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7 Prevention of Adverse Effects SUMMARY Prevention Interventions That Specifically Target Families with Depressed Parents â¢ Studies of interventions that target families with depressed parents have shown the potential to prevent adverse outcomes in children across all developmental stages. These include interventions that prevent or treat depression in the parent, those that target the vulnerabilities of the children, and those that improve parent-child relationships and parenting practices. However, the evaluation of these interventions has rarely included large-scale trials or wide- spread implementation or dissemination. Broadly Focused Prevention Interventions in Families with Depressed Parents â¢ Some evidence suggests that prevention strategies that focus more broadly on parenting and child development can be effective even when there is a high rate of depression among parents. However, most evidence-based prevention strategies have not been evaluated for their relative effectiveness in families with depressed parents. Enhancements of these strategies with components targeted spe- cifically to families with depressed parents have also rarely been evaluated. 281
282 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN â¢ Existing service programs for families, such as early childhood edu- cation and home visitation, often provide preventive services that focus more broadly on parenting and child development. These service programs often serve a large number of depressed parents. Although these programs offer opportunities to identify depression in parents and to integrate treatment and prevention services, few programs routinely do so. Prevention for Vulnerable Families â¢ Some prevention programs targeted to families with depression have been shown to be effective in low-income families and in families from varied cultural and linguistic backgrounds. There is less evidence on the effectiveness of these programs in families with co-occurring conditions such as exposure to trauma and co-existing mental and substance abuse disorders. â¢ A variety of existing service programs serve vulnerable families, such as social welfare programs and substance abuse services. Al- though these programs offer opportunities to identify depression in parents and to integrate treatment and prevention services, few programs routinely do so. ____________________ As described in this report, major depression is a highly prevalent disorder among adults of parenting age, and, as a consequence, millions of children in the United States are exposed every year to the risk associated with depression in a parent. Even more children are exposed to heightened levels of depressive symptoms in parents who do not meet diagnostic crite- ria; these children have also been demonstrated to be at increased risk. So far we have focused on identifying and treating depression in parents. This chapter focuses on efforts to prevent the effects that depression in parents can have on their families, as described in Chapter 4. The importance of preventive efforts is underscored by the scope of the problem and by the high percentage of adult depression, including parents, that goes untreated. Treating parental depression, attending to childrenâs needs, and assisting parenting are all necessary components to foster resilience, promote health, and prevent disorder in families in which parents are depressed. An important framework exists for understanding the available litera- ture. The National Academies recently published a report on the preven- tion of mental, emotional, and behavioral disorders among young people (National Research Council and Institute of Medicine, 2009). The com- mittee strongly supports the overall perspective on prevention presented in
PREVENTION OF ADVERSE EFFECTS 283 Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The report emphasizes several general points about prevention that apply to the prevention of depression in families: (1) prevention requires a shift to a public health focus from the traditional disease model, in which one waits for the occurrence of disease before action; (2) not only are the immediate needs of the child and family important but also their longer term needs; (3) mental health and physical health are inseparable and should be viewed as different aspects of the same underlying developmental processes; (4) mental, emotional, and behavioral disorders and their prevention are inherently developmental, and coordi- nated systems-level interventions are needed to address them. The preven- tion report emphasizes the need for a developmental perspectiveâjust as this report does in considering the prevention of adverse outcomes of parental depression. The needs of children are quite different at ages 4, 8, or 12, so different interventions need to be tailored for children and their parents at different developmental stages. Studies of parental depression can involve different types of focus. In some studies, severely ill parents with depression are identified, and the interventions focus primarily on depression. In others, depression in par- ents often serves as the identifier of a constellation of adversities that may include poverty, minority status, living in low-resource, difficult neighbor- hoods, social isolation, and exposure to violence. Although parental depres- sion is an important condition to be addressed, comprehensive prevention efforts must also address these other factors. Additional risk factors that often need to be addressed systematically include comorbidity, divorce, and diminished social status. The committee reviewed the relevant literature in order to identify ex- amples of interventions or programs that target families with a depressed parent or that illustrate important conceptual principles for addressing the needs of these families, as well as to identify areas in which relatively little intervention research has been conducted. The committee did not seek to systematically identify all existing interventions and program evaluations. We drew on existing meta-analyses and systematic reviews whenever pos- sible and supplemented with additional literature searches to identify rel- evant evidence-based programs. Whenever possible, we limited our review to interventions that have been evaluated in at least one randomized trial. In some cases, nonrandomized studies are discussed if that was the best available evidence for an approach to families with a depressed parent. The chapter text focuses on concepts and major outcomes. A table at the end of the chapter summarizes methodological details, study population demographics, and outcome measures for interventions that target families with a depressed parent. The chapter begins with the available evidence on prevention of depres-
