Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting...

DOI: 10.1542/peds.2005-2948 2006;118;659Pediatrics

James F. Paulson, Sarah Dauber and Jenn A. LeifermanFathers on Parenting Behavior

Individual and Combined Effects of Postpartum Depression in Mothers and

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ARTICLE

Individual and Combined Effects of PostpartumDepression in Mothers and Fathers onParenting BehaviorJames F. Paulson, PhDa, Sarah Dauber, PhDa, Jenn A. Leiferman, PhDb

aCenter for Pediatric Research, Eastern Virginia Medical School, Norfolk, Virginia; bSchool of Medicine, University of Colorado Denver, Health Sciences Center, Denver,Colorado

The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT

BACKGROUND. Pediatric anticipatory guidance has been associated with parentingbehaviors that promote positive infant development. Maternal postpartum depres-sion is known to negatively affect parenting and may prevent mothers fromfollowing anticipatory guidance. The effects of postpartum depression in fathers onparenting is understudied.

OBJECTIVE.Our purpose with this work was to examine the effects of maternal andpaternal depression on parenting behaviors consistent with anticipatory guidancerecommendations.

METHODS. The 9-month-old wave of data from a national study of children and theirfamilies, the Early Childhood Longitudinal Study, provided data on 5089 2-parentfamilies. Depressive symptoms were measured with a short form of the Center forEpidemiologic Studies Depression Scale. Interviews with both parents provideddata on parent health behaviors and parent-infant interactions. Logistic and linearregression models were used to estimate the association between depression ineach parent and the parenting behaviors of interest. These models were adjustedfor demographic and socioeconomic status indicators.

RESULTS. In this national sample, 14% of mothers and 10% of fathers exhibitedlevels of depressive symptoms on the Center for Epidemiologic Studies DepressionScale that have been associated with clinical diagnoses, confirming other findingsof a high prevalence of postpartum maternal depression but highlighting thatpostpartum depression is a significant issue for fathers as well. Mothers who weredepressed were 1.5 times more likely to engage in less healthy feeding and sleeppractices with their infant. In both mothers and fathers, depressive symptoms werenegatively associated with positive enrichment activity with the child (reading,singing songs, and telling stories).

CONCLUSIONS. Postpartum depression is a significant problem in both mothers andfathers in the United States. It is associated with undesirable parent health behav-iors and fewer positive parent-infant interactions.

www.pediatrics.org/cgi/doi/10.1542/peds.2005-2948

doi:10.1542/peds.2005-2948

KeyWordsanticipatory guidance, parenting, fathers,depression, child development

AbbreviationsECLSEarly Childhood Longitudinal StudyBBirth CohortCES-DCenter For Epidemiologic StudiesDepression ScaleSESsocioeconomic statusORodds ratioCIcondence interval

Accepted for publication Feb 23, 2006

Address correspondence to James F. Paulson,PhD, Center for Pediatric Research, EasternVirginia Medical School, 855 W BrambletonAve, Norfolk, VA 23510. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright 2006 by theAmerican Academy of Pediatrics

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A NOW SUBSTANTIAL body of literature documentsthe negative effects of parental (in most cases ma-ternal) depression.1 Much attention has been placed onchild outcomes, which have included decrements in so-cial development, behavior problems, emotional difficul-ties, and a range of physical health problems.2 The long-presumed mechanism of these poor outcomes has beenimpaired parenting practices (eg, decreased display ofemotion, involvement, and warmth), which result indisrupted parent-child relationships and consequentchild difficulties. However, parenting-level mechanismsfor the translation of parental depression to poor childoutcomes have only recently undergone more system-atic investigation.3

Anticipatory guidance for parenting infants is an areathat directly addresses these mechanisms and has anestablished association with positive infant develop-ment. In a review article of health care services andpromotion of child development, Regalado and Halfon4

report that pediatric anticipatory guidance in areas suchas sleep habits, discipline, and reading effectively pro-motes child development in the first 3 years of life. Morespecifically, studies have shown that anticipatory guid-ance provided by pediatricians is associated with betterinfant sleep patterns, increased frequency of reading,and improved quality of parent-child interactions.5 TheAmerican Academy of Pediatrics anticipatory guidancerecommendations for parents of children ages birth to 1year include breastfeeding, putting the infant to sleep onits back, putting the infant to sleep awake, not puttingthe infant to sleep with a bottle, and engaging in positiveinteractive activities with the child.6 These interactiveactivities include reading stories and playing together,both of which have been found to promote languagedevelopment, as well as social and emotional develop-ment in young children.79

