Depression in Parents, Parenting, and Children

Opportunities to Improve Identification, Treatment, and Prevention

Committee on Depression, Parenting Practices, and the Healthy Development of Children

Board on Children, Youth, and Families

Division of Behavioral and Social Sciences and Education

NATIONAL RESEARCH COUNCIL AND INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Depression in Parents, Parenting, and Children Opportunities to Improve Identification, Treatment, and Prevention Committee on Depression, Parenting Practices, and the Healthy Development of Children Board on Children, Youth, and Families Division of Behavioral and Social Sciences and Education

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Grant No. 61299 between the National Academy of Sciences and the Robert Wood Johnson Foundation; by Grant No. 20062466 with The California Endowment; by Grant No. 205.0794 with the Annie E. Casey Foundation; by Contract No. HHSH250200446009I with the Health Resources and Services Administration; and by Con- tract No. 270-03-6002 with the Substance Abuse and Mental Health Services Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data National Research Council (U.S.). Committee on Depression, Parenting Practices, and the Healthy Development of Children. Depression in parents, parenting, and children : opportunities to improve identification, treatment, and prevention / Committee on Depression, Parenting Practices, and the Healthy Development of Children, Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. p. cm. Includes bibliographical references and index. ISBN 978-0-309-12178-1 (hardcover) — ISBN 978-0-309-12179-8 (pdf) 1. Depression, Mental. 2. Depression in children. 3. Parenting—Psychological aspects. I. Title. RC537.N375 2009 362.2’5—dc22 2009023655 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council and Institute of Medicine. (2009). Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention. Committee on Depression, Parenting Practices, and the Healthy Development of Children. Board on Children, Youth, and Families. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON DEPRESSION, PARENTING PRACTICES, AND THE HEALTHY DEVELOPMENT OF CHILDREN MARY JANE ENGLAND (Chair), Regis College SERGIO AGUILAR-GAXIOLA, Center for Reducing Health Disparities, Clinical Translational Science Center School of Medicine, University of California, Davis KATHRYN E. BARNARD, Family and Child Nursing, University of Washington WILLIAM RIGBY BEARDSLEE, Department of Psychiatry, Children’s Hospital, Boston HOWARD J. CABRAL, Department of Biostatistics, Boston University School of Public Health BRUCE E. COMPAS, Center for Research on Human Development, Vanderbilt University PATRICK R. FINLEY, Psychopharmacology and Behavioral Health, University of California, San Francisco SHERRYL H. GOODMAN, Department of Psychology, Emory University CONSTANCE HAMMEN, Department of Psychology, University of California, Los Angeles ELIZABETH A. HOWELL, Departments of Health Policy and Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine MAREASA R. ISAACS, National Alliance of Multi-Ethnic Behavioral Health Associations, Washington, DC HENDREE E. JONES, Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Johns Hopkins School of Medicine JANE KNITZER, National Center for Children in Poverty, Mailman School of Public Health, Columbia University PATRICIA O’CAMPO, Centre for Research on Inner City Health, St. Michael’s Hospital, Toronto ARDIS L. OLSON, Pediatrics and Community and Family Medicine, Dartmouth Medical School ROBERT PHILLIPS, JR., Robert Graham Center for Policy Studies in Family Medicine and Primary Care, American Academy of Family Medicine, Washington, DC FRANK W. PUTNAM, Pediatrics and Psychiatry, Cincinnati Children’s Hospital Medical Center LESLIE J. SIM, Study Director KIMBERLY SCOTT, Senior Program Officer (until April 2008) v

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BRIDGET B. KELLY, Program Officer SARAH JOESTL, Research Associate (June–August 2008) JULIENNE PALBUSA, Research Assistant (from December 2008) REINE Y. HOMAWOO, Senior Program Assistant MATTHEW D. McDONOUGH, Senior Program Assistant (until April 2008) SARA LANGSTON, Senior Program Assistant (November 2008–January 2009) vi