284 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN sion in parents, which is a first-line approach to preventing the adverse ef- fects on children. The main focus of the chapter, however, is on approaches to reduce adverse outcomes in children, with a special emphasis whenever possible on interventions that take a two-generation approach to addressing the parentâs depression, parenting, and child outcomes. The committeeâs review revealed promising programs and important conceptual frameworks related to preventing the effects that depression in parents can have on families. These studies themselves and the broader con- text of prevention research indicate that there is a considerable promise to the approach and that current lines of investigation need expansion. How- ever, despite the immense costs of parental depression in many different areas of life, as yet there are no large-scale, widely implemented prevention programs within systems in the United States to address parental depres- sion. There is, therefore, a need to develop large-scale programs based on the existing knowledge base and on promising programs and, at the same time, to refine and evaluate these programs at various levels in order to determine the most effective and cost-effective preventive interventions. A FRAMEWORK FOR PREVENTIVE INTERVENTIONS Significant interest and a substantial knowledge base in the area of prevention have accumulated over the past 15 years. A broad framework for preventive interventions has been presented by the Institute of Medicine (IOM) report Reducing Risks for Mental Disorders (1994) and the previ- ously mentioned report Preventing Mental, Emotional, and Behavioral Dis- orders Among Young People (National Research Council and Institute of Medicine, 2009). As outlined in the these reports, the usual sequence lead- ing to the eventual widespread dissemination of preventive interventions is, first, the identification of risk factors and protective mechanisms, then the development of promising approaches and efficacy studies of preven- tive interventions, followed by large-scale effectiveness and dissemination studies, and finally the implementation of prevention programs. Chapter 4 described evidence related to the first step in prevention research, reviewing a number of identified mechanisms that mediate the association between de- pression in parents and adverse outcomes in children, including biological, psychological, and interpersonal processes. This chapter considers preven- tive interventions, with a focus on those that have been designed to directly address the source of risk for children by reducing parental depression through prevention or treatment and by targeting possible mechanisms of risk, including psychological vulnerabilities in children of depressed parents (e.g., Clarke et al., 2001), family relationships (e.g., Beardslee et al., 2007), and parenting and childrenâs ways of coping (e.g., Compas, Forehand, and Keller, 2009).
PREVENTION OF ADVERSE EFFECTS 285 The IOM framework defines prevention as intervening before the onset of a disorder in order to prevent or reduce risk for the disorder. This is distinct from treatment, which is targeted to individuals with a diagnos- able disorder and is intended to cure the disorder or reduce its symptoms or negative effects on that individual. The framework also distinguishes between preventive interventions delivered to the general population (called universal prevention), to individuals exposed to known risk factors (selec- tive prevention), and to individuals exhibiting signs or symptoms of a disorder (indicated prevention). By definition, interventions that target the children of parents with current or past depression are either selective or indicated: the target populations are identified by exposure to the risk of parental depression (selective prevention) and, in some cases, by the onset in the children and adolescents of symptoms of related adverse outcomes (indicated prevention). Preventive interventions have been delivered in a variety of contexts, including health care settings, early childhood settings, schools, and communities. Evaluating the effects of prevention programs is complex, as effects may not manifest for months or years after delivery of the intervention, and lasting preventive effects must be documented over long periods of time. PREVENTION OF DEPRESSION IN PARENTS Adults and Adolescents of Parenting Age A first-line approach to preventing the effects of depression in parents is prevention of depression in adults and adolescents of parenting age. This is an important aspect, along with treatment, of reducing the burden of disease and its effects on parenting and child development. A recent meta- analysis reviewed 19 studies that used a randomized design to examine whether prevention programs are capable of reducing the incidence of de- pression (Cuijpers et al., 2008). This review was not designed to examine depression in parents but did include some studies of parents or adults of parenting age. Of these 19 studies, 11 included interventions with adults and 7 involved adolescents. Of the 11 studies with adults, 4 involved inter- ventions delivered to pregnant women, 3 with women during the postpar- tum period, 1 with older adults, and 3 with adults in the typical parenting age range (ages 18â50). Interventions were delivered in a variety of settings using universal, selective, and indicated approaches. The mean incidence rate ratio was 0.78, indicating a reduction in incidence of depression by 22 percent, although the limited duration of follow-up in most studies makes it difficult to distinguish whether this reflects a true reduction in incidence or a delay in onset. Thus, as reflected in this meta-analysis, there is promising evidence that