Given the documented positive effects of anticipatoryguidance on child development, it is important to exam-ine factors that may prevent parents from followingthese recommended practices. Parental postpartum de-pression may be one such factor, because it has beenlinked to poor child health and development outcomesand compromised parenting practices.10 Depression isaddressed variably in this literature and, although some-times defined by a clinical diagnosis, is most often cap-tured with self-report screening instruments on whichscores above a given threshold are associated with pos-itive clinical diagnoses.2,11 Maternal postpartum depres-sion is prevalent, with 8% to 25% of women experienc-ing subclinical depressive symptomatology sometimeduring the first year postpartum.12 Several recent studieshave found similar rates of postpartum depression innew fathers, particularly in families where the mother isalso experiencing depression.1316 However, to ourknowledge, no study exists that examines paternal de-pression in the first year postpartum in a large, nation-

ally representative sample. Postpartum depression inmothers has been linked with negative parenting behav-iors associated with negative child outcomes.17,18 Studieshave also found links between paternal depression andpsychopathology in children and adolescents, but mostof these studies did not focus on the postpartum period.19

Very little research to date has been conducted on theeffects of paternal postpartum depression on fathersparenting behaviors.

Several studies have examined the relationship be-tween maternal postpartum depression and specifichealth-related parenting behaviors recommended by pe-diatricians, such as infant sleep position and breastfeed-ing. However, many of these studies have been limitedby small samples and inconsistent definitions of healthbehaviors. Several studies have found that infants andyoung children of depressed mothers tend to have moresleep-related problems than those of nondepressedmothers.2022 It has been suggested that these sleep prob-lems may be a result of depressed mothers use of inef-fective sleep practices.23 In one study of mothers of8-month-old infants, depressed mothers were morelikely to sleep with their infants and nurse them to sleep,both behaviors that have been associated with later sleepdifficulties.22 In addition, a study of single, low-incomeblack women found that mothers with persistent depres-sive symptoms were less likely to use the back sleepposition for their infants.24 To our knowledge, no studyto date has examined the effects of paternal postpartumdepression on sleep-related parenting behaviors in par-ents of infants.

The relationship between depression and breastfeed-ing is understudied and equivocal to date.2527 Breast-feeding may positively influence a womans mental stateeither through hormonal changes or emotional attach-ment. For example, hormonal fluctuations involvingoxytocin and cortisol have been linked to improvedmental health.28,29 Moreover, aspects of breastfeeding,such as physical proximity and touching, influence amothers emotional attachment to her infant and mayattenuate mental distress.30,31 On the other hand, severalstudies have found that maternal depression negativelyimpacts breastfeeding. Specifically, depressed mothershave been found to breastfeed for shorter durations, aswell as to experience breastfeeding more negatively thannondepressed mothers.3234 Only 1 known study has ex-amined the impact of paternal depression on breastfeed-ing.35 This study found no effect of paternal depressionon breastfeeding interruption; however, mothers whofelt that their husbands actively supported breastfeedinghad a longer duration of breastfeeding.

The existing literature suggests that depressed moth-ers may be less likely to follow anticipatory guidancerecommendations regarding infant sleep practices andbreastfeeding. In addition to these specific health behav-iors, anticipatory guidance for parents of young children

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includes recommendations regarding positive parent-child interactions, such as reading and playing together.A large body of literature has demonstrated negativeeffects of maternal depression on the quality of mother-child interactions. In a meta-analysis of studies in thisarea,3 depressed mothers of infants and young childrenwere found to be more irritable and hostile, to be moredisengaged from their child, and to have lower rates ofplay and other positive social interactions with theirchild. Very few studies have looked at the impact ofpaternal depression on parenting practices related toparent-child interaction. Moreover, little research hasexamined the joint effects of maternal and paternal de-pression on parenting behaviors and on child outcomes.One notable exception is a study by Mezulis et al,36

which found that paternal depression during the post-partum period exacerbated the effects of maternal de-pression on later child behavior problems only if thefather spent significant amounts of time caring for thechild in infancy. In addition, being exposed to a nonde-pressed father did not buffer the effects of maternaldepression even if they spent high amounts of time withtheir infants. In general, these findings suggest that fa-ther involvement in the postpartum period generallyimpacts children of depressed mothers but has little to noimpact on children of nondepressed mothers. Only 1known study has examined the relations between ma-ternal and paternal depression and specific types of in-teractions, such as reading, with very young children.16

This study of parents of children ages birth to 3 years ina large national sample found that depressed motherswere less likely to play with or read to their childrenafter controlling for social and demographic covariates.Paternal depression did not affect fathers frequency ofinteractions with their children after covariates werecontrolled.

Overall, the current study intends to examine theextent to which postpartum depression among parentsof infants influences their engagement in parenting be-haviors that are consistent with anticipatory guidancerecommendations and that have been associated with astable household environment and child well-being.This study extends past research by examining the indi-vidual and interactive effects of both mothers and fa-thers depressive symptoms on their parenting practicesduring the postpartum period in a large, nationally rep-resentative sample. As in much of the previous litera-ture, we define depression with a rating scale thatcharacterizes individuals both in terms of symptom se-verity and with an empirically driven cut point, abovewhich a respondent is likely to receive a clinical diagno-sis of depression. On the basis of the findings of previousstudies, we expected that mothers and fathers depres-sion would negatively impact their parenting behaviors,such that parents who are depressed would be less likelyto engage in positive health behaviors, as well as enrich-

ment and play activities, with their infants than parentswho are not depressed. In addition, we expected to findparenting behaviors to be the most compromised infamilies where both parents were depressed.

