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ARTICLE
The authors have indicated they have no nancial relationships relevant to this article to disclose.
ABSTRACT
BACKGROUND. Pediatric anticipatory guidance has been associated with parenting
behaviors that promote positive infant development. Maternal postpartum depression is known to negatively affect parenting and may prevent mothers from
following anticipatory guidance. The effects of postpartum depression in fathers on
parenting is understudied.
OBJECTIVE. Our purpose with this work was to examine the effects of maternal and
www.pediatrics.org/cgi/doi/10.1542/
peds.2005-2948
doi:10.1542/peds.2005-2948
Key Words
anticipatory guidance, parenting, fathers,
depression, child development
Abbreviations
ECLSEarly Childhood Longitudinal Study
BBirth Cohort
CES-DCenter For Epidemiologic Studies
Depression Scale
SESsocioeconomic status
OR odds ratio
CI condence interval
Accepted for publication Feb 23, 2006
Address correspondence to James F. Paulson,
PhD, Center for Pediatric Research, Eastern
Virginia Medical School, 855 W Brambleton
Ave, Norfolk, VA 23510. E-mail: paulsojf@evms.
edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2006 by the
American Academy of Pediatrics
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659
660
PAULSON et al
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includes recommendations regarding positive parentchild interactions, such as reading and playing together.
A large body of literature has demonstrated negative
effects of maternal depression on the quality of motherchild interactions. In a meta-analysis of studies in this
area,3 depressed mothers of infants and young children
were found to be more irritable and hostile, to be more
disengaged from their child, and to have lower rates of
play and other positive social interactions with their
child. Very few studies have looked at the impact of
paternal depression on parenting practices related to
parent-child interaction. Moreover, little research has
examined the joint effects of maternal and paternal depression 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 postpartum period exacerbated the effects of maternal depression on later child behavior problems only if the
father spent significant amounts of time caring for the
child in infancy. In addition, being exposed to a nondepressed father did not buffer the effects of maternal
depression even if they spent high amounts of time with
their infants. In general, these findings suggest that father involvement in the postpartum period generally
impacts children of depressed mothers but has little to no
impact on children of nondepressed mothers. Only 1
known study has examined the relations between maternal and paternal depression and specific types of interactions, such as reading, with very young children.16
This study of parents of children ages birth to 3 years in
a large national sample found that depressed mothers
were less likely to play with or read to their children
after controlling for social and demographic covariates.
Paternal depression did not affect fathers frequency of
interactions with their children after covariates were
controlled.
Overall, the current study intends to examine the
extent to which postpartum depression among parents
of infants influences their engagement in parenting behaviors that are consistent with anticipatory guidance
recommendations and that have been associated with a
stable household environment and child well-being.
This study extends past research by examining the individual and interactive effects of both mothers and fathers depressive symptoms on their parenting practices
during the postpartum period in a large, nationally representative sample. As in much of the previous literature, we define depression with a rating scale that
characterizes individuals both in terms of symptom severity and with an empirically driven cut point, above
which a respondent is likely to receive a clinical diagnosis of depression. On the basis of the findings of previous
studies, we expected that mothers and fathers depression would negatively impact their parenting behaviors,
such that parents who are depressed would be less likely
to engage in positive health behaviors, as well as enrich-
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661
TABLE 1 Demographics and Mean CES-D Scores for Mothers and Fathers With High and Low Depressive Symptoms (Total N 5089)
Variable
Mothers
Full
Sample,
N (Column %)
Age, y
20
2034
35
Race
White
Black
Hispanic
Asian/Pacic Islander
Other
Education
12th grade
High school graduate
Some college
Work status
Full-time
Part-time
Unemployed
Mean CES-D score (SD)
Low Depression
(N 4536),
N (Column %)
Fathers
High Depression
(N 733),
N (Column %)
High Depression
(N 522),
N (Column %)
151 (3.5)
3261 (74.9)
944 (21.7)
50 (6.8)
541 (73.8)
142 (19.4)
63 (1.2)
3291 (64.7)
1735 (34.1)
57 (1.2)
2925 (64.0)
1585 (34.7)
6 (1.1)
366 (70.1)
150 (28.7)
2853 (56.1)
372 (7.3)
732 (14.4)
808 (15.9)
318 (6.3)
2464 (56.6)
308 (7.1)
633 (14.6)
687 (15.8)
258 (5.9)
389 (53.1)
64 (8.7)
99 (13.5)
121 (16.5)
60 (8.2)
2915 (57.4)
419 (8.2)
737 (14.5)
725 (14.3)
286 (5.6)
2637 (57.8)
350 (7.7)
667 (14.6)
654 (14.3)
253 (5.5)
278 (53.4)
69 (13.2)
70 (13.4)
71 (13.6)
33 (6.3)
888 (17.4)
1046 (20.6)
3155 (62.0)
711 (16.3)
868 (19.9)
2777 (63.8)
177 (24.1)
178 (24.3)
378 (51.6)
742 (14.6)
1335 (26.2)
3012 (59.2)
633 (13.9)
1171 (25.6)
2763 (60.5)
109 (20.9)
164 (31.4)
249 (47.7)
1665 (32.8)
984 (19.4)
2432 (47.9)
4.58 (4.96)
1476 (33.9)
858 (19.7)
2015 (46.3)
2.96 (2.67)
189 (25.8)
126 (17.2)
417 (57.0)
14.19 (4.50)
4249 (86.1)
246 (5.0)
441 (8.9)
3.69 (4.67)
3866 (87.2)
208 (4.7)
360 (8.1)
2.45 (2.59)
383 (76.3)
38 (7.6)
81 (16.1)
14.53 (4.75)
Health Behaviors
Six items from the biological mother interview were
used to assess parental engagement in the following
health behaviors: putting the child to sleep on its back,
putting the child to bed without a bottle, putting the
child to sleep awake, and breastfeeding. Mothers were
asked to report the position in which they put their
infant to sleep as a newborn and as a 3-month-old.
PAULSON et al
Low Depression
(N 4567),
N (Column %)
201 (3.9)
3802 (74.7)
1086 (21.3)
662
Full Sample,
N (Column %)
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ficient variability in response: 99% of mothers and fathers reported tickling their child a few times a week or
more.
Because many of the items addressing parent-child
interactions were similar, exploratory factor analysis42
was used to determine whether a more parsimonious
approach to operationalizing parent-child interactions
was feasible. The principal components method with
varimax rotation was conducted on the 7 items described above for mothers and fathers separately. This
revealed 2 coherent factors of parent-child interactions
that were very similar for mothers and fathers. The
2-factor solution allows us to describe parent-child interactions with 2 variables rather than the original 7.
This approach explains 45.84% of variance for mothers
and 47.92% of variance for fathers. Factor 1 includes the
following 3 items, all of which measure enrichment
activities: read to child, tell stories to child, and sing
songs with child. Factor 2 includes the following 4 items,
which measure play activities: play peekaboo, tickle
child, take child on errands, and take child outside to
walk or play. Because of the logical consistency of their
constituent items, we named these factors enrichment
and play.
Demographic Covariates
A number of demographic variables known to be associated with the outcome variables were controlled for in
the analyses and operationalized as follows. Child gender was coded as male and female. Mother and father
age were trichotomized into the following groups: 20 to
34 years, 20 years, and 34 years. Mother and father
race were dichotomized into white and other racial
backgrounds. Mother and father education were coded
into 3 groups: some college or more, high school graduate or equivalent, and 12 years. Mother and father
work status were coded into full-time employment,
part-time employment, and unemployed. A composite
variable measuring socioeconomic status (SES) was derived by the authors of the ECLS-B on the basis of
household income, education, and occupation. This
variable was coded into 3 SES groups, representing highest, middle, and lowest. Child birth weight was coded as
normal or low, and birth status was coded as singleton or
multiple birth. Household income was included as a
continuous variable. Parity was coded as a continuous
variable as the number of additional children residing in
the household with the target child, which ranged from
0 to 6.
Data Analysis
Descriptive statistics for all of the outcome variables
were computed and compared for mother and father
depression groups using the 2 statistic (see Table 2).