286 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN it is feasible to reduce depression in adults and adolescents through preven- tive interventions, and these approaches could potentially be used to target parents of children at all developmental stages, starting with preconception. Although some of the existing interventions that have been rigorously tested were delivered to adults of parenting age, with the exception of strategies specifically targeting pregnant or postpartum women (see the next section), they were not designed specifically to prevent depression in parents, nor did they assess whether the subjects were parents or analyze outcomes for parents as a distinct subgroup. Indeed, just as there is a limited number of treatment studies analyzing outcomes in parents, there is a lack of evidence on effective prevention strategies targeted to parents and on the relative ef- fectiveness in parents of current prevention strategies devised for adults in general. Further evaluation of current preventive interventions is needed in which the parenting status of the participants is tracked and outcomes for parents are analyzed. In addition, evaluations are needed of new interven- tions or adaptations of existing interventions that incorporate approaches specifically targeted to adults or adolescents who are parents, including, for example, multigenerational approaches such as those described in this chapter. Pregnant and Postpartum Women Although broad intervention approaches to prevent depression in adults are generally not targeted to parents, there are prevention strategies specifically focusing on pregnancy and the postpartum period. A variety of approaches have been used in interventions designed to prevent depression in the postpartum period. These include psychotherapeutic approaches based on the same principles as approaches for the treatment of postpartum depression, including cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT), along with psychoeducation, social support, and other supportive services. Evidence from rigorous evaluations of prevention models is limited, and the results are mixed. Although a few programs have been shown to be promising, others fail to demonstrate significant effects on measures of depressive symptoms or a diagnosis of depression (Battle and Zlotnick, 2005; Dennis, 2005; Dennis and Creedy, 2004). A few examples of programs that have shown promise in at least one randomized trial are described below. In addition, most evaluations of interventions to prevent postpartum depression do not include measures of child outcomes, so the impact of these interventions on reducing adverse outcomes for children is not known. Further evaluation of these approaches in diverse populations of mothers and delivered in diverse settings is needed to determine if more widespread implementation would be warranted.
PREVENTION OF ADVERSE EFFECTS 287 The ROSE Program:â Zlotnick conducted two randomized clinical trials of an interpersonal psychotherapy-based group intervention to prevent depres- sion in pregnant women receiving public assistance who were at high risk for depression (Zlotnick et al., 2001, 2006). Known as the ROSE Program (Reach Out, Stand Strong, Essentials for New Mothers), the intervention is designed to help an ethnically diverse group of mothers-to-be on public assistance improve close interpersonal relationships, build social support networks, and master their transition to motherhood. At 3 monthsâ post- partum, mothers in the intervention group were significantly less likely to have a diagnosis of postpartum depression. Telephone Peer Support:â Using a different approach, Dennis et al. (2009) reported a large, randomized trial of an individualized, telephone-based peer support intervention. The participants were women receiving post- partum care in seven health regions in Canada who were identified as high risk for depression owing to elevated depressive symptoms. They were matched with trained peer volunteers who had recovered from postpartum depression and received a minimum of four peer-support phone sessions starting at 2 weeksâ postpartum. At 12 weeksâ postpartum, a significantly fewer number of the mothers in the intervention group had scores on the Edinburgh Postnatal Depression Scale (EPDS) consistent with postpartum depression. Other interventions designed to prevent depression in the postpar- tum period through psychotherapeutic, psychoeducational, and social sup- port approaches have been evaluated in randomized trials but have not demonstrated an effect. For example, some approaches that have not demonstrated similar success have included a six-session group cognitive- behavioral therapyâbased program targeted at mothers of very preterm infants (Hagan, Evans, and Pope, 2004); a single, individual critical incident stress debriefing session after childbirth (Priest et al., 2003); and a series of six weekly prenatal and one postnatal group classes focused on cognitive and problem-solving approaches and enhancing social support (Brugha et al., 2000). This difference in outcomes may result from methodological differences and intervention design, but it may also be explained by the level of risk in the study population. The ROSE Program is distinct from these other trials because it targeted a high-risk population in terms of both demographics and depressive symptoms. The peer telephone support intervention was evaluated in a more general demographic population but was also targeted to women at high risk based on symptoms. Thus, there appears to be prom- ise for indicated prevention approaches to address postpartum depression in women at high risk, but universal approaches have not been as successful. Universal prevention is discussed later in this chapter.
