Review articleThe effects of paternal depression on child and adolescent outcomes: A systematic review
Introduction
Depression is a significant mental health issue, commonly associated with functional impairments across the lifespan. Evidence suggests that depression in childhood and adolescence is associated with a heightened risk of psychiatric hospitalization, recurrent disorder and elevated risk of attempted suicide in adulthood (Harrington et al., 1990, Harrington et al., 1994). Depression is also highly comorbid and commonly associated with increased risk of alcoholism and anxiety disorders (Boden and Fergusson, 2011; Moffitt et al., 2007). Offspring of depressed parents are frequently exposed to an elevated risk of externalizing and internalizing problems, lower neurobiological development, social and academic difficulties and subsequent development of adult psychopathology (Goodman and Gotlib, 1999, Natsuaki et al., 2014, Weissman et al., 2006). Indeed, children of depressed parents are almost three times as likely to experience a lifetime episode of depression as offspring of non-depressed parents (Lieb et al., 2002, Weissman et al., 1997). These negative associations between perinatal maternal depression and adverse child developmental outcomes have been widely studied (Beck, 1998, Goodman et al., 2011). However, the literature has tended to focus on the impact of maternal depression on offspring outcomes. There has been a recent increase in empirical research investigating the effects fathers’ depression can have on offspring outcomes, with some evidence for an effect. However, the magnitude, mediators and timing is poorly understood (Kane and Garber, 2004, Kvalevaag et al., 2013), particularly with regard to potential critical periods.
Paternal depressive symptoms during pregnancy have been shown to increase likelihood of excessive infant crying (van den Berg et al., 2009). From a developmental perspective, excessive infant crying has been associated with higher levels of negative reactivity and lower emotional regulation, as well as hearing difficulties as development continues (Hestbaek et al., 2014, Stifter and Spinrad, 2002). This association has also been linked with higher scores on the emotional symptoms scale when compared with children of fathers without depression at that stage (Ramchandani et al., 2008a, Ramchandani et al., 2008b) and a higher risk of internalizing and externalizing problems (Kane and Garber, 2009). Research on postnatal depression and child development is more abundant and results indicate a strong association, with increased risk of emotional and behavioral problems in school-aged children (Weitzman et al., 2011). These heightened risks have also been linked with poorer academic performance (Doctoroff et al., 2006, Metsapelto et al., 2015), prosocial behavior and peer problems (Davé et al. 2008), as well as internalizing symptoms (Ramchandani et al., 2005) which are highly comorbid (Cummings et al., 2014). Moreover, fewer paternal depressive symptoms can act as a protective factor or “buffer” for offspring when maternal depression is present in the family environment (Melrose, 2010). Similar results exist regarding the association of paternal depression and adolescent functioning with increased likelihood of anxiety and depressive symptoms and Major Depressive Disorder (Klein et al., 2005, Reeb et al., 2010, Reeb et al., 2015). Functional impairments like these make adolescents 6 times as likely to receive a diagnosis of a disorder in adulthood when compared with their typically developing peers (Hofstra et al., 2002).
Although genetic risks have been identified in the transmission of depression (Merikangas et al., 2002), gene environment interactions may constitute important moderators of risk for developing children (Caspi et al., 2003). Cultural and societal changes may also be relevant as fathers spend more direct time with their children than historically (Cabrera et al., 2000) with a corresponding impact on child development (Ramchandani and Psychogiou, 2009). Being raised by a depressed father may thus constitute an ‘environmental’ risk for offspring development (Natsuaki et al., 2014). Epidemiological research suggests that approximately 10% of fathers are susceptible to depression in the prenatal and postpartum stage with the highest risk existing in the 3–6 month postpartum period (Paulson et al., 2010).
