Does Maternal Depression Hamper Child Development? Evidence from a Randomized Control Trial

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1 Slide #1 Does Hamper Child? Evidence from a Randomized Control Trial Victoria Baranov 1 Sonia Bhalotra 2 Joanna 3 1 Department of Economics, University of Melbourne 2 ISER, University of Essex 3 Department of Psychology, Duke University SSPH+ Summer School August 25, 2015 The follow-up study was funded by two research awards from Grand Challenges Canada awarded to Bhalotra and jointly with Siham Sikander and Atif Rahman

2 Motivation Slide # % of children exposed to maternal depression in first year of life (Rahman, 2005) depression is often undiagnosed Potentially harmful consequences for the mother, family stability, child development Children: Adverse psychological and intellectual competence observed in childhood & into adulthood (Murray et al., 1996, 1999) Limited causal evidence. Limited evidence of longer-term effects

3 Mechanisms In what ways might perinatal depression impact child development? Slide #3 Physiological 1 Prenatal Slower fetal growth Elevated maternal cortisol (Diego et al., 2009) behaviors including loss of appetite, poor sleep 2 Postpartum Parenting difficulties symptoms make it more difficult for mothers to engage/bond with the child, breastfeed, provide stimulation (Murray and Cooper, 1997; Rahman et al., 2008) Behavioral 1 Optimal parental investment Physiological effects reduce child s human capital endowment Reinforcing investment mechanism, due to static complementarity, means reduced investment (Becker and Tomes, 1986) Compensating mechanism, if parents are inequality averse, means increased investment Protective behavior, anticipating possible shock, sufficiently buffers effects

4 Mechanisms In what ways might perinatal depression impact child development? Slide #3 Physiological 1 Prenatal Slower fetal growth Elevated maternal cortisol (Diego et al., 2009) behaviors including loss of appetite, poor sleep 2 Postpartum Parenting difficulties symptoms make it more difficult for mothers to engage/bond with the child, breastfeed, provide stimulation (Murray and Cooper, 1997; Rahman et al., 2008) Behavioral 1 Optimal parental investment Physiological effects reduce child s human capital endowment Reinforcing investment mechanism, due to static complementarity, means reduced investment (Becker and Tomes, 1986) Compensating mechanism, if parents are inequality averse, means increased investment Protective behavior, anticipating possible shock, sufficiently buffers effects

5 Mechanisms: Trajectories of Slide #4 Do impacts fade, persist or magnify after infancy? Gaps in cognitive and personality traits that emerge early in life persist and often increase over time through dynamic complementarity (Conti and Heckman, 2014; Cunha et al., 2010) But some impacts of preschool interventions fade (Chetty et al., 2011) Depends on: Endogenous family responses: compensating or reinforcing Persistence of maternal depression

6 Related Slide #5 Early life risk factors have dynamic persistent effects Almond and Currie (2011) But no evidence on maternal depression as a risk factor Closest relatives are Black et al. (2014); Persson and Rossin-Slater (2014) on maternal bereavement. They use non-experimental variable and find conflicting results Preschool/home environment is critical to child development Attanasio et al. (2014); Carneiro and Ginja (2014), Heckman Doyle et al. (2013) found parenting intervention impacted parental investment but no detectible effect on child development Results for caregiver stimulation but no evidence on maternal depression Recent economic studies find CBT interventions have large effects on behavior (Blattman et al., 2015; Heller et al., 2015, 2013) Mental health and economic decision-making (Bernard et al., 2014; Haushofer and Fehr, 2014; Mullainathan and Shafir, 2013)

7 Slide #6 (age 1) Preview of our results was effective: 78pp reduction in maternal depression rate by 1 year Treatment group improved child inputs (arranging for delivery, breastfeeding, immunizations), and increased play frequency with infant Treatment group children were 25pp less likely to have had a recent acute respiratory infection, somewhat less likely to have had recent diarrhea episode... but no detectible effects on child growth at age 1 year Longer-term (age 7) We find no apparent effects on overall cognitive, physical, or socio-emotional development can rule out effects on the order of 0.2 standard deviations There are some notable significant effects on maternal depression for mothers with low social support or no grandmother present, with treatment reducing likelihood of depression by 9 pp for these subgroups (Baranov et al., 2015) parental investments such as the HOME score, private schooling, education expenditures and expectations increased in response to treatment some evidence of reduced hospitalization and improvements in processing speed but these individual significant effects are not always consistent or robust when accounting for attrition and multiple hypothesis testing Overall, parental investment index increased by 0.2 standard deviations