288 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Infant Sleep:â Maternal depression has been associated with infant sleep problems (Bayer et al., 2007), and a recent randomized trial tested the ef- fects of an infant sleep intervention on depression in mothers. A behavior modification program designed to improve infant sleep was delivered by well-child nurses to 8-month-old infants in well-child care centers in Aus- tralia with mothers reporting a problem with their infantsâ sleep (Hiscock et al., 2007, 2008). Infant sleep problems were significantly reduced at 10 and 12 months compared with the control group, maternal depressive symptoms were also significantly reduced for the sleep intervention group, and the EPDS scores of the intervention group improved consistent with a reduction in postpartum depression. Parenting practices were also assessed using the Parent Behavior Checklist, as was child mental health using the Child Behavior Checklist. Neither measure differed markedly between the intervention and control groups (Hiscock et al., 2008). This trial was conducted in a more generalized population of mothers and suggests that targeting infant sleep problems may be an additional promising approach to preventing postpartum depression. PREVENTION OF ADVERSE OUTCOMES IN CHILDREN There are at least six potential models preventive interventions for chil- dren of depressed parents: (1) treatment of depression in adults (including parents), (2) early childhood interventions, (3) teaching parenting skills, (4) cognitive-behavioral interventions to address the childrenâs risk factors, (5) interventions to strengthen family functioning, and (6) family cognitive- behavioral interventions to teach both parenting skills to depressed parents and coping skills to their children. Research on these approaches is at vari- ous stages of maturity. Treatment of Parentsâ Depression Arguably the most direct method of prevention of adverse outcomes in children of depressed parents would involve the treatment of parentsâ depression to remission and prevention of relapse. However, only a few investigations have examined the influence of antidepressants or psycho- therapy on parenting or child outcomes. Therefore, key questions remain about the effects of treatment on families and the role of treatment in the prevention of adverse outcomes for children of depressed parents. Gunlicks and Weissman (2008) reviewed the findings of 10 studies that examined the association between improvement in parentsâ depres- sion and their childrenâs psychopathology. They conclude that, although there is some evidence that successful treatment of parentsâ depression has
PREVENTION OF ADVERSE EFFECTS 289 been associated with improvement in childrenâs symptoms and functioning, treatment may not be sufficient for improving cognitive and other aspects of child development. However, they note that research on the effects of treating parentsâ depression as a means of preventing adverse outcomes in children is in its early stages and that further study is needed. This review was not limited to interventions evaluated in randomized trials. It includes some randomized trials of interventions focused specifically on treatment for the parent (included in the examples described immediately below) as well as interventions that included components targeting parent-child inter- action (described in the later section on parenting interventions). Findings from the child component of the Sequence Treatment Alter- natives to Relieve Depression (STAR*D) trial are illustrative of the status of research on the effects of treatment of parentsâ depression on childrenâs mental health (Weissman et al., 2006). The study found that successful pharmacological treatment of mothersâ depression to remission over 3 months was associated with significant reductions in mental health prob- lems in their children compared with baseline. During the year following initiation of treatment for maternal major depressive disorder, decreases in the childrenâs psychiatric symptoms were significantly associated with decreases in maternal depression severity (Pilowsky et al., 2008). An ad- ditional analysis of the STAR*D trial examined the fates of single mothers: investigators found that this population was much less likely to complete treatment and less likely to remit if they remained in treatment (Talati et al., 2007). The impact of the single motherâs remission on her children was less dramatic than that found with two-parent households, but these results failed to achieve statistical significance. Two other studies examined the familial impact of successfully treating dysthymia, a persistent form of low-grade depressive illness (Browne et al., ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ 2002; Byrne et al., 2006)ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ . The authors reported a decrease in emotional and behavioral symptoms for children whose parents had successfully re- sponded to pharmacotherapy (sertraline), interpersonal psychotherapy, or a combination thereof. Other studies have focused specifically on treatment of postpartum de- pression. A study reported by Murray et al. (2003) and Cooper et al. (2003) investigated the effects of three different psychological treatments delivered by home visits for depressed postnatal women on maternal and childhood outcomes. They measured immediate and long-term maternal mood and depression as well as child and parenting outcomes. Although there were initial benefits at 4.5 months postpartum, the effects on maternal depres- sion did not persist after 9 months, and they found no persistent impact of parental treatment on behavioral management, childhood attachment, or cognitive outcomes (Cooper et al., 2003; Murray et al., 2003).