METHODS

DataThis study used data from the first wave of the EarlyChildhood Longitudinal Study (ECLS)-Birth Cohort(B).37 The ECLS-B is a multisource, multimethod study,conducted by the National Center for Education Statis-tics, designed to evaluate a range of influences on chil-drens early development. The population from whichthe ECLS-B sample was extracted consisted of childrenborn in 2001, with an oversampling of specific ethnicminority groups (eg, American Indian and Asian andPacific Islander infants), low birth weight infants, andtwins. Births were sampled within primary samplingunits from the National Center for Health Statistics vitalstatistics system. The primary sampling units were strat-ified by geographical region, median household income,proportion minority population, and metro versus non-metro area. More than 14 000 births were sampled,yielding a final sample of 10 688 completed parent re-spondent interviews at the 9-month data collectionpoint. This represents a response rate of 76.8%.

Sample SelectionData were collected from mothers, resident fathers, non-resident fathers, and infants using a combination ofcomputer-assisted personal interviews, self-adminis-tered questionnaires, and direct developmental assess-ments of the infants. The current study used data fromthe biological mother interviews and self-report ques-tionnaires and resident father questionnaires. Because ofthe nature of our research question, we limited oursample to only those cases with complete mother andfather mental health data. Of the 10 688 completed par-ent interviews, 9447 had complete depression data avail-able. Of these, we included only those cases where bio-logical mothers were living with the target child (n 9327) and excluded 462 cases that were duplicate dataon twin infants, resulting in 8865 cases. We furthernarrowed down the sample to include only those bio-logical mothers with corresponding resident father data,yielding a final sample size of 5089. Details on sampledemographics and depression data appear in Table 1.

Measures

DepressionDepression for both mothers and fathers was measuredby an abbreviated form of the Center for EpidemiologicStudies Depression (CES-D) Scale.38 The CES-D shortform measures different depressive symptoms, includingdepressed affect, positive affect, somatic symptoms, psy-


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chomotor retardation, and interpersonal activity and hasbeen used in past research studies39 and national healthsurvey collection efforts.40 The CES-D short form con-tains 12 items with each item coded on a 4-point scalebetween 0 and 3. The range of total scores is 0 to 36, witha total score between 10 and 14 representing moderatedepression and 15 representing severe depression.Cronbachs for the study sample was .863 for themothers and .862 for the fathers. Note that the termdepression used throughout this article refers to indi-viduals who report high levels of depressive symptom-atology and is not intended to refer to individuals whoare diagnosed with clinical depression.

CES-D results were used in 2 different ways in thisstudy. For analyses using logistic regression, dichoto-mous depression scores for mothers and fathers werecreated using cut points established by the ECLS re-search team based on previous research. For linear re-gressions, continuous scores on the CES-D for mothersand fathers were used. This enabled us to examine theimpact of both the likely presence or absence of depres-sion and the influence of the degree of depressive symp-toms on outcomes.

Health BehaviorsSix items from the biological mother interview wereused to assess parental engagement in the followinghealth behaviors: putting the child to sleep on its back,putting the child to bed without a bottle, putting thechild to sleep awake, and breastfeeding. Mothers wereasked to report the position in which they put theirinfant to sleep as a newborn and as a 3-month-old.

Responses were combined into 1 item for sleep positionand coded as putting the child to sleep on the back atboth ages versus any other sleep position at either orboth ages. Putting the child to bed with a bottle andputting the child to bed awake were both coded yesversus no. Breastfeeding was coded on the basis of moth-ers responses to whether they had ever breastfed theirinfant (yes versus no).

Parent-Child InteractionParent-child interactions were assessed with 7 items,reported by both mothers and fathers. Parents wereasked how often in a typical week they read to theirchild, tell their child stories, sing songs with their child,and take their child on errands (not at all, once or twice,36 times, or every day). These 4 items were dichoto-mized into every day versus less often. In addition, par-ents were asked how often in the past month theyplayed peekaboo with their child, tickled their child, ortook their child outside to walk or play (not at all, rarely,a few times a month, a few times a week, about once aday, or more than once a day). These 2 items weredichotomized into a few times a week or more versusless often. Similar methods for dichotomizing theseitems have been used in previous studies.41 The first 4items have been used in the National Household Educa-tion Survey, a large, population-based survey adminis-tered every 2 years from 1991 to 2001. The last 2 itemswere used in the Early Head Start Research and Evalu-ation Project.40 All of the items except for tickle childwere used as dependent variables in the logistic regres-sions. Tickle child was excluded because of lack of suf-

TABLE 1 Demographics and Mean CES-D Scores for Mothers and Fathers With High and Low Depressive Symptoms (Total N 5089)