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BOARD ON CHILDREN, YOUTH, AND FAMILIES BERNARD GUYER (Chair), Bloomberg School of Public Health, Johns Hopkins University JANE D. BROWN, School of Journalism and Mass Communication, University of North Carolina at Chapel Hill LINDA MARIE BURTON, Sociology Department, Duke University ANGELA DIAZ, Department of Pediatrics and Department of Community and Preventive Medicine, Mount Sinai School of Medicine GARY W. EVANS, Department of Human Development, Cornell University CHRISTINE C. FERGUSON, School of Public Health and Health Services, George Washington University SHERRY A. GLIED, Mailman School of Public Health, Columbia University WILLIAM T. GREENOUGH, Department of Psychology, University of Illinois RUBY HEARN, Robert Wood Johnson Foundation (emeritus), Princeton, NJ JACQUELINE JONES, Division of Early Childhood Education, New Jersey Department of Education MICHELE D. KIPKE, Saban Research Institute, University of Southern California Children’s Hospital, Los Angeles BETSY LOZOFF, Center for Human Growth and Development, University of Michigan PAMELA MORRIS, Policy Area on Family Well-Being and Children’s Development, MDRC, New York CHARLES A. NELSON, Laboratory of Cognitive Neuroscience, Harvard Medical School and Children’s Hospital, Boston PATRICIA O’CAMPO, University of Toronto and Centre for Research on Inner City Health, St. Michael’s Hospital, Canada FREDERICK P. RIVARA, Schools of Medicine and Public Health, University of Washington, and Children’s Hospital and Regional Medical Center, Seattle JOHN R. WEISZ, Judge Baker Children’s Center and Harvard Medical School HIROKAZU YOSHIKAWA, Graduate School of Education, Harvard University MICHAEL ZUBKOFF, Department of Community and Family Medicine, Dartmouth Medical School ROSEMARY CHALK, Board Director WENDY KEENAN, Program Associate vii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Hortensia Amaro, Bouve College of Health Sciences, Institute on Urban Health Research, Northeastern Uni- versity; Linda Beeber, School of Nursing, University of North Carolina at Chapel Hill; Joseph T. Coyle, McLean Hospital, Harvard Medical School; Deborah A. Gross, Johns Hopkins University; Milton Kotelchuck, Maternal and Child Health Department, School of Public Health, Boston University; Joanne Nicholson, Center for Mental Health Services Research, Depart- ment of Psychiatry, University of Massachusetts Medical School; Paul A. Nutting, Research Director’s Office, Center for Research Strategies, Denver, CO; Harold Alan Pincus, Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatry Insti- tute, New York Presbyterian Hospital; Mary Rainwater, Integrated Behav- ioral Health Project, The Tides Center, Los Angeles, CA; Kenneth B. Wells, Semel Institute Health Services Research Center, University of California, Los Angeles; and Joan Yengo, Programs Division, Mary’s Center for Ma- ternal and Child Care, Inc., Washington, DC. ix

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x REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Floyd E. Bloom, Department of Molecular and Integrative Neuroscience, The Scripps Re- search Institute and Elena O. Nightingale, Scholar-in-Residence, Institute of Medicine, Washington, DC. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface Today, as science continues to produce new knowledge every day on the myriad ways depression affects parents, parenting, and children in a rap- idly changing and stressful social environment, it is extremely important to integrate and apply that new knowledge so we can provide evidence-based identification, treatment, and prevention efforts across a broad spectrum of society. Of particular concern today is the recognition of the increased num- ber of depressed parents whose condition directly affects their families. To address these issues and develop recommendations for improv- ing services in families with depressed parents, five organizations and federal agencies—the Robert Wood Johnson Foundation, the Annie E. Casey Foundation, The California Endowment, and the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services—provided funding to the National Research Council–Institute of Medicine (NRC–IOM) Board on Children, Youth, and Families. Through the Board, the NRC and IOM formed the Committee on Depression, Par- enting Practices, and the Healthy Development of Children in 2008. This report, Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention, is the product of a multidisciplinary collaboration among committee members, NRC–IOM staff, and consultants. The committee held five meetings and one public workshop. Committee members and staff conducted two site visits to learn firsthand about creative approaches to providing mental health services in substance abuse settings, especially in underserved groups. We participated in vigorous discussion xi

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xii PREFACE regarding the best approaches to prevent, engage, and treat families with depressed parents, clarifying the underlying approach to this problem, and reconciling different perspectives and priorities. It is our hope that the find- ings and recommendations presented in this report will help policy makers, service providers and payers, researchers, and government agencies shift the current fragmented approach of depression care in parents from a series of individual services into a family-based system of care. The committee could not have done its work without the outstand- ing guidance and support provided by NRC–IOM staff Leslie Sim, study director; Bridget Kelly, program officer; and Kimberly Scott, senior pro- gram officer. Reine Homawoo, Wendy Keenan, Sara Langston, Matthew McDonough, and Julienne Palbusa provided highly skilled logistical sup- port. Rosemary Chalk’s guidance and counsel were invaluable throughout our deliberations. Finally, health professionals who participated in our workshops and those who shared their stories during our site visits deserve special thanks. Their experience in coping with the current system of care and their aspirations for something better fueled the committee’s resolve to make a difference. Parents today face daunting challenges, but knowledge brought to the heart and applied can help parents, children, and families. That is what this report is about. Mary Jane England, Chair Committee on Depression, Parenting Practices, and the Healthy Development of Children