290 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Another study investigated the impact of interpersonal psychotherapy for maternal postpartum depression on child and parent outcomes. Al- though treatment improved maternal depression, it did not have a sig- nificant impact on parenting or child outcomes, even when mothers who responded successfully to treatment were analyzed separately (Forman et al., 2007; OâHara et al., 2000). Based on the available data, treatment to remission seems promising for reduction of child psychopathology in older children. However, these studies have not measured possible changes in parenting behaviors as a function of mothersâ depression status, leaving unanswered at present the question of the role of possible improvements in parenting that are suffi- cient to improve child outcomes. In addition, treatment interventions have not shown sustained success in infant children of depressed mothers or in improving parenting skills, parent-child relationships, or child developmen- tal outcomes other than psychopathology. In addition, it remains unclear whether treatment that improves symptoms but does not lead to remission can have any benefits for child outcomes or whether any beneficial effects of parental treatment to remission are lost if the depression recurs. Gunlicks and Weissman (2008) call for more careful documentation of the relation between parental and child symptoms, the differential effect of parentsâ treatment with psychological versus pharmacological treatment, and pos- sible mediators and moderators of the relation between parental improve- ment and child psychopathology. In addition to measures of childrenâs symptoms and diagnoses related to psychopathology, it is important to more fully understand the effects of parentsâ treatment on other functional developmental outcomes for children, such as social, emotional, and aca- demic competence, as well as on quality of parenting. Interventions for Children of Depressed Parents in Early Childhood There is good evidence that intensive intervention early in life for high- risk children and their parents can have significant long-term effects on childrenâs outcomes (National Research Council and Institute of Medicine, 2009). These interventions target those at risk because of multiple factors, including in some cases parental depression; when reported, parental de- pression is found to be highly prevalent in some studies of early childhood interventions, such as Early Head Start (Administration for Children and Families, 2002). Early childhood interventions take place in a variety of settings, and many target multiple domains, such as health, mental health, social and emotional development, relationships, and parenting. The effectiveness of these interventions for children of parents with depression has not been specifically examined in most studies. In addition, there are few examples of programs that deliver interventions designed to
PREVENTION OF ADVERSE EFFECTS 291 target changes in both childrenâs outcomes and parentsâ depression, either when parental depression is the primary concern or when depression serves as the identifier of a constellation of risk factors. Examples of approaches or programs with promise or informative evidence for future interventions are described below. Home Visitation A wide range of home visitation services exist that are intended to improve maternal well-being and to promote optimal child development, but only a few have been rigorously evaluated. A recent meta-analysis showed that home visiting programs do have significant cognitive and social-emotional development gains for children (Sweet and Appelbaum, 2004). Two national models, the Nurse-Family Partnership (NFP) and Healthy Families America (HFA), have each been subjected to at least three randomized controlled trials. Significant outcomes replicated across two or more trials include (1) improved prenatal health, (2) fewer child- hood injuries, (3) increased maternal employment, and (4) improved school readiness. Evidence for the prevention of child maltreatmentâa major community justification for funding these programsâhas proven harder to document, although several recent evaluations point to reductions in maternally reported maltreatment and harsh parenting. Home visiting programs offer an opportunity for access to depressed mothers and their children, and home visiting has been evaluated as a set- ting for treatment of postpartum depression (see Chapter 6). However, there have not been many rigorous, randomized evaluations of home visiting programs or program enhancements designed specifically for mothers with depression and their children, nor have there been many studies specifically assessing the links between child outcomes and maternal depression in home visiting programs. There have been some small trials of interventions delivered through home visiting that have evaluated both maternal and child outcomes. These include the treatment intervention described earlier, which showed some short-term benefit for maternal depression but had no effect on parenting or child outcomes (Cooper et al., 2003; Murray et al., 2003) as well two mother-child interventions described later in this chapter, which showed some promising effects on parent-child interaction and child development but no effect on maternal depressive symptoms (Horowitz et al., 2001; van Doesum et al., 2008). There is also some limited evidence on the effects of maternal depres- sion on the effectiveness of more broadly targeted home visiting programs. Program developers and researchers have identified three major impedi- ments to effectiveness that transcended the different home visiting ser- vice models: domestic violence, substance abuse, and maternal depression
292 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN (National Research Council and Institute of Medicine, 1999). These are widely recognized as seriously undermining maternal engagement, motiva- tion, and the utilization of skills and opportunities offered by home visita- tion services, and a 1999 National Academies workshop report observed that âdepression, for example, interferes with engagement and motivation to follow up on visits, which makes it more likely that a family will not fully experience the programâ (National Research Council and Institute of Medicine, 1999, p. 11). An evaluation of Healthy Families Massachusetts (Jacobs et al., 2005) found that symptoms of depression interfered with parenting beliefs, knowledge, and confidence and was negatively correlated with peer social support. Maternal depression was also a significant predic- tor of decreased emotional availability of the child. Given that maternal depression can interfere with the effectiveness of home visiting programs, and home visiting offers an opportunity to de- liver interventions to address maternal depression, one promising approach may be to both embed ways to recognize parental depression in existing programs and enrich these programs with interventions specifically for depressed parents when needed. Early Childhood Education Early education programs that combine early education with compre- hensive health and social services have been shown to have a lasting impact on childrenâs cognitive scores, behavioral development, school retention, and adult productivity (Nelson, Westhues, and MacLeod, 2003). Although there are several different effective programs, few examples of interventions in this setting specifically address depression in parents. Early Head