Variable Mothers Fathers

FullSample,

N (Column %)

Low Depression(N 4536),N (Column %)

High Depression(N 733),

N (Column %)

Full Sample,N (Column %)

Low Depression(N 4567),N (Column %)

High Depression(N 522),

N (Column %)

Age, y20 201 (3.9) 151 (3.5) 50 (6.8) 63 (1.2) 57 (1.2) 6 (1.1)2034 3802 (74.7) 3261 (74.9) 541 (73.8) 3291 (64.7) 2925 (64.0) 366 (70.1)35 1086 (21.3) 944 (21.7) 142 (19.4) 1735 (34.1) 1585 (34.7) 150 (28.7)

RaceWhite 2853 (56.1) 2464 (56.6) 389 (53.1) 2915 (57.4) 2637 (57.8) 278 (53.4)Black 372 (7.3) 308 (7.1) 64 (8.7) 419 (8.2) 350 (7.7) 69 (13.2)Hispanic 732 (14.4) 633 (14.6) 99 (13.5) 737 (14.5) 667 (14.6) 70 (13.4)Asian/Pacic Islander 808 (15.9) 687 (15.8) 121 (16.5) 725 (14.3) 654 (14.3) 71 (13.6)Other 318 (6.3) 258 (5.9) 60 (8.2) 286 (5.6) 253 (5.5) 33 (6.3)

Education12th grade 888 (17.4) 711 (16.3) 177 (24.1) 742 (14.6) 633 (13.9) 109 (20.9)High school graduate 1046 (20.6) 868 (19.9) 178 (24.3) 1335 (26.2) 1171 (25.6) 164 (31.4)Some college 3155 (62.0) 2777 (63.8) 378 (51.6) 3012 (59.2) 2763 (60.5) 249 (47.7)

Work statusFull-time 1665 (32.8) 1476 (33.9) 189 (25.8) 4249 (86.1) 3866 (87.2) 383 (76.3)Part-time 984 (19.4) 858 (19.7) 126 (17.2) 246 (5.0) 208 (4.7) 38 (7.6)Unemployed 2432 (47.9) 2015 (46.3) 417 (57.0) 441 (8.9) 360 (8.1) 81 (16.1)

Mean CES-D score (SD) 4.58 (4.96) 2.96 (2.67) 14.19 (4.50) 3.69 (4.67) 2.45 (2.59) 14.53 (4.75)


ficient variability in response: 99% of mothers and fa-thers reported tickling their child a few times a week ormore.

Because many of the items addressing parent-childinteractions were similar, exploratory factor analysis42

was used to determine whether a more parsimoniousapproach to operationalizing parent-child interactionswas feasible. The principal components method withvarimax rotation was conducted on the 7 items de-scribed above for mothers and fathers separately. Thisrevealed 2 coherent factors of parent-child interactionsthat were very similar for mothers and fathers. The2-factor solution allows us to describe parent-child in-teractions with 2 variables rather than the original 7.This approach explains 45.84% of variance for mothersand 47.92% of variance for fathers. Factor 1 includes thefollowing 3 items, all of which measure enrichmentactivities: read to child, tell stories to child, and singsongs with child. Factor 2 includes the following 4 items,which measure play activities: play peekaboo, ticklechild, take child on errands, and take child outside towalk or play. Because of the logical consistency of theirconstituent items, we named these factors enrichmentand play.

Demographic CovariatesA number of demographic variables known to be asso-ciated with the outcome variables were controlled for inthe analyses and operationalized as follows. Child gen-der was coded as male and female. Mother and fatherage were trichotomized into the following groups: 20 to34 years, 20 years, and 34 years. Mother and fatherrace were dichotomized into white and other racialbackgrounds. Mother and father education were coded

into 3 groups: some college or more, high school grad-uate or equivalent, and 12 years. Mother and fatherwork status were coded into full-time employment,part-time employment, and unemployed. A compositevariable measuring socioeconomic status (SES) was de-rived by the authors of the ECLS-B on the basis ofhousehold income, education, and occupation. Thisvariable was coded into 3 SES groups, representing high-est, middle, and lowest. Child birth weight was coded asnormal or low, and birth status was coded as singleton ormultiple birth. Household income was included as acontinuous variable. Parity was coded as a continuousvariable as the number of additional children residing inthe household with the target child, which ranged from0 to 6.