8 Slide #6 (age 1) Preview of our results was effective: 78pp reduction in maternal depression rate by 1 year Treatment group improved child inputs (arranging for delivery, breastfeeding, immunizations), and increased play frequency with infant Treatment group children were 25pp less likely to have had a recent acute respiratory infection, somewhat less likely to have had recent diarrhea episode... but no detectible effects on child growth at age 1 year Longer-term (age 7) We find no apparent effects on overall cognitive, physical, or socio-emotional development can rule out effects on the order of 0.2 standard deviations There are some notable significant effects on maternal depression for mothers with low social support or no grandmother present, with treatment reducing likelihood of depression by 9 pp for these subgroups (Baranov et al., 2015) parental investments such as the HOME score, private schooling, education expenditures and expectations increased in response to treatment some evidence of reduced hospitalization and improvements in processing speed but these individual significant effects are not always consistent or robust when accounting for attrition and multiple hypothesis testing Overall, parental investment index increased by 0.2 standard deviations

9 The Trial Slide #7 depression intervention conducted in rural Pakistan in Apr 2005-Mar clusters: All women in third trimester of pregnancy (16-45, married, no major illness) screened for depression Women diagnosed as clinically depressed included in the trial: 20 treated [n = 463] & 20 [n = 440] control clusters. Community lady health workers were trained to deliver the intervention. Scaleable. Setup: 16 home visits in both arms. Control arm received enhanced routine care. Pregnant women screened for depression start 1st followup complete 2nd followup 3rd followup Child Age -3m -1m 6m 10m 12m 7yrs

10 Slide #8 of the on Evaluated by a psychiatrist Mother depressed (MDE) % 52% 58% 25% 31% 25% Baseline 1year 6month SB2013 THP study Treated Control 95% CI

11 Our 7-Year Followup Slide #9 We successfully located and re-enrolled 83% (n = 585) women and children in March 2013-January % (n = 296) control and 80.3% (n = 289) treated. We also enrolled 300 mother-child dyads from among (3242) women pregnant at baseline and diagnosed as undepressed in the perinatal period. No baseline characteristics for this group Each interview had 2 parts: 1st in the woman s home, 2nd in the child s school or the LHW s house (cognitive tests). For women in the trial we have four data points: baseline, 6 mo, 12 mo, 7 years

12 Testing Randomization: Balance Slide #10 We investigate balance between the treated and control group women in the 1-year and 7-year follow-up samples. Test of mean differences for several characteristics Balance was not fully achieved by randomization at the UC level : e.g. perceived social support, presence of grandmother were greater in the treated group We present all estimates conditional upon characteristics As this barely changes the point estimates, it seems unlikely that unobservables play any substantial role in driving our findings (Altonji et al., 2005)

13 Slide #11 Balance at baseline Rahman (2008) sample: N = 704 Saving Brains (2013) sample: N = 585 Control Control mean (s.d.) mean (s.d.) p-value mean (s.d.) mean (s.d.) p-value (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Mother s characteristics and mental health Mother s age (4.8) (5.0) (4.8) (5.1) 0.31 Mother s education 4.35 (4.0) 3.77 (3.9) (3.9) 3.81 (3.9) 0.12 Parity 2.13 (1.7) 2.37 (1.8) (1.7) 2.40 (1.8) 0.05 Mother s height (cm) 157 (5.5) 156 (5.5) (5.5) 156 (5.4) 0.31 Mother s BMI (4.0) (4.1) (4.0) (4.1) 0.45 Hamilton depression score (4.1) (3.9) (4.2) (3.9) 0.14 BDQ disability score 8.08 (2.7) 8.27 (2.7) (2.8) 8.17 (2.7) 0.72 Perceived social support score (16.0) (16.1) (16.5) (16.3) 0.04 Household characteristics Joint/extended family structure 0.61 (0.5) 0.56 (0.5) (0.5) 0.56 (0.5) 0.13 Grandmother lives with 0.55 (0.5) 0.44 (0.5) (0.5) 0.44 (0.5) 0.01 No. member per room 3.60 (1.5) 3.73 (1.6) (1.5) 3.74 (1.6) 0.11 Father s education 7.08 (3.9) 7.20 (3.9) (3.8) 7.21 (3.8) 0.43 Father employed 0.89 (0.3) 0.91 (0.3) (0.3) 0.90 (0.3) 0.88 Father non-manual worker 0.29 (0.5) 0.30 (0.5) (0.5) 0.30 (0.5) 0.76 log(income) 4.19 (3.0) 4.04 (2.9) (3.1) 4.21 (3.0) 0.75 SES (1=Rich, 5=Poor) 3.57 (1.0) 3.65 (1.0) (1.0) 3.63 (1.0) 0.32 Wealth Index 0.12 (2.0) (1.9) (2.0) (1.9) 0.11 LTFU (from 2008, N = 704) 0.19 (0.4) 0.14 (0.4) 0.12 LTFU (from baseline, N = 903) 0.38 (0.5) 0.33 (0.5) 0.13 Observations p <.10, p <.05, p <.01 Notes: This table tests for balance along a number of baseline characteristics among the original Rahman et al. (2008) sample, and in the mothers found in the 2013 Saving Brains followup. Using the sample of infants followed at 1 year post-intervention from Rahman et al. (2008), columns 1 and 2 show the means and standard deviations (in parentheses), by intervention arm. Column 3 shows the p-value of the difference. Similarly, columns 4 and 5 show means and standard deviations in the Saving Brains subsample, and column 6 shows the p-value of the difference between intervention and control arms.