Start has been evaluated in a large-scale random assign- ment study (Administration for Children and Families, 2002). Designed for children from birth to age 3, Early Head Start includes early education, parenting education, health and mental health services, and family support. The data suggest that Early Head Start strengthens parenting and has sig- nificant but somewhat modest effects on child development. The strongest findings were in programs that had both home visiting and center-based services and programs that were well implementedâthat is, the most com- prehensive programs had the largest effect. However, the program did not have a favorable impact for families with three or more demographic risk factors (single parent, receiving public assistance, unemployed parent, teen- age parent, parent lacking high school diploma or GED). Although not designed to target parental depression, in a subsample of programs that measured depression, about half of mothers in the project were depressed. Greater positive effects of Early Head Start on some parent- ing and child outcomes were seen in families in which the mother was at
PREVENTION OF ADVERSE EFFECTS 293 risk for depression compared with children whose mothers were not at risk (Administration for Children and Families, 2002). Early Head Start had no effect on maternal depression 1 year after enrollment, but, after 3â5 years, depressive symptoms were reduced. The earlier impacts on child outcomes mediated this effect on maternal depression (Chazan-Cohen et al., 2007). Given the high prevalence of maternal depression in early childhood programs such as Early Head Start, these programs offer an opportunity to deliver interventions to address maternal depression. Therefore, as with home visitation programs, one promising approach may be to embed ways to recognize parental depression in existing early childhood programs and to enrich these programs with parenting interventions specifically for de- pressed parents and referral for mental health services. In addition, because the combination of multiple risk factors was associated with worse out- comes, program enhancements to address other family needs, for example, income and educational needs, may also be warranted in order to maximize program outcomes. Interventions for Children of Depressed Parents in Childhood and Adolescence Clarke and colleagues have developed a cognitive-behavioral preven- tive intervention for youth at high risk of depression and have evaluated it specifically in children of depressed parents (Clarke et al., 1995, 2001). Adolescent youth with subdiagnostic depressive symptoms whose parents were being treated for depression received 15 1-hour group sessions or usual care (Clarke et al., 2001). Adolescents in the intervention reported significantly fewer symptoms of depression at postintervention and 12- month follow-up and a significantly lower rate of newly diagnosed major depressive episodes at 12-month follow-up. This trial has recently been replicated in a larger, four-site randomized trial (Garber et al., 2007, 2009). In this case, the participants had current depressive symptoms or a history of depression or both and also had a parent with a current or past episode of major depression. At 8 months after enrollment, a significant preventive effect was found, but this was moderated by parental depression at enroll- ment. For adolescents with parents with a history of depression but not currently depressed at baseline, the intervention led to reduced onset of depression. However, when the adolescents in the intervention group had a parent with current depression at enrollment, the rates of new depression posttreatment were not significantly different. Depression is one of the major adverse outcomes for children of de- pressed parents, and this intervention demonstrates that it is possible to prevent episodes of major depression in these children. However, the impor- tance of the current status of the parentâs depression in the expanded rep-
294 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN lication trial highlights the concept that preventive interventions targeting the children of depressed parents may not be sufficient unless the depressed parent is also adequately treated. Interventions Targeting Parent-Child Relationships and Parenting Skills As described in Chapter 4, parenting skills and practices are disrupted and impaired in parents with depression. Therefore, a third approach to preventive intervention for their children is to address parenting as a me- diator of the effects of the depression. Many parent training approaches have demonstrated effectiveness on a range of child and parent outcomes (Kaminski et al., 2008; National Research Council and Institute of Medi- cine, 2009). However, only a few parenting interventions have been specifi- cally designed to improve the quality of parenting by depressed parents or have been evaluated specifically in a population of depressed parents. There is some evidence, however, on the relative effectiveness of par- enting interventions for parents with depression in evaluations of more broadly targeted parenting interventions. On one hand, some parenting interventions have been shown not only to improve outcomes for children of depressed parents but also to reduce depressive symptoms in parents. On the other hand, elevated symptoms of depression have been found in some studies to limit the effectiveness of parenting interventions. Thus, although parents who are struggling with depressive symptoms may be less likely to benefit from efforts to improve their parenting skills, participation in parenting interventions can contribute to a reduction in parentsâ depressive symptoms and improve child outcomes. Parent-Child Interactions in Infancy and Early Childhood Many of the treatment and preventive interventions described earlier in this chapter and in Chapter 6 that target depression in postpartum women have not assessed outcomes for children or focused on the parenting re- lationship. However, there is a robust literature on approaches in early childhood that foster interactions between mothers and infants or toddlers, and some of these approaches have been evaluated in mothers with depres- sion or depressive symptoms. In these evaluations, these interventions have shown positive effects on parent-child interactions, indicating that these interventions can be effective even in the presence of maternal depression and in both low-income mothers and more generalized populations. Some have also been shown to treat maternal depression. Horowitz et al. (2001) evaluated interaction coaching in the setting of home visits for depressed mothers with the goal of improving maternal re- sponsiveness or the motherâs ability to accommodate to an infantâs behavior