Data AnalysisDescriptive statistics for all of the outcome variableswere computed and compared for mother and fatherdepression groups using the 2 statistic (see Table 2).Logistic regression was used to model the relationshipbetween maternal and paternal dichotomized depressionscores and categorical outcome variables.43 Unadjustedand adjusted effects of depression were examined, andthe final results are displayed in Table 3. In the initialadjusted model, all of the covariates described abovewere entered; however, mother and father age, fatherrace, SES group, birth weight, and birth status (singletonversus multiple) were not significant and were droppedfrom additional analyses. All of the models were exam-ined both with and without the interaction term(mother depression father depression), and no differ-ences in main effects were observed. Therefore, finalreported results include the interaction term. The final

TABLE 2 Descriptive Statistics: Mother and Father Depression and Outcome Variables

Variable FullSample,N (%)

Both NotDepressed,

N (%)

MotherDepressed,

N (%)

FatherDepressed,

N (%)

BothDepressed,

N (%)

P

Back sleep position 2685 (52.8) 2163 (54.4) 259 (44.2) 203 (54.1) 60 (40.8) .001Child ever breastfed 3784 (74.4) 3021 (75.9) 403 (68.8) 266 (70.9) 94 (63.9) .001Child to bed without bottle 3816 (75.1) 3064 (77.1) 391 (66.7) 270 (72.0) 91 (61.9) .001Child to bed awake 3100 (61.1) 2402 (60.4) 368 (63.3) 250 (66.7) 80 (54.4) .05M read to child every day 1695 (33.3) 1384 (34.8) 157 (26.8) 107 (28.5) 47 (32.0) .001M tell stories every day 1375 (27) 1126 (28.3) 127 (21.7) 86 (22.9) 36 (24.5) .01M sing songs every day 3785 (74.4) 2991 (75.2) 417 (71.2) 267 (71.2) 110 (74.8) .10M take child on errands every day 2946 (57.9) 2298 (57.8) 342 (58.4) 219 (58.4) 87 (59.2) NSM play peekaboo a few times a week or more 4635 (91.1) 3656 (91.9) 517 (88.2) 336 (89.6) 126 (85.7) .01M tickle child a few times a week or more 5033 (98.9) 3942 (99.1) 578 (98.6) 369 (98.4) 144 (98.0) NSM play outside a few times a week or more 3780 (74.3) 2986 (75.1) 421 (71.8) 271 (72.3) 102 (69.4) NSF read to child every day 409 (8.2) 331 (8.4) 41 (7.1) 29 (7.9) 8 (5.6) NSF tell stories every day 534 (10.8) 422 (10.9) 60 (10.4) 38 (10.4) 14 (10.0) NSF sing songs every day 1731 (34.9) 1379 (35.7) 180 (31.3) 130 (35.6) 42 (29.0) .10F take child on errands every day 1177 (23.4) 911 (23.2) 134 (23.0) 101 (27.2) 31 (21.2) NSF play peekaboo a few times a week or more 4354 (87.7) 3421 (88.2) 497 (87.2) 315 (84.9) 121 (85.2) NSF tickle child a few times a week or more 4937 (98.8) 3864 (98.9) 568 (98.8) 366 (98.9) 139 (97.2) NSF play outside a few times a week or more 3006 (60.4) 2387 (61.3) 338 (59.0) 206 (55.5) 75 (52.8) .05

M indicates mother; F, father; NS, not signicant.


results are reported in the form of odds ratios (ORs),allowing for ease of interpretation. All estimates arepresented with 95% confidence intervals (CIs). All of theanalyses were conducted using Stata 8 computer soft-ware (Stata Corp, College Station, TX),44 and adjust-ments were made to account for the sampling designused in the ECLS.

Following the logistic regressions described above, anadditional set of analyses was conducted to examinewhether the degree of maternal and paternal depression(measured continuously) might influence the degree ofparent-child interaction measured by the 4 factor scoresdescribed above. Linear regressions were run on thesevariables to determine whether the degree of motherand father depression (measured using the continuousscale score on the CES-D) impacted the degree of parent-

child interaction. These analyses used the continuousCES-D scores for mothers and fathers as the independentvariables and the factor scores described above as thedependent variables. Both unadjusted and adjusted ef-fects were examined, following the same format de-scribed above for the logistic regressions (see Table 4).All of the results discussed below are the results from theadjusted models.

RESULTS

Depression in Mothers and Fathers: Descriptive StatisticsOn the basis of the dichotomous depression scores, 14%of mothers and 10% of fathers had moderate or severedepressive symptoms. On the continuous CES-D scores,mothers had a mean score of 4.58 (SD: 4.96) and fathers

TABLE 3 Adjusted Effects of Maternal and Paternal Depression on Outcomes

Variable Depression No Yes OR (95% CI)

MD FD MD FD

Sleep position back other 1.40 (1.111.76)a 0.80 (0.601.06) 0.74 (0.421.30)Ever breastfed yes no 1.48 (1.131.94)a 0.98 (0.681.41) 0.92 (0.382.21)Bed with bottle no yes 1.53 (1.162.02)a 0.99 (0.681.45) 1.08 (0.542.16)Bed awake yes no 0.75 (0.551.02)b 0.66 (0.470.91)c 2.73 (1.236.06)c

Mother read every day less often 1.24 (0.971.60) 1.04 (0.741.47) 0.59 (0.311.14)Mother tell stories every day less often 1.42 (1.081.86)c 1.40 (1.011.94)c 0.54 (0.251.17)Mother sing songs every day less often 1.12 (0.851.47) 1.16 (0.831.62) 0.60 (0.271.37)Mother errands every day less often 1.10 (0.891.35) 1.20 (0.891.63) 0.72 (0.431.20)Mother peekaboo few times a week

less often1.57 (1.082.28)c 1.12 (0.661.92) 1.11 (0.403.11)