14 Testing Randomization: Attrition Slide #12 The 7-year follow-up contained 83% of the original sample. Potential concern about endogeneity in sample attrition Treated mothers slightly more likely to attrit than controls mothers (19 vs 15%) but the difference is not statistically significant Attriting mothers were poorer, perceived less social support, and were less likely to have a grandmother present Tests of attritor characteristics by treatment group show no significant differences We estimate attrition bounds (Lee, 2009), without tightening

15 Slide #13 The intervention was randomized at the Union Council (cluster) level. The estimation equation is Y ic = α+βt c +Γ X ic +ε ic (1) Y is the individual child outcome, T is an indicator for whether the mother was in a treated cluster, X is a vector of controls i indexes the individual, c indexes cluster (Union Council) The baseline specification includes only interviewer fixed effects Additional controls include baseline (lagged) values of indicators of maternal mental health measures (Hamilton, BDQ, and MSPSS scores and their squares) Also mother s age, its square, parity, mother s and father s education, family structure, grandmother present, a PCA-weighted wealth index, household income, child gender, age (in months), and interview date (in days after the start of data collection) Robust standard errors are clustered at the Union Council level

16 Slide #14 treatment effects: depression and child outcomes Sample means Treatment effect (ITT) Control Unadjusted Adjusted Variable (1) (2) (3) (4) Panel A: Mother outcomes Depressed (6mo) Depressed (12mo) Hamilton depression score (6mo) Hamilton depression score (12mo) BDQ disability score (6mo) BDQ disability score (12mo) GAF score (6mo) GAF score (12mo) Perceived social support score (6mo) Perceived social support score (12mo) Panel B: Child outcomes Child weight KG (6mo) Child weight KG (12mo) Child length CM (6mo) Child length CM (12mo) Diarrhea episodes (6mo) Diarrhea episodes (12mo) Acute Respiratory Infection (6mo) Acute Respiratory Infection (12mo) Observations p <.10, p <.05, p <.01 Notes: This table replicates the results in the Rahman et al. (2008) study, using the sample of women that were found for the Saving Brains 2013 followup. Columns 1 and 2 show sample means by randomization arm. Columns 3 and 4 show the treatment effects, estimated using OLS, without and with adjustments for baseline demographic characteristics (controls). Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Additional controls include baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, and child s age at the time of the interview.

17 Slide #15 Distributional : Figure 1 : Quantile Treatment of THP on maternal depression QTE for Mother's Hamilton score (at 6 months) QTE for Mother's Hamilton score (at 1 year) Percentile Percentile 90% QTE 90% CI ATE QTE CI ATE (a) QTE estimates on Hamilton score (6 month) (b) QTE estimates on Hamilton score (1 year) Notes: Quantile Treatment of THP on maternal depression severity, measured by the Hamilton depression rating (where higher values indicate more severe depression). 90% confidence intervals for the QTE were calculated by bootstrapping using 1,000 replications with replacement, clustering at the UC level. The average treatment effect (ATE), the mean difference, is presented for comparison.

18 Slide #16 treatment effects: Health behavior and maternal relationships Sample means Treatment effect Control Unadjusted Adjusted Variable (1) (2) (3) (4) Panel A: Inputs to child well-being Exclusive breastfeeding (6mo) Breastfeeding (12mo) Mother play frequency with infant (12mo) Father play frequency with infant (12mo) Discussed child s development with family (12mo) Selected appropriate place for delivery Arranged transport for delivery Arranged finances for delivery Practicing birth spacing Panel B: Relationship quality Husband looks after basic needs Mother receives pocket money Husband understand feelings Husband supports in difficult situations Happy with husband behavior Arguments lead to physical violence Relationship with husband Relationship with mother-in-law Observations p <.10, p <.05, p <.01 Notes: This table expands the results in Table 14 by looking at the effect on health behavior and relationship quality at 6 and 12 months. Columns 1 and 2 show sample means by randomization arm. Columns 3 and 4 show the treatment effects, estimated using OLS, without and with adjustments for baseline demographic characteristics (controls). Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Additional controls include baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, and child s age at the time of the interview.

19 Summary of short-run findings Slide #17 depression responded strongly to the intervention, it was successful Significant effects everywhere along the distribution at 6 months and 12 months No detectible effects on infant growth But there is considerable evidence that mother s health behavior and home environment improved in the short-run These results predispose us towards expecting persistent impacts on child development, so we followed up to age 7...