PREVENTION OF ADVERSE EFFECTS 295 through regulation of her own behavioral responses. Interaction coaching took place during three home visits when the infants were ages 4â18 weeks. The researchers found significant improvements in maternal-infant respon- siveness but did not find an effect on depressive symptoms. In another recent example, an individually tailored mother-baby inter- vention was delivered through home visits in the Netherlands to depressed mothers with infants ages 1â12 months (van Doesum et al., 2008). The mothers met diagnostic criteria for a major depressive episode or dysthymia and were under concurrent outpatient treatment that was not part of the intervention. The major components of the intervention were modeling of parenting, cognitive restructuring, practical pedagogical support, and infant massage. At 6-month follow-up, the intervention group showed significant improvements in infant attachment security, mother-child interaction, and child socioemotional competence. Child externalizing, internalizing, and dysregulation measures were not significant. The improvement in maternal- infant interaction for the intervention group was not attributable to de- creased maternal depressive symptoms, which decreased equally in both groups. In another approach to improving mother-infant interaction, depressed lower-income mothers were trained to assess their newborn infantsâ be- havior using an instrument called Motherâs Assessment of the Behavior of Her Infant (Hart, Field, and Nearing, 1998). Mothers then carried out this assessment weekly for 1 month. This intervention led to significant improvements compared with control mother-infant pairs on measures of the Neonatal Behavioral Assessment Scale. The intervention did not have any effect on maternal depression. Field et al. (2000) evaluated a more comprehensive intervention for low-income adolescent mothers with depressive symptoms and their infants. This multicomponent intervention was delivered in a public vocational school and consisted of free day care for the infants; social, educational, and vocational programs for the mothers; several mood induction interventions for the mothers, including relaxation therapy and music mood induction; and infant massage therapy and mother-infant interaction coaching, which have previously been shown to improve child outcomes and parenting in- teractions for mothers with depression (Field et al., 1996; Malphurs et al., 1996; Pelaez-Nogueras et al., 1996). At 12 months postpartum, the mothers who received the intervention had significantly reduced depressive symp- toms compared to depressed mothers who did not receive the intervention, although they were not reduced to the level of nondepressed control moth- ers. Their parent-child interactions also significantly improved, and their infants scored significantly better on measures of infant development. Another approach in early childhood that targets both the parent and the child and has been evaluated in mothers with depression is toddler-
296 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN parent psychotherapy (TPP) (Lieberman, Weston, and Pawl, 1991). In TPP, mothers and their toddlers are seen in joint sessions with a therapist with the aim of improving the mother-child interaction and maternal responsiv- ity. TPP has been shown to increase attachment security and foster cogni- tive development in children of depressed mothers (Cicchetti, Rogosch, and Toth, 2000; Cicchetti, Toth, and Rogosch 1999). In more recently published evaluation results, Cicchetti and colleagues (Cicchetti, Toth, and Rogosch, 2004; Toth et al., 2006) again demonstrated the efficacy of TPP in fostering secure attachment in mothers with depression. There were no effects on the mothersâ depression. Parent Training Interventions In a review of the effects of group-based parenting programs on mater- nal psychological health, Barlow, Coren, and Stewart-Brown (2008) identi- fied 11 programs that measured depression or depressive symptoms using a range of standardized instruments. A meta-analysis of these programs showed a small but significant improvement in the intervention groups. Of the 11 studies, 7 showed no difference or only a nonsignificant dif- ference favoring the parents who received the intervention (Cunningham, Bremner, and Boyle, 1995; Greaves, 1997; Gross, Fogg, and Tucker, 1995; Irvine et al., 1999; McGillicuddy et al., 2001; Nixon and Singer, 1993; Patterson et al., 2002), and 4 of the individual studies showed significant effects (Pisterman et al., 1992; Scott and Stradling, 1987; Sheeber and Johnson, 1994; Taylor et al., 1998). Although depression was measured as an outcome for parents, none of these four trials was specifically targeted to parents with depression. Scott and Stradling (1987) demonstrated significant improvement in depression levels on the Irritability, Depression, and Anxiety Scale for moth- ers of children with parent-reported behavior problems after a seven-session series of behavioral parenting sessions. Sheeber and Johnson (1994) studied a series of nine weekly sessions of a program focused on behavioral strate- gies for parents of children with âdifficult temperaments.â They found a significant reduction in levels of depression on the depression subscale of the Parenting Stress Index. In an evaluation of the Parent and Child Series (PACS) Program, Taylor et al. (1998) found significant improvements in depression as measured by the Beck Depression Inventory (BDI). This in- tervention used videotape modeling for parents of children with a diagnosis of conduct disorder. In contrast, two other studies evaluating the PACS Program (Gross, Fogg, and Tucker, 1995; Patterson et al., 2002) did not find significant effects. Pisterman et al. (1992) found significant improve- ment on the depression subscale of the Parenting Stress Index for parents of children with attention deficit disorder with hyperactivity who participated
