530 19.1
Employed 1,979 71.2
AN
Family income (€/month) 2,792 1,166.97 (583.31)
Migration background 2,809
Yes 268 9.5
No 2,541 90.5
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Community size 2,810

Rural 680 24.2
Small-town 711 25.3
Medium-sized-town 758 27.0
D

Metropolitan 661 23.5

Note. a Missing values were given for n = 35 for maternal education, n = 27 for
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maternal age, n = 29 for maternal employment, n = 18 for family income and n = 1 for
migration background.
b
Living with only the biological mother/father (single-parent family) or living with the
biological mother/father with her/his new partner (step-parent family).
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Table 2

Mental health problems in children and adolescents as well as in mothers for each
measurement point

Baseline 1-year follow-up 2-year follow-up 6-year follow-up

a b
Mental health n 2,803 2,157 2,089 775
problems (SDQ M 8.07 7.57 7.37 7.30
Total Score) SD 5.27 5.25 5.10 4.58

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Maternal mental n 2,488 1,966 1,924 615
health problems M 5.37 5.23 4.48 4.83
(SCL-S-9) SD 4.68 4.64 4.41 4.65

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Note. SDQ = Strengths and Difficulties Questionnaire (Goodman, 1997), SCL-S-9 = Symptom-
Checklist Short version (Klaghofer & Braehler, 2001; Prinz et al., 2013).
a b
n = 18 were censored due to age. The reduced sample size at the 6-year follow-up of n = 775 is
due to the fact that parent-reports of the SDQ were only collected for participants aged 7 to 17

SC
years, thus n = 636 were censored due to age.

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Table 3
Trajectories of mental health problems in children and adolescents (parent-reports)

Mental health problems

(parent-reported SDQ Total Score,
range: 0-40)
Estimate 95% CI
Fixed Effects
Intercept 6.14*** 5.41;6.87
Slopes Time (years, linear) -0.04 -0.16;0.09

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Predictors
Gender (male) 1.51*** 0.71;2.32
Age B0 (years, centered) -0.02 -0.16;0.12
a
Maternal education (CASMIN)

RI
Low 1.02* 0.15;1.89
Medium 0.27 -0.45;0.99
Family structure (without both biological parents) -0.54 -1.54;0.46

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Interactions
Time × gender (male) -0.24*** -0.35;-0.12
Time × age B0 -0.02 -0.04;0.01
Time × gender (male) × age B0 -0.03 -0.07;0.00
Time × maternal education

U
Low -0.08 -0.23;0.08
Medium -0.06 -0.18;0.06
AN
Gender (male) × age B0 -0.06 -0.17;0.05
Gender (male) × maternal education
Low 0.14 -0.90;1.18
Medium -0.48 -1.36;0.40
M

Age B0 × maternal education

Low -0.18* -0.34;-0.02
Medium -0.09 -0.23;0.05
Family structure (without both parents) × maternal education
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Low 2.94*** 1.67;4.21

Medium 1.82** 0.72;2.91
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Control variables
Maternal mental health (SCL-S-9) 0.17*** 0.15;0.19
Maternal age B0 (years, centered) -0.08*** -0.11;-0.05
b
Maternal employment B0
Unemployed 0.96** 0.39;1.53
EP

Released from work -0.15 -0.56;0.26

Family income B0 (in 100€, centered) -0.08*** -0.11;-0.05
Migration B0 (yes) 0.50 -0.06;1.06
Community size B0
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Rural -0.79*** -1.26;-0.33

Small-town -0.76** -1.21;-0.30
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Medium-sized town -0.31 -0.76;0.13

Random Effects
Intercept 16.43*** 15.33;17.61
Slope Time (years, linear) 0.15*** 0.10;0.22
Covariance Intercept × time (linear) -0.73*** -0.95;-0.51
Residuum 7.26*** 6.93;7.60
Model fit ICC null-/final model .71 / .69
AIC null-/final model 43,993 / 42,419
2
-2 log-likelihood difference test ∆χ (29, 2,810) = 1,631.61, p ≤ .01
Note. Individual growth modeling, N=2,810, 7- to 19-year-olds, baseline assessment 2003-2006 (B0), CI =
confidence interval, SCL-S-9 = Symptom-Checklist Short version (Klaghofer & Braehler, 2001; Prinz et al.,
2013), ICC = intra-class correlation, AIC = Akaike information criterion.
a b
reference group = high maternal education (CASMIN) reference group = employed
*** p ≤ .001 ** p ≤ .01 * p ≤ .05
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(T0) (T1) (T2) (T6)
Figure 1. Mean trajectories of children’s and adolescents’ mental health problems (parent-
reported SDQ Total Difficulties score) for low, medium, and high maternal education across
M

the four measurement points (error bars representing 95% confidence intervals)
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Acknowledgements

The authors thank all children, adolescents, their parents and young adults who participated in the
BELLA study. We are very grateful to all experts who supported our project, especially to Prof. Dr.
Walper and Prof. Dr. Brüderl as well as the advisory board of the EBWo project and the BELLA study
group. Further, we would like to thank the Robert Koch Institute for their ongoing support and
cooperation.

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Research highlights

• High maternal education is related to better mental health in both girls and boys.

• The effect of maternal education on mental health is stronger at younger ages.

• Children in single/step-parent families benefit even more from maternal education.

• Prevention programs may benefit from these findings.

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• Future research on underlying mechanisms is needed.

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