20 Longer-term treatment effects: Overall program effect Slide #18 Generate indices, following Anderson (2008); O Brien (1984) in 4 domains: Child development: (1) cognitive development WPPSI FSIQ, Urdu and Math scores, Stroop, and grade attainment (2) physical development weight-for-age, height-for-age, motor function score, severe illness, hospitalizations, eye and hearing problems (3) socio-emotional development Spence Anxiety score and SDQ score Parenting: (4) parent investment HOME score (consisting of 8 dimensions: responsivity, encouragement of maturity, emotional climate, learning materials and opportunities, enrichment, family companionship, family integration, and physical environment), private school, class size, expectations on grade attainment, and expenditures Addresses the problem of multiple inference, but also improves the power of our statistical test for whether the intervention had broad effects Index is a Generalized Least Squares estimate, puts more weight on outcomes with greater unique (uncorrelated) information

21 Slide #19 Correlates of Indices Cognitive development index Physical development index Socio-emotional index Parental investment index (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) Girl (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.08) (0.08) (0.08) Child age (0.4) (0.4) (0.4) (0.4) (0.4) (0.5) (0.4) (0.4) (0.4) (0.6) (0.6) (0.5) Wealth (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) (0.03) Mother s educ (0.01) (0.01) (0.01) (0.02) (0.02) (0.02) (0.02) (0.02) (0.02) (0.01) (0.01) (0.01) Father s educ (0.02) (0.01) (0.01) (0.02) (0.02) (0.02) (0.02) (0.02) (0.02) (0.01) (0.01) (0.01) Mother s age (0.06) (0.06) (0.05) (0.07) (0.07) (0.06) (0.07) (0.07) (0.07) (0.08) (0.08) (0.08) Mother s age (0.0007) (0.0008) (0.0007) (0.0008) (0.0009) (0.0008) (0.0009) (0.0009) (0.0009) (0.001) (0.0009) (0.0009) No. kids (0.04) (0.04) (0.04) (0.07) (0.06) (0.05) (0.03) (0.03) (0.03) (0.05) (0.05) (0.05) Grandmother at baseline (0.07) (0.07) (0.06) (0.1) (0.1) (0.1) (0.1) (0.1) (0.2) (0.1) (0.1) (0.1) Mother depressed (0.1) (0.1) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) Baseline depression severity (0.06) (0.06) (0.07) (0.08) (0.05) (0.06) (0.06) (0.06) Mother play at 1y (0.1) (0.2) (0.2) (0.1) Father play at 1y (0.08) (0.2) (0.2) (0.1) Diarrhea at 1y (0.10) (0.2) (0.1) (0.10) Breastfeeding at 6m (0.10) (0.2) (0.1) (0.2) Breastfeeding at 1y (0.1) (0.1) (0.2) (0.09) ARI at 1y (0.10) (0.1) (0.10) (0.1) Observations R p <.10, p <.05, p <.01 Notes: This table shows correlates of the outcome indices in the control group. The correlates include baseline demographic and economic characteristics, maternal depression at the time of the survey and mother s depression severity at baseline, and mediating factors at 6 months and 1 year such as parental play and infant health. Mother s baseline depression severity is a standardized index combining Hamilton depression rating, BDQ, and MSPSS scores. All regressions contain interviewer controls, and standard errors are cluster at the Union Council.

22 Longer-term effects on child development Slide #20 Indices are clearly sensitive to covariates Some mediating factors at 1y were significantly correlated with development index measures at age 7 (father play, illness) Domains are broad, but distinctively different (correlated with different demographics)

23 Cognitive Skills and Education Slide #21 Cognitive skills: Wechsler Preschool and Primary Scale of Intelligence, designed for children between 2.5 and 7.5 years old (WPPSI-IV) Sub-component scores for verbal comprehension (VCI), visual spatial (VSI), fluid reasoning (FRI), working memory (WMI), and processing speed (PSI) Basic literacy and numeracy tests were administered, involving alphabet, word and number recognition, and addition. These yield math and urdu scores The interviewer assessed school grade, attendance, and class size as reported by the teacher The mother answered questions regarding the type of school the child attends (private/public), expenditures on education, and expected grade attainment for the child

24 Executive Function and Motor Skills Slide #22 Executive functioning was assessed using a Stroop-like Day/ Night test, which gauges inhibition and working memory Motor skills were assessed using the Grooved Pegboard Test, which asks the child to place pegs in a correct orientation on a board and records the amount of time the child took to complete the task

25 Psychosocial Competencies/Socio-emotional Slide #23 Two broad domains: Behavioral and emotional problems were assessed with the Strengths and Difficulties Questionnaire (SDQ) Anxiety was assessed with the Spence Children s Anxiety Scale (SCAS) Both measures are based on sets of questions answered by the mother so there may be endogenous reporting bias