Mother play outside few times aweek less often

1.29 (0.941.75) 1.26 (0.931.71) 0.87 (0.501.49)

Father read every day less often 1.55 (0.942.53) 1.04 (0.581.86) 0.90 (0.272.98)Father tell stories every day less often 0.99 (0.691.42) 1.23 (0.752.01) 0.76 (0.301.91)Father sing songs every day less often 1.39 (1.061.83)c 0.92 (0.681.25) 0.85 (0.431.69)Father errands every day less often 1.06 (0.761.47) 1.15 (0.791.67) 1.37 (0.583.22)Father peekaboo few times a week

less often1.00 (0.681.49) 1.28 (0.812.03) 0.50 (0.201.25)

Father play outside few times aweek less often

1.23 (0.981.55) 1.42 (1.101.85)a 0.71 (0.371.36)

The following covariates were controlled: child gender, household income, mother race, mother and father employment, mother and fathereducation, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction betweenmother and father depression. Brackets indicate reference group. Source: ECLS-B.a P .01.b P .10.c P .05.

TABLE 4 Adjusted Effects of Degree of Maternal and Paternal Depression on Degree of ParentalEngagement in Enrichment and Play Activities

Variable Depression B (SE)

MD FD MD FD

Mother enrichment activities .008 (.003)a .007 (.005) .001 (.001)a

Mother play activities .007 (.004) .000 (.005) .001 (.001)Father enrichment activities .005 (.004) .010 (.004)a .000 (.001)Father play activities .003 (.004) .005 (.004) .000 (.001)

The following covariates were controlled: child gender, household income, mother race, mother and father employment, mother and fathereducation, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction betweenmother and father depression. Brackets indicate reference group. Source: ECLS-B.a P .05.


had a mean score of 3.69 (SD: 4.67). Both mothers andfathers continuous scores on the CES-D ranged from 0to 36. 2 analyses were conducted to examine simpleassociations among maternal and paternal depressionand the outcome variables. For the purpose of theseanalyses, the sample was divided into the following 4groups, on the basis of mother and father depressionstatus using the dichotomized CES-D scores: neither par-ent depressed (N 3981; 78.2%), mother only de-pressed (N 586; 11.5%), father only depressed (N 375; 7.4%), and both parents depressed (N 147;2.9%).

Maternal and Paternal Depression and Health Behaviors

Descriptive Statistics Based on 2 AnalysesSignificant differences were found for all of the healthbehaviors, with anticipatory guidance recommendationsmost likely to be followed when neither parent suffereddepressive symptoms and least likely to be followedwhen both parents were depressed (see Table 2). Spe-cifically, when both parents were depressed, the childwas less likely to be put to sleep on his/her back (2 [3] 30.16; P .001), was less likely to have ever beenbreastfed (2 [3] 25.39; P .001), and was more likelyto be put to bed with a bottle (2 [3] 45.74; P .001).One exception to this pattern was found for putting thechild to bed awake, which was most likely to occur whenfathers only were depressed (2 [3] 9.62; P .05).

Logistic RegressionsAfter adjusting for covariates, several effects of parentaldepression on health behaviors were found in the logis-tic regressions (see Table 2). Depressed mothers wereless likely to put their infants to sleep on their backs (OR:1.40; P .01), less likely to have ever breastfed theirinfants (OR: 1.48; P .01), and more likely to put theirinfants to bed with a bottle (OR: 1.53; P .01). De-pressed fathers were more likely to put their infants tobed awake (OR: 0.66; P .05). In addition, a significantinteraction between maternal and paternal depressionwas found for putting the infant to bed awake, suggest-ing that when both parents were depressed, the infantwas less likely to be put to bed awake.

Maternal and Paternal Depression and Parent-ChildInteraction Behaviors

Descriptive Statistics Based on 2 AnalysesOn the basis of the 2 analyses, significant or trend-leveldifferences were found for 4 mother-reported parent-child interaction behaviors, with mothers being overallmore engaged with their children when neither they northeir spouse suffered depressive symptoms. Interest-ingly, mothers were least likely to read to their child (2

[3] 19.06; P .001), tell stories (2 [3] 15.45; P .01), or sing songs (2 [3] 6.50; P .10) when either

they or the childs father (but not both) was depressed.As expected, mothers were least likely to play peekaboowith their infants when both parents were depressed (2

[3] 15.50; P .01). No significant differences werefound for mother-reported taking the child on errands,tickling the child, or playing outside with the child.