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Acknowledgments Beyond the hard work of the committee and project staff, this report reflects contributions from various other individuals and groups that we want to acknowledge. The committee greatly benefited from the opportunity for discussion with the individuals who made presentations and attended the committee’s workshops and meetings (see Appendix B). This study was sponsored by the the Robert Wood Johnson Founda- tion, the Annie E. Casey Foundation, The California Endowment, and the Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. We wish to thank Elaine Cassidy, Patrick Chaulk, Gwen Foster, Lark Huang, Karen Hench, Jane Isaacs Lowe, Robert Phillips, and Linda White-Young for their support. We appreciate the extensive contributions of Robert Cole, Janice Cooper, Sara Jaffee, Sarah Joestl, Kenneth Kendler, Frances Lynch, and David Racine, who we commissioned to provide technical reviews of vari- ous portions of the report. Their insight and expertise added to the quality of the evidence presented. Katherine Elliott and Cristiana Giordano of the UC Davis Center for Reducing Health Disparities as well as Alinne Barrera of University of California, San Francisco, provided outstanding assistance in organizing literature for the committee. The committee was grateful for the opportunity to conduct site visits to two residential substance abuse treatment programs for women and their children. Committee members and staff toured the facilities and met with xiii

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xiv ACKNOWLEDGMENTS program staff to learn about the program history, services offered, sources of funding and support, and partnerships with other service organizations. Thank you to the leaders of the Entre Familia Program of the Boston Public Health Commission, including Hortensia Amaro, Barbara Ferrer, and Rita Nieves, as well as the other clinical and support staff, current cli- ents, and program graduates who took the time to meet with us and show us the facility. Thank you also to Shela Chapman and Peggy Johnson who joined us from Entre Familia partner organizations. Thank you to the staff who took the time to meet with us at the PROTOTYPES Women’s Center in Pomona, CA, including Rocksy Chenev- ert, Andrea Heinz, Julie Poirier, Garrett Staley, and April Wilson, as well as staff from other PROTOTYPES partner programs, including Jill McKenzie, Sharmelle Parker, Edith Vega, and Qiana Wallace. As well, we are indebted to others at the NRC–IOM, including Kirsten Sampson Snyder, DBASSE reports officer, who patiently worked with us through several revisions of this report; Yvonne Wise, DBASSE produc- tion editor, who managed the production process through final publica- tion; Christine McShane, who edited several revisions of the report; and Matthew Von Hendy, DBASSE librarian, who performed multiple literature searches throughout the production of this report. Mary Jane England, Chair Committee on Depression, Parenting Practices, and the Healthy Development of Children

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Contents Summary 1 1 Introduction and Magnitude of the Problem 15 2 Approach to Research and Its Evaluation 43 3 The Etiology of Depression 73 4 Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning 119 5 Screening for Depression in Parents 183 6 Treatment of Depression in Parents 205 7 Prevention of Adverse Effects 281 8 Working from the Present to the Future: Lessons Learned from Current Practice 343 9 Strengthening Systemic, Workforce, and Fiscal Policies to Promote Research-Informed Practices 385 10 Opportunities for Innovative Reforms and Knowledge Development 409 xv

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xvi CONTENTS APPENDIXES A Acronyms 431 B Depression and Parenting Workshop Agenda and Participants 435 C Biographical Sketches of Committee Members and Staff 441 Index 453

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Tribute to Jane Knitzer This report is dedicated to Dr. Jane Knitzer, Ed.D., who served as a member of this project’s committee until she passed away on March 29, 2009. Dr. Knitzer was a long-time advocate for children’s mental health, child welfare, and early childhood, adding tremendous value over her lifetime to the work of The National Center for Children in Poverty at Co- lumbia University’s Mailman School of Public Health, Cornell University, New York University, and Bank Street College of Education. Dr. Knitzer influenced many individuals and communities through her advocacy and impact on public policies for America’s most vulnerable children, youth, and families. Dr. Knitzer was an extremely committed activist, scholar, and moral leader. She provided inspiration and guidance through her work, through her extraordinary mentorship of several generations of those who worked in many diverse roles with children, youth, and their families and through her absolute insistence that children and their families deserve justice and fairness above all. Her keen instincts on policy led researchers, policy mak- ers, practitioners, and parents alike to resonate with her message for im- proving the lives of children and their families based on research-informed strategies and interventions. She particularly brought to our attention the need to attend to those who had the highest risk: children in poverty, children afflicted by violence, those in vulnerable situations, and children whose parents suffered from mental illness and related adversities. She truly helped make invisible children visible and demanded that we attend to their needs. Above all Dr. Knitzer was dedicated to highlighting the need to invest in America’s youngest children, demanding that as a nation we give children and their families the best start possible irrespective of their life circumstances. Jane Knitzer was indomitable in her cause, which was the cause of the most vulnerable among us, and she never wavered in her pursuit of what was best for children and families. Her insights and scholarship guided the deliberations and content of this report, and we dedicate it to her memory. Members of the Committee on Depression, Parenting Practices, and the Healthy Development of Children May 2009 xvii

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