26 Slide #24 Longer-term treatment effects: Overall program effects on child development Cognitive Physical Socio-emotional development development development index index index (1) (2) (3) Panel A: Baseline specification Treatment (0.09) (0.08) (0.08) N Panel B: Full set of controls Treatment (0.08) (0.08) (0.07) N Control mean of dep. var St. dev p <.10, p <.05, p <.01 Notes: Index variables were created following Anderson (2008), with positive values always associated with positive outcomes for all indices. Cognitive development includes FSIQ, Urdu and Math scores, Stroop, and grade attainment. Physical development index includes weight-for-age, height-for-age, motor function score, severe illness, hospitalizations, eye and hearing problems. Socio-emotional index includes the Spence and SDQ scores. Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Panel A reports baseline effects controlling only for interview fixed effects. Panel B estimates attrition bounds based on Lee (2009), using the starting sample of N = 704. Panel C includes additional controls for baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, and child s age at the time of the interview.

27 What could be causing us to find null results? Slide #25 1 Power? should be able to detect 0.35 sd with 80% power Attanasio et al. (2014) paper on micronutrient supplementation and stimulation in Colombia powered at 0.33 standard deviation MDE with 80% power Their intervention contact intensity was similar to our study (18 months, weekly home visits) Found an effect of 0.26 SDs of stimulation alone on cognitive development Measured outcomes shortly after intervention ended Results by grandmother at baseline 2 Attrition? Lee (2009) bounds Intuition: sample is trimmed (from above or below) such that share of observed individuals is equal for both groups Non-parametric approach, but requires monotonicity assumption (assignment to treatment can only affect attrition in one direction) 3 Shocks to clusters? Check with non-depressed sample

28 What could be causing us to find null results? Slide #25 1 Power? should be able to detect 0.35 sd with 80% power Attanasio et al. (2014) paper on micronutrient supplementation and stimulation in Colombia powered at 0.33 standard deviation MDE with 80% power Their intervention contact intensity was similar to our study (18 months, weekly home visits) Found an effect of 0.26 SDs of stimulation alone on cognitive development Measured outcomes shortly after intervention ended Results by grandmother at baseline 2 Attrition? Lee (2009) bounds Intuition: sample is trimmed (from above or below) such that share of observed individuals is equal for both groups Non-parametric approach, but requires monotonicity assumption (assignment to treatment can only affect attrition in one direction) 3 Shocks to clusters? Check with non-depressed sample

29 Estimation: Including the not depressed sample Slide #26 The estimating equation is Y ic = α+ηt c Depressed ic +δdepressed ic +γ c +Γ X ic +ε ic (2) Depressed is an indicator for the mother having been prenatally depressed. η is the coefficient of interest. This allows us to control for area fixed effects, γ c (absorb treatment, T c, indicator) Alternative specification, without FEs, tests if overall treated clusters affected Y ic = α+ηt c Depressed ic +δdepressed ic +γt c +Γ X ic +ε ic δ indicates the difference in outcomes between perinatally depressed and not depressed mothers in control clusters X now includes only time-invariant characteristics since no baseline data for undepressed sample It ensures that our results are not driven spuriously due to some areas experiencing shocks unrelated to treatment in the period after the 1-year follow-up

30 Slide #27 Longer-term treatment effects: Are attrition or cluster-level trends hiding an effect? Cognitive Physical Socio-emotional development development development index index index (1) (2) (3) Panel C: Attrition Bounds Lower Upper % CI of ITT [ -0.37, 0.20] [ -0.27,0.29 ] [ -0.45,0.12 ] Panel D: Difference-in-difference: UC fixed effects Depr Treat (0.1) (0.1) (0.1) Depr (0.09) (0.1) (0.09) N Panel E: Difference-in-difference: Treatment UC dummy Depr Treat (0.1) (0.1) (0.1) Treatment UC (0.1) (0.10) (0.1) Depr (0.09) (0.09) (0.09) Control mean of dep. var St. dev p <.10, p <.05, p <.01 Notes: Four index variables were created following Anderson (2008), with positive values always associated with positive outcomes for all indices. Cognitive development includes FSIQ, Urdu and Math scores, Stroop, and grade attainment. Physical development index includes weight-for-age, height-for-age, motor function score, severe illness, hospitalizations, eye and hearing problems. Socio-emotional index includes the Spence and SDQ scores. Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Panel D estimates a DD model using the sample of perinatally non-depressed mothers children, controlling for age of mother and its square, father s and mother s education, parity, child gender and age, and the date of interview using UC fixed effects. Panel E estimates a DD model without UC fixed effects but with a dummy equal to 1 if UC was a treatment cluster.