For father-reported enrichment/play activities, only 1significant (play outside) and 1 trend-level (sing songs)difference was found. Fathers were most likely to playoutside with their children when neither parent wasdepressed and least likely to do so when both parentswere depressed (2 [3] 8.94; P .05). In addition,fathers were most likely to sing songs with their infantswhen neither parent was depressed or when only themother was depressed and were least likely to sing songswhen both parents were depressed (2 [3] 6.66; P .10).

Logistic RegressionsAfter adjusting for covariates, several significant effectsof maternal and paternal depression on parent-child in-teraction activities were found. Specifically, depressedmothers were less likely to tell their child stories everyday (OR: 1.42; P .05) and played peekaboo less often(OR: 1.57; P .05). When mothers were depressed,fathers were less likely to sing songs with their childrenevery day. Two significant effects of paternal depressionwere found: when fathers were depressed, mothers wereless likely to tell stories to their child every day, anddepressed fathers played outside less often with theirchildren (OR: 1.42; P .01). No significant interactionswere found.

Linear RegressionsAfter adjusting for covariates, mother enrichment activ-ities was predicted by maternal depression, as well as bya significant interaction between mother and father de-pression. A further analysis of this interaction revealed astronger negative effect of maternal depression onmother enrichment activities when the father was notdepressed than when the father was also depressed.Father depression predicted father enrichment activities,such that fathers who were more depressed engaged inless enrichment activities with their infants. No signifi-cant effects of maternal or paternal depression werefound on mother and father play activities.

DISCUSSIONThe effects of maternal and paternal depression on par-enting practices related to positive child health and de-velopment has undergone very little investigation todate. The present study was among the first to examinethe individual and combined effects of postpartum de-pression in mothers and fathers in a large, nationallyrepresentative sample of 2-caregiver families with9-month-old children across the United States. Parent-


ing behaviors that are emphasized in anticipatory guid-ance by pediatricians were the particular focus of thisstudy. We predicted that both maternal and paternaldepression would be negatively associated with parenthealth behaviors and positive interactions that are rec-ommended in anticipatory guidance. Moreover, we pre-dicted that maternal and paternal depression, together,would have a greater negative impact than just 1 parentbeing depressed. The findings that are discussed beloware those that were observed after controlling for childgender, parental work, education, race, household in-come, and number of children.

The prevalence of postpartum depression in mothers(14%) reported in our study was consistent with otherresearch and national estimates.12 Postpartum depres-sion in fathers was strikingly high (10%) and more thantwice as common than in the general adult male popu-lation in the United States.45 This finding is similar to the1 previous national finding on this topic16 in that higherthan expected rates of depression were found amongfathers in the early parenting years. It adds to the bodyof knowledge, however, in that Lyons-Ruth et al16 in-cluded parents of children birth to age 3 years, and thecurrent study focused on the postpartum period only.Because the first year of a childs life is particularlysensitive to parent-level influences, our current findingssuggest the call for increased awareness of postpartumdepression in men.

In support of the maternal depression component ofour hypothesis, maternal depression had a strong asso-ciation, overall, with fewer desirable health behaviors,including putting the infant to sleep in the back positionless often, a lower likelihood of ever breastfeeding, andputting the child to bed with a bottle more often. Thesefindings are consistent with past research showing thatdepressed mothers are less likely to engage in preventivehealth behaviors.17,18 In addition, these findings suggestthat maternal postpartum depression may preventmothers of infants from adhering to anticipatory guid-ance recommendations.

Contrary to our expectations, paternal depression wassignificantly associated only with a greater likelihood ofthe child being put to bed awake, which is consistentwith anticipatory guidance for promoting good sleephabits in children. There was a similar trend for maternaldepression. These counterintuitive findings (parental de-pression seems here to be associated with a desirablecaregiving behavior) does not necessarily suggest thatdepressed parents attend more carefully to anticipatoryguidance recommendations but may rather be an artifactof other behaviors in parents that are associated withpaternal depression (eg, 1 parent puts child to bed awaketo tend to the depressed parents needs). Contrastingthis, an interaction was observed between maternal andpaternal depression on putting a child to bed awake,such that when both parents were depressed, the child

was 3 times more likely to be put to bed asleep. Thisfinding is consistent with past literature that suggeststhat negative effects of parental depression may be ex-acerbated when both parents are depressed.36

Overall, these findings suggest that higher levels ofdepressive symptoms in parents, particularly mothers,are associated with parenting practices that are inconsis-tent with anticipatory guidance recommendations andthat have been linked to poorer health outcomes inchildren. Mothers who are distressed and experiencingthe cognitive and psychosomatic symptoms of depres-sion may be less able to attend to recommendations foreven simple preventive measures. Although the generallack of significant association between paternal depres-sion and health behaviors does not support paternaldepression as a risk factor, our study is limited by theavailability of only mother report for health behaviors.

In terms of the effects of parental depression on par-ent-child interaction, we found that maternal depressionwas associated with a lower likelihood of the motherregularly telling stories and playing peekaboo with thechild. Maternal depression was also associated with adecreased likelihood of the father singing songs to thechild every day. Paternal depression was associated witha lower likelihood of the father playing with the childoutside regularly and a lower likelihood of the mothertelling the child stories every day. These findings are ofparticular interest, because they suggest that maternaland paternal depression, in addition to negatively im-pacting the positive interactions of the suffering parent,have an impact on the other parents interactions withtheir child.