There is also evidence that suggests depressed mothers are more likely than non-depressed mothers to practice poor parenting behaviors and have negative interactions with their children (Hops, 1995). Depressed mothers are also less likely to promote safety behaviors that may prevent injury and harm among their children and are more likely to use corporal punishment (Chung et al., 2004; Mclennan and Kotelchuck, 2000). In light of this, it has been proposed that the impact of depression on parenting behaviors (Middleton et al., 2009, Ramchandani and Psychogiou, 2009) could be a mediating mechanism for transmission of risk to offspring. Indeed, an impaired caregiver is considered to be a major childhood risk in the Adverse Childhood Experience (ACE) literature. ACE literature has found that parental mental illness and subsequent parenting behaviors contribute to an increased risk of offspring developing a range of medical and psychological disorders (Anda et al., 2002, Chartier et al., 2010). In addition, the ACE literature indicates that exposure to stress has a greater detrimental effect of developmental outcomes on a dose-equivalent basis, and if exposure to stress occurs in the first 2–3 years of life (e.g. Shonkoff et al., 2012, Kelly-Irving et al., 2013). This corresponds with evidence that the parenting a child or adolescent receives can significantly impact on emotional and behavioral development (Bayer et al., 2008, Stormshak et al., 2000). As parenting behaviors change due to depressive symptoms, hostility and marital conflict may increase, whilst the quality and frequency of father-child interaction decreases, which consequently impacts on offspring functioning (Davé et al., 2008, Franck and Buehler, 2007, Gutierrez-Galve et al., 2015, Middleton et al., 2009, Wilson and Durbin, 2010). Parents who exhibit harsh parenting techniques or display low levels of warmth towards their children have been found to increase the risk of developing depressed mood and conduct problems for their offspring (Hipwell et al., 2008, Young et al., 1995). Moreover, research indicates that depression among fathers increases the likelihood of spanking their one-year-old infants (Davis et al., 2011) and they are more likely to express aggravation and stress in parenting, when compared with non-depressed fathers (Bronte-Tinkew et al., 2007). This is of significance as emotional and behavioral difficulties can manifest themselves because of severe discipline from the caregiver towards the child (Bayer et al., 2008). Depressive disorders may also impact on quantity and quality of paternal-offspring interaction time a father spends with their child (Paulson et al., 2006, Ramchandani and Psychogiou, 2009).
There are also methodological difficulties with this emergent literature. In particular, there is a lack of consensus regarding operationalized definitions of paternal perinatal depression and male postpartum depression (Pilyoung and Swain, 2007). Several studies have used the maternal postpartum depression definition to form the basis of a parental postpartum depression definition (Pilyoung and Swain, 2007). However, this rests on the proposition that perinatal maternal and paternal present in the same way. In addition, there is evidence of variance in the measurement of paternal depression. It is possible that issues regarding methodology, and the broader questions regarding timing and transmission of risk could be best informed by focussing on prospective study designs.
Although there have been narrative reviews of the field (Ramchandani and Psychogiou, 2009), there has as yet, been no systematic review of prospective studies investigating the outcomes for offspring of depressed fathers. Therefore, this review sought to synthesize and critically evaluate prospective studies that have examined the association between paternal depression and offspring outcomes. Our primary aim was to establish the strength of association between paternal depressive symptoms or diagnosis of depression and negative child and adolescent outcomes. Secondary aims were to identify whether parenting behavior was likely to mediate the associations between paternal depression and child and adolescent outcomes. We also sought to identify and evaluate potential methodological sources of bias in the literature.
Section snippets
Inclusion & exclusion criteria
Inclusion criteria were articles that included (i) an assessment of paternal depressive symptoms or diagnosis based on self-report or interview measures, (ii) a measure of offspring internalizing and/or externalizing behaviors, (iii) offspring sample of 21 years or younger, (iv) data which is presented and extractable on the association between paternal depression and offspring outcome (v) follow-up, cohort designs, (vi) were published in English.
Exclusion criteria were (i) studies that
Characteristics of the studies
All 21 of the studies included in the review employed a prospective cohort design; with the exception of Pilowsky et al., 2014, Gross et al., 2008 which both reported secondary analyses of longitudinal Randomised Control Trials and Batenburg-Eddes et al. (2013) which used a cross-cohort design. Batenburg-Eddes et al. (2013) combined findings from the prospective Avon Longitudinal Study of Parents and their Children (ALSPAC; Fraser et al., 2013) cohort and the Generation R (Jaddoe et al., 2010)
Discussion
The results of our systematic review indicate a pattern of associations between paternal depression and increased risk of internalizing and externalizing behaviors in offspring. This association is evident across the developmental frame from offspring age of 2 months to 21 years old. Associations were stronger and more common in early childhood, suggesting this may be a particularly sensitive period of development. This is consistent with previous literature examining the impact of maternal
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