31 What could be causing us to find null results? Slide #28 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)? 5 Heterogeneity by grandmother at baseline? Effect of treatment was greater and more persistent for this subgroup 6 Mothers/families don t know how to interact with children? Heterogeneity by family education (defined as sum of mother and father s education)

32 What could be causing us to find null results? Slide #28 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)? 5 Heterogeneity by grandmother at baseline? Effect of treatment was greater and more persistent for this subgroup 6 Mothers/families don t know how to interact with children? Heterogeneity by family education (defined as sum of mother and father s education)

33 Slide #29 Longer-term treatment effects: Are attrition or cluster-level trends hiding an effect? Cognitive Physical Socio-emotional development development development index index index (1) (2) (3) Panel F: Heterogeneity by gender Girl Treat (0.2) (0.1) (0.2) Treatment (0.1) (0.1) (0.1) Girl (0.1) (0.1) (0.1) Panel G: Heterogeneity by grandmother at baseline Grandma Treat (0.2) (0.1) (0.2) Treatment (0.1) (0.1) (0.1) Grandmother lives with (0.1) (0.1) (0.1) Panel H: Heterogeneity by family education Low educ Treat (0.1) (0.2) (0.2) Treatment (0.10) (0.1) (0.1) Low educ (0.1) (0.1) (0.1) Control mean of dep. var St. dev p <.10, p <.05, p <.01 Notes: Index variables were created following Anderson (2008), with positive values always associated with positive outcomes for all indices. Cognitive development includes FSIQ, Urdu and Math scores, Stroop, and grade attainment. Physical development index includes weight-for-age, height-for-age, motor function score, severe illness, hospitalizations, eye and hearing problems. Socio-emotional index includes the Spence and SDQ scores. Heterogeneity robust standard errors, clustered by Union Council, in parentheses. All regression include full controls for baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, child s age at the time of the interview, and interviewer FEs. Panel A looks at effects by child gender, Panel B looks at effect by presence of grandmother at baseline (roughly 50% of the sample, and Panel C looks at effect by family education (where low education is defined as below the median sum of mother and father education).

34 What could be causing us to find null results? Slide #30 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education)... no if anything children from low education families benefitted the most from the intervention in cognitive domain 7 Distributional effects?

35 What could be causing us to find null results? Slide #30 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education)... no if anything children from low education families benefitted the most from the intervention in cognitive domain 7 Distributional effects?

36 QTEs Figure 3 : Quantile Treatment of THP on child outcomes at the 7 year followup Slide # Cognitive Physical Socio-emotional Percentile Percentile Percentile QTE 90% CI ATE (a) QTE estimates on Cognitive, Physical, and Socio-emotional Indices Notes: Quantile Treatment of THP on child outcomes at the 7 year followup. 90% confidence intervals for the QTE were calculated by bootstrapping using 1,000 replications with replacement, clustering at the UC level. The average treatment effect (ATE), the mean difference, is presented for comparison. All effects are expressed in standard deviations of the control group.

37 Slide #32 No significant differences between treatment and controls groups anywhere along the distribution for all three dimension of development. Perhaps heterogeneity by gender is masking distributional effects?

38 QTEs By Gender Figure 5 : Quantile Treatment of THP on child outcomes at the 7 year followup Slide #33 Girls: Cognitive Boys: Cognitive Physical Physical Socio-emotional Socio-emotional Percentile Percentile Percentile (a) QTE estimates on Cognitive, Physical, and Socio-emotional Indices by Gender Notes: Quantile Treatment of THP on child outcomes at the 7 year followup. 90% confidence intervals for the QTE were calculated by bootstrapping using 1,000 replications with replacement, clustering at the UC level. The average treatment effect (ATE), the mean difference, is presented for comparison. All effects are expressed in standard deviations of the control group.

39 Slide #34 Perverse effects of the intervention on socio-emotional development appears to be driven by the boy sub-sample. Other than this, no distributional patterns even within gender.

40 What could be causing us to find null results? Slide #35 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment? Check the parental investment index

41 Longer-term treatment effects: Are parental investments compensating for maternal depression? Parental investment index Slide #36 Panel A: Baseline specification Treatment 0.21 (0.09) Panel B: Full set of controls Treatment 0.19 (0.09) Panel C: Attrition Bounds Lower Upper 95% CI of ITT [-0.07, 0.47] Panel D: Difference-in-difference: UC fixed effects Depr Treat 0.19 Depr (0.1) (0.07) Panel E: Difference-in-difference: Treatment UC dummy Depr Treat 0.20 (0.1) Depr (0.07) Treatment UC (0.1) Control mean of dep. var St. dev 1.00 Parental investment index Panel F: Heterogeneity by gender Girl Treat 0.26 (0.1) Treatment (0.1) Girl (0.10) Panel G: Heterogeneity by grandmother at baseline Grandma Treat (0.2) Treatment 0.21 (0.1) Grandmother lives with (0.1) Panel H: Heterogeneity by family education Low educ Treat 0.28 (0.1) Treatment (0.1) Low educ (0.1) Control mean of dep. var St. dev 1.00 Notes: Index variables were created following Anderson (2008), with positive values always associated with positive outcomes for all indices. Paternal investment index includes home score (which include 8 dimensions: responsivity, encouragement of maturity, emotional climate, learning materials and opportunities, enrichment, family companionship, family integration, and physical environment), private school, class size, expectations on grade attainment, and expenditures. Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Panel A reports baseline effects controlling only for interview fixed effects. Panel C, F, G, and H include additional controls for baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, and child s age at the time of the interview. Panels D and E include only a subset of baseline controls.