Overall, our results suggest that where day-to-dayinteractions are concerned, depressed mothers and fa-thers engage in less positive interaction with their chil-dren, with a particular reduction in the degree of enrich-ment interactions, including reading, telling stories, andsinging songs. These findings support the existing liter-ature linking maternal depression to impaired parent-child interaction3 and extend the findings to includefathers as well. These findings are concerning, becausethey suggest that the pathway from positive parent-childinteraction to developmental success46 may be jeopar-dized by depression in either parent. The moderationeffect of paternal depression on mother enrichment be-havior is unusual and has not, to our reading, beenreported in previous literature. The effect is small andshould be interpreted cautiously, but it is suggestive of afamily compensatory model in which maternal depres-sion maintains a negative association with enrichmentwhen paternal depression is not pronounced, but thisrelationship goes to 0 when fathers are more depressed.As such, mothers ignore their depression to interact atbaseline levels with their children when fathers might bemore impaired by their own depression.

This study has several limitations. First, data from the


IoniEvideniere

IoniEvideniere

9-month wave of the ECLS are cross-sectional and per-mit inferences about association but not causation. Withfuture waves of the ECLS birth cohort, however, pro-spective analysis and stronger causal assessments of therole of parental depression will become possible. In ad-dition, this study used the CES-D to assess parentaldepression, a measure that does not provide an affirmedclinical diagnosis. CES-D scores reflect a range of depres-sive symptoms that, when above an empirically deter-mined threshold, are strongly associated with a diagnosisof depression. Nevertheless, scores above the CES-Dthreshold are not fully analogous to clinically verifieddepression. Our measures of parenting behaviors aresimilarly limited in that they rely on parent self-reportalone. Although parent report of behaviors has beenfound to correspond fairly well with observational mea-sures, our data on health behaviors (ie, breastfeeding,sleep position, and sleep practices) only representmother report, one possible reason why paternal depres-sion seemed to have a largely negligible effect on thesebehaviors. Furthermore, the narrow range of responseoptions given to parents may provide a generally weakmeasure of the association between depression and care-giving and/or parenting style. It is also important to notethat depression and parenting behaviors were measuredby self-report from the same source. Future studiesshould take these limitations into account and make useof more detailed parenting style and behavior instru-ments that are available47 and/or use supplementaryobservational or diary methods. Finally, this study didnot measure whether parents actually received anticipa-tory guidance from their pediatricians on the relevanttopics. Given the increased emphasis on anticipatoryguidance in the American Academy of Pediatrics, it isreasonable to assume that most parents in the study didreceive some information from their pediatricians. How-ever, future studies are warranted that examine therelationship of parental depression to adherence to an-ticipatory guidance while considering amount of antici-patory guidance actually received. The overwhelmingstrength of this study was its careful sampling to allowfor inference to the general population of the UnitedStates. Because the ECLS is an ongoing prospectivestudy, additional waves of data will allow this study to beextended incrementally to provide a stronger picture ofthe role of depression in parenting behavior over time.

PRACTICE IMPLICATIONSThe primary practical application of these findings re-lates to identification and management of postpartumdepression in both parents. Some attention (albeit insuf-ficient) has been paid to the identification of and treat-ment for depression in mothers, particularly in the peri-natal period. Our findings suggest that postpartumdepression in both parents can interfere with the suc-cessful adherence to anticipatory guidance. Research has

shown that pediatricians are increasingly delivering an-ticipatory guidance to parents of infants during well-child visits, although many parents report areas of un-met needs.48 Our findings suggest that postpartumdepression in parents may be one factor that preventsparents from successfully applying their pediatriciansrecommendations. Thus, whereas the message may bedelivered to parents, it is not necessarily received. Thissupports the call for pediatricians to take more respon-sibility for the identification of depressive symptoms inmothers of young children.4951 Training pediatricians inthe diagnosis of depression may enhance their ability torecognize parental depression.49 Moreover, some re-search has supported the use of brief screening tools inpediatric settings in identifying mothers with depressivesymptoms who may benefit from treatment.52 Consider-ing the present findings here regarding the effect ofdepression on a fathers parenting behavior, such effortsmay bear investigation for both parents. Also, althoughthe research on the effects of paternal depression onchild outcomes is limited,19 current knowledge indicatesthat depressed fathers tend to have children with higherlevels of physical and mental health difficulties, enhanc-ing the urgency of catching this problem in families atthe earliest opportunity.

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DOI: 10.1542/peds.2005-2948 2006;118;659Pediatrics

James F. Paulson, Sarah Dauber and Jenn A. LeifermanFathers on Parenting Behavior

Individual and Combined Effects of Postpartum Depression in Mothers and

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