PREVENTION OF ADVERSE EFFECTS 297 in 12 weekly parent training sessions focused on improving parent-child interaction and child compliance. In another, more recent, example of a parenting program with a demon- strated effect on depression in parents, DeGarmo, Patterson, and Forgatch (2004) found that changes in parenting by single or separated mothers led to subsequent reductions in their sonsâ (mean age 8 years at baseline) exter- nalizing and internalizing behavior problems. Changes in the sonsâ behavior problems in turn led to reductions in mothersâ depressive symptoms over a period of 2.5 years. Thus, in this intervention, the effects of teaching parent- ing skills on maternal depressive symptoms were mediated by the decrease in childrenâs behavior problems. Tonge et al. (2006) also found that a parent education and behavior management intervention led to improvements in parentsâ depression. This intervention for parents of children with autism led to a reduction on the depression measure of the General Health Ques- tionnaire for parents who began the trial with high levels of depressive symptoms. Effects on child outcomes were not reported. These studies provide evidence that teaching parenting skillsâsuch as responsive and nurturing behavior, effective use of positive reinforcement, consistency in responding to child behavior, positive interactions with the child, promoting social skillsânot only can improve outcomes for children but also can contribute to reductions in parentsâ depressive symptoms, similar to interventions to improve parent-child interactions in infancy and early childhood. Kaminski et al. (2008) note that an increased sense of self- efficacy that results from improvement in parenting skills and reductions in childrenâs behavior problems may contribute directly to reductions in parentsâ depressive symptoms. However, it is also possible that parenting interventions help to mobilize parents to seek additional mental health ser- vices that are responsible for reducing their depressive symptoms. Most of these parent training programs evaluating effects on depression in parents have not been targeted to parents with depression. Rather, they have been targeted to parents of children with behavioral problems or clinical diag- noses or parents experiencing additional stressors, such as separation. It is therefore not clear how well these results can be generalized to a broader population of families. There is also some evidence that parental depression can reduce the effectiveness of some parenting programs, as was seen with the home visit- ing and early childhood programs described above. The Incredible Years, for example, is a training program that includes components for parents, teachers, and children designed to promote social, emotional, and academic competence, to reduce childrenâs aggression and behavioral problems, and to prevent them from developing conduct problems. Two randomized tri- als in Head Start have shown that the Incredible Years Parenting Training Program resulted in significant improvement in parent-child interactions
298 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN and child behaviors (Webster-Stratton, 1998; Webster-Stratton, Reid, and Hammond, 2001). In an evaluation of the role of mental health factors and parental engagement, researchers found that parental depression had a small negative effect on program engagement, a factor that was associated with program benefits in a dose-response fashion. The estimates of program effectiveness were also slightly lower for parents with elevated levels of depressive symptoms. However, these differences were small, and families with a depressed parent nonetheless significantly benefited from the pro- gram (Baydar, Reid, and Webster-Stratton, 2003). This suggests that parents with depression can benefit from parenting programs and from enhance- ments to increase their engagement and link them to treatment. The Triple P Program, for example, is a parenting intervention with multiple levels of interventions, including an enhanced component that provides skills and support to deal with parental depression, marital discord, or other family challenges (Sanders, 1999). Combining Parent Training and Treatment of Depression Two randomized controlled trials have combined interventions to teach parenting skills with treatment for parentsâ depression and assessed the effects of the interventions on maternal depression and childhood behav- ioral problems (Sanders and McFarland, 2000; Verduyn et al., 2003). Sanders and McFarland (2000) randomized a small number of families with depressed mothers of young children with behavior problems to ei- ther a behavioral family intervention or a family intervention integrating CBT strategies for treatment of depression with the teaching of parent- ing skills. Both treatments were equally effective in reducing depressive symptoms in the mothers and behavior problems in the children immedi- ately post-intervention. However, at 6 months, more families that received the CBT family intervention maintained the reductions in both depressive symptoms and had concurrent changes in depressive symptoms and child behavior problems than the families receiving behavioral therapy. Verduyn et al. (2003) also examined CBT for depression with parenting skills en- hancement for depressed mothers of young children in a randomized trial with a mothersâ support group and no intervention as comparison groups. Although within-group analyses revealed improvement of child behavior problems and maternal depression in the CBT group pretest to posttest at 6 and 12 months, there was no difference among the three randomized comparison groups.
PREVENTION OF ADVERSE EFFECTS 299 Two-Generation Preventive Interventions Based on the evidence for the effects of depression on parenting qual- ity and child outcomes, there is a strong theoretical basis to suggest that the most effective prevention interventions will incorporate multiple ap- proaches and target both generations by including active components for both parents and children. There is therefore a need to design and evaluate comprehensive, two-generation interventions that focus on parenting and take preventive approaches to address the needs of children and their de- pressed parents. Family Talk Intervention Beardslee and colleagues have developed and evaluated a preventive intervention for children at risk for depression owing to their parentsâ depression. This intervention was designed so that it could be used with all families facing parental depression. Its aim is to increase protective processes in the familyâfor example, better communication, increased understanding of one another and of the illness, and support for resilience- enhancing activities in children, such as accomplishing age-appropriate developmental tasks or experiencing good peer relationships (Beardslee and Podorefsky, 1988). This intervention has been evaluated in three randomized trials com- paring two active forms of intervention, one a two-session lecture for par- ents in a group format and the other a clinician-facilitated intervention of a series of sessions with both family meetings and separate meetings with parents and children