42 Parental Investments Slide #37 Treatment induced significant improvements in parenting of 0.19 sd Parental investments are not compensating for maternal depression Thus, compensating behavior cannot explain our null findings on the effects on children Patterns in heterogeneity: girls and low educ families (marg. sig) appear to benefit differentially more from treatment There is some fairly robust evidence that treatment induced improvements in parental investment (similar findings to Doyle et al. (2013))

43 What could be causing us to find null results? Slide #38 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Are the effects of depression just very small?

44 What could be causing us to find null results? Slide #38 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Are the effects of depression just very small?

45 What could be causing us to find null results? Slide #38 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Are the effects of depression just very small?

46 What differences do we expect to find? Slide #39 We have a sample of women who were not perinatally depressed Can compare outcomes for control group vs nondepressed sample Not causal, other confounds certainly present Direction of bias would likely lead to overstating true differences Thus, upper bound on what to expect

47 Slide #40 Are children from the depressed and nondepressed sample different? Non-causal Child Outcomes at Age 7: (1) (2) (3) (4) Depressed Non-depressed Difference P-value Panel B: Controlling for baseline demographics Cognitive development index Physical development index Parental investment index Socio-emotional development index Stunted (Height <2SD) Thin (BMI <2SD) Severe illness Hospitalized Spence anxiety score SDQ score VCI VSI Child Full Scale IQ Stroop Private school Urdu Math Educ Expenditure Expected grade attainment Observations

48 Summary of Comparison of Child Outcomes for Women With and Without Prenatal Slide #41 Significant differences in socio-emotional development and health Children of perinatally non-depressed mothers are less anxious and have fewer behavioral difficulties, somewhat less likely to be ill/hospitalized Limited differences in other child outcomes at age 7, including cognitive and physical outcomes These comparisons are only descriptive but they cohere with the results from the trial The bias in these comparisons will tend to make it more likely that we see worse outcomes for children of depressed mothers. So if we see no difference, it is despite the bias

49 : Fading Slide #42 Fading: We saw a range of positive effects of the intervention at the 6 and 12 month follow-up. We cannot strictly infer fading by age 7 as the outcomes measured are (appropriately) different. But it may be that effects fade (Chetty et al., 2011) Control mothers recover depression spontaneously- but if infancy is a critical age then depression in infancy should count most Control mothers received enhanced routine care and this helped them catch up Endogenous parental responses are compensating However, we show that there were reinforcing investments using a fairly multi-domain index Fading is unlikely because (1) we find no evidence of compensation; (2) previous work shows that inputs in infancy have lasting effects; and (3) because despite any enhanced care that the control group received, the short term effects all favor the treated group

50 : Weak or Spurious Slide #43 The apparent effectiveness of the intervention is spurious Mothers receiving CBT reported feeling better because of Hawthorne effects but their mental health did not actually improve Suggests need to collect biomarkers eg. cortisol If Hawthorne effects, then we cannot conclude that maternal depression does not affect child development But, significant effects of intervention on long-term maternal depression suggests that the short-run effects on maternal depression were not only Hawthorne effect The intervention had weak effects because of its design: it was initiated too late in pregnancy or stopped too early So it created behavioral change which is evident at the 6 and 12 month follow up But damage to child development was done in utero and was hard to reverse with the treatment: suggests maternal depression affects child development through in utero rather than postnatal mechanisms. If so, important for intervention design This again is undermined by the descriptive comparisons btw depressed and non-dep mothers

51 Slide #44 What could be causing us to find null results? 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Fading... unlikely 11 Hawthorne effects... unlikely 12 Weak Design effects... no 13 Are the effects of depression just very small at this age?

52 Slide #44 What could be causing us to find null results? 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Fading... unlikely 11 Hawthorne effects... unlikely 12 Weak Design effects... no 13 Are the effects of depression just very small at this age?

53 Slide #44 What could be causing us to find null results? 1 Power? should be able to detect 0.35 sd with 80% power 2 Attrition?... no 3 Shocks to clusters?... no 4 Heterogeneity in response (by gender)?... no 5 Heterogeneity by grandmother at baseline?... no 6 Mothers don t know how to interact with children (heterogeneity by mother s education) if anything families with low education benefitted the most from the intervention... no 7 Distributional effects?... no 8 Compensating parental investment?... no 9 Are our measures bad for this setting? The correlates of indices suggest not 10 Fading... unlikely 11 Hawthorne effects... unlikely 12 Weak Design effects... no 13 Are the effects of depression just very small at this age?