Logistic regression was used to model the relationship
between maternal and paternal dichotomized depression
scores and categorical outcome variables.43 Unadjusted
and adjusted effects of depression were examined, and
the final results are displayed in Table 3. In the initial
adjusted model, all of the covariates described above
were entered; however, mother and father age, father
race, SES group, birth weight, and birth status (singleton
versus multiple) were not significant and were dropped
from additional analyses. All of the models were examined both with and without the interaction term
(mother depression father depression), and no differences in main effects were observed. Therefore, final
reported results include the interaction term. The final
TABLE 2 Descriptive Statistics: Mother and Father Depression and Outcome Variables
Variable
Full
Sample,
N (%)
Both Not
Depressed,
N (%)
Mother
Depressed,
N (%)
Father
Depressed,
N (%)
Both
Depressed,
N (%)
2685 (52.8)
3784 (74.4)
3816 (75.1)
3100 (61.1)
1695 (33.3)
1375 (27)
3785 (74.4)
2946 (57.9)
4635 (91.1)
5033 (98.9)
3780 (74.3)
409 (8.2)
534 (10.8)
1731 (34.9)
1177 (23.4)
4354 (87.7)
4937 (98.8)
3006 (60.4)
2163 (54.4)
3021 (75.9)
3064 (77.1)
2402 (60.4)
1384 (34.8)
1126 (28.3)
2991 (75.2)
2298 (57.8)
3656 (91.9)
3942 (99.1)
2986 (75.1)
331 (8.4)
422 (10.9)
1379 (35.7)
911 (23.2)
3421 (88.2)
3864 (98.9)
2387 (61.3)
259 (44.2)
403 (68.8)
391 (66.7)
368 (63.3)
157 (26.8)
127 (21.7)
417 (71.2)
342 (58.4)
517 (88.2)
578 (98.6)
421 (71.8)
41 (7.1)
60 (10.4)
180 (31.3)
134 (23.0)
497 (87.2)
568 (98.8)
338 (59.0)
203 (54.1)
266 (70.9)
270 (72.0)
250 (66.7)
107 (28.5)
86 (22.9)
267 (71.2)
219 (58.4)
336 (89.6)
369 (98.4)
271 (72.3)
29 (7.9)
38 (10.4)
130 (35.6)
101 (27.2)
315 (84.9)
366 (98.9)
206 (55.5)
60 (40.8)
94 (63.9)
91 (61.9)
80 (54.4)
47 (32.0)
36 (24.5)
110 (74.8)
87 (59.2)
126 (85.7)
144 (98.0)
102 (69.4)
8 (5.6)
14 (10.0)
42 (29.0)
31 (21.2)
121 (85.2)
139 (97.2)
75 (52.8)
.001
.001
.001
.05
.001
.01
.10
NS
.01
NS
NS
NS
NS
.10
NS
NS
NS
.05
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663
Variable
Sleep position back other
Ever breastfed yes no
Bed with bottle no yes
Bed awake yes no
Mother read every day less often
Mother tell stories every day less often
Mother sing songs every day less often
Mother errands every day less often
Mother peekaboo few times a week
less often
Mother play outside few times a
week less often
Father read every day less often
Father tell stories every day less often
Father sing songs every day less often
Father errands every day less often
Father peekaboo few times a week
less often
Father play outside few times a
week less often
MD
FD
MD FD
1.40 (1.111.76)a
1.48 (1.131.94)a
1.53 (1.162.02)a
0.75 (0.551.02)b
1.24 (0.971.60)
1.42 (1.081.86)c
1.12 (0.851.47)
1.10 (0.891.35)
1.57 (1.082.28)c
0.80 (0.601.06)
0.98 (0.681.41)
0.99 (0.681.45)
0.66 (0.470.91)c
1.04 (0.741.47)
1.40 (1.011.94)c
1.16 (0.831.62)
1.20 (0.891.63)
1.12 (0.661.92)
0.74 (0.421.30)
0.92 (0.382.21)
1.08 (0.542.16)
2.73 (1.236.06)c
0.59 (0.311.14)
0.54 (0.251.17)
0.60 (0.271.37)
0.72 (0.431.20)
1.11 (0.403.11)
1.29 (0.941.75)
1.26 (0.931.71)
0.87 (0.501.49)
1.55 (0.942.53)
0.99 (0.691.42)
1.39 (1.061.83)c
1.06 (0.761.47)
1.00 (0.681.49)
1.04 (0.581.86)
1.23 (0.752.01)
0.92 (0.681.25)
1.15 (0.791.67)
1.28 (0.812.03)
0.90 (0.272.98)
0.76 (0.301.91)
0.85 (0.431.69)
1.37 (0.583.22)
0.50 (0.201.25)
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 father
education, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction between
mother 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 Parental
Engagement in Enrichment and Play Activities
Variable
Depression B (SE)
MD
FD
.008 (.003)a
.007 (.004)
.005 (.004)
.003 (.004)
.007 (.005)
.000 (.005)
.010 (.004)a
.005 (.004)
MD FD
.001 (.001)a
.001 (.001)
.000 (.001)
.000 (.001)
The following covariates were controlled: child gender, household income, mother race, mother and father employment, mother and father
education, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction between
mother and father depression. Brackets indicate reference group. Source: ECLS-B.
a P .05.
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665
ing behaviors that are emphasized in anticipatory guidance by pediatricians were the particular focus of this
study. We predicted that both maternal and paternal
depression would be negatively associated with parent
health behaviors and positive interactions that are recommended in anticipatory guidance. Moreover, we predicted that maternal and paternal depression, together,
would have a greater negative impact than just 1 parent
being depressed. The findings that are discussed below
are those that were observed after controlling for child
gender, parental work, education, race, household income, and number of children.
The prevalence of postpartum depression in mothers
(14%) reported in our study was consistent with other
research and national estimates.12 Postpartum depression in fathers was strikingly high (10%) and more than
twice as common than in the general adult male population in the United States.45 This finding is similar to the
1 previous national finding on this topic16 in that higher
than expected rates of depression were found among
fathers in the early parenting years. It adds to the body
of knowledge, however, in that Lyons-Ruth et al16 included parents of children birth to age 3 years, and the
current study focused on the postpartum period only.