54 : Latent Slide #45 Latent effects: The effects could emerge later; differences at age 7 may be small or latent Technology of human capital production e.g. importance of dynamic complementarities. Predicts the individual trajectories widen with age (Conti and Heckman, 2014) Reinforcing parental responses (Almond and Mazumder, 2013) Can only confirm with longer term follow up

55 : Reflections on Related Studies Slide #46 Black et al. (2014) study how the death of a parent of the mother during pregnancy which creates grief-related maternal stress- influences birth outcomes and long run outcomes for her births They find small negative effects on birth outcomes- birth weight and APGAR score. But no long run effects- education, labor market Similar pattern in this study. We additionally measure maternal investments in children and the home environment Chetty et al. (2011) study Project Star, an intervention from KG to grade 3, that randomized children and teachers across classrooms. They find cognitive gains that fade by grade 8 but they nevertheless find earnings increases. They speculate that these flow from non-cognitive skills s designed to improve cognitive skills may have larger effects on non-cognitive skills and vice versa. So, evaluation sometimes concludes no effects when in fact it may be that it measures the wrong outcome. But here we measure a pretty comprehensive range of indicators of child development

56 Conclusion Slide #47 Randomized experiment generated strong effects on maternal depression But we find no detectible effects on child outcomes by age 7 Our results can generally reject improvements as small as 0.2 standard deviations Results consistent with Black et al. (2014) Positive effects do not appear hidden by attrition, heterogeneity, compensating behavior, not enough dimensions measured The intervention did improving parental investments by 0.20 sd Main conclusion: possible latent effects but we cannot rule out no effects (children are resilient)

57 Slide #48 Appendix References Density Distributions of Severity Figure 7 : Densities of maternal depression severity (Hamilton score) Mother's Hamilton score (at 6 months) Mother's Hamilton score (at 1 year) Density All Groups Treatment Control Baseline (All) Baseline (T) Baseline (C) All Groups Treatment Control Baseline (All) Baseline (T) Baseline (C) (a) Hamilton score (6 month) (b) Hamilton score (1 year) Notes: depression, measured using the Hamilton depression score, with higher values indicating more severe depression, at the 6-month and 1-year followups by treatment arm. Baseline distributions for treatment and controls arms are also plotted for comparison. Histograms of the data for combined groups (treatment and control) at baseline and the followups are plotted in the background.

58 Slide #49 Appendix References Longer-term treatment effects: Main child development outcomes Cognitive Function: WPPSI-IV Physical Growth Socio-emotional WPPSI Components: Full SCAS SDQ VCI VSI FRI WMI PSI Scale IQ Stunted Thin Anxiety total (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Panel A: Baseline specification Treatment (1.5) (1.2) (0.9) (1.3) (0.9) (1.1) (0.03) (0.04) (1.0) (0.5) N Panel B: Attrition Bounds Lower Upper % CI of ITT [-2.54,4.82] [-5.44,2.70] [-2.00,4.52] [-4.59,3.81] [-0.97,4.35] [-2.55,3.76] [-0.42,0.21] [-0.35,0.27] [-1.27,6.14] [-0.90,1.97] Panel C: Full set of controls Treatment (1.3) (1.1) (0.8) (1.3) (0.7) (0.9) (0.03) (0.04) (1.1) (0.4) N Panel D: Heterogeneity of treatment effect by gender Girl Treat (1.8) (2.4) (2.2) (2.2) (1.4) (1.8) (0.06) (0.05) (2.2) (0.9) Treatment (1.6) (1.7) (1.5) (1.5) (1.0) (1.3) (0.04) (0.05) (1.5) (0.6) Girl (1.4) (1.7) (1.5) (1.6) (1.2) (1.4) (0.04) (0.04) (1.4) (0.7) Panel E: Difference-in-difference: using sample of perinatally non-depressed Depr Treat (2.1) (1.9) (1.9) (2.1) (1.4) (1.9) (0.05) (0.06) (1.4) (0.7) Depr (1.4) (1.3) (1.3) (1.5) (1.1) (1.3) (0.04) (0.04) (1.1) (0.5) Control mean of dep. var St. Dev Notes: This table presents the main effects on child outcomes at age 7, similar to et al (2015). Heterogeneity robust standard errors, clustered by Union Council, in parentheses. Panel A reports baseline effects controlling only for interview fixed effects. Panel B estimates attrition bounds based on Lee (2009), using the starting sample of N = 704. Panel C includes additional controls for baseline values of age, age-squared, family structure, presence of grandmother (mother or mother-in-law of depressed mother), mother s education, father s education, parity, log of HH income, PCA-weighted wealth index, Hamilton score, Hamilton-squared, BDQ score, BDQ-squared, MSPSS score, and MSPSS-squared, and child s age at the time of the interview.

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