Because the first year of a childs life is particularly
sensitive to parent-level influences, our current findings
suggest the call for increased awareness of postpartum
depression in men.
In support of the maternal depression component of
our hypothesis, maternal depression had a strong association, overall, with fewer desirable health behaviors,
including putting the infant to sleep in the back position
less often, a lower likelihood of ever breastfeeding, and
putting the child to bed with a bottle more often. These
findings are consistent with past research showing that
depressed mothers are less likely to engage in preventive
health behaviors.17,18 In addition, these findings suggest
that maternal postpartum depression may prevent
mothers of infants from adhering to anticipatory guidance recommendations.
Contrary to our expectations, paternal depression was
significantly associated only with a greater likelihood of
the child being put to bed awake, which is consistent
with anticipatory guidance for promoting good sleep
habits in children. There was a similar trend for maternal
depression. These counterintuitive findings (parental depression seems here to be associated with a desirable
caregiving behavior) does not necessarily suggest that
depressed parents attend more carefully to anticipatory
guidance recommendations but may rather be an artifact
of other behaviors in parents that are associated with
paternal depression (eg, 1 parent puts child to bed awake
to tend to the depressed parents needs). Contrasting
this, an interaction was observed between maternal and
paternal depression on putting a child to bed awake,
such that when both parents were depressed, the child
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9-month wave of the ECLS are cross-sectional and permit inferences about association but not causation. With
future waves of the ECLS birth cohort, however, prospective analysis and stronger causal assessments of the
role of parental depression will become possible. In addition, this study used the CES-D to assess parental
depression, a measure that does not provide an affirmed
clinical diagnosis. CES-D scores reflect a range of depressive symptoms that, when above an empirically determined threshold, are strongly associated with a diagnosis
of depression. Nevertheless, scores above the CES-D
threshold are not fully analogous to clinically verified
depression. Our measures of parenting behaviors are
similarly limited in that they rely on parent self-report
alone. Although parent report of behaviors has been
found to correspond fairly well with observational measures, our data on health behaviors (ie, breastfeeding,
sleep position, and sleep practices) only represent
mother report, one possible reason why paternal depression seemed to have a largely negligible effect on these
behaviors. Furthermore, the narrow range of response
options given to parents may provide a generally weak
measure of the association between depression and caregiving and/or parenting style. It is also important to note
that depression and parenting behaviors were measured
by self-report from the same source. Future studies
should take these limitations into account and make use
of more detailed parenting style and behavior instruments that are available47 and/or use supplementary
observational or diary methods. Finally, this study did
not measure whether parents actually received anticipatory guidance from their pediatricians on the relevant
topics. Given the increased emphasis on anticipatory
guidance in the American Academy of Pediatrics, it is
reasonable to assume that most parents in the study did
receive some information from their pediatricians. However, future studies are warranted that examine the
relationship of parental depression to adherence to anticipatory guidance while considering amount of anticipatory guidance actually received. The overwhelming
strength of this study was its careful sampling to allow
for inference to the general population of the United
States. Because the ECLS is an ongoing prospective
study, additional waves of data will allow this study to be
extended incrementally to provide a stronger picture of
the role of depression in parenting behavior over time.
PRACTICE IMPLICATIONS
The primary practical application of these findings relates to identification and management of postpartum
depression in both parents. Some attention (albeit insufficient) has been paid to the identification of and treatment for depression in mothers, particularly in the perinatal period. Our findings suggest that postpartum
depression in both parents can interfere with the successful adherence to anticipatory guidance. Research has
shown that pediatricians are increasingly delivering anticipatory guidance to parents of infants during wellchild visits, although many parents report areas of unmet needs.48 Our findings suggest that postpartum
depression in parents may be one factor that prevents
parents from successfully applying their pediatricians
recommendations. Thus, whereas the message may be
delivered to parents, it is not necessarily received. This
supports the call for pediatricians to take more responsibility for the identification of depressive symptoms in
mothers of young children.4951 Training pediatricians in
the diagnosis of depression may enhance their ability to
recognize parental depression.49 Moreover, some research has supported the use of brief screening tools in
pediatric settings in identifying mothers with depressive
symptoms who may benefit from treatment.52 Considering the present findings here regarding the effect of
depression on a fathers parenting behavior, such efforts
may bear investigation for both parents. Also, although
the research on the effects of paternal depression on
child outcomes is limited,19 current knowledge indicates
that depressed fathers tend to have children with higher
levels of physical and mental health difficulties, enhancing the urgency of catching this problem in families at
the earliest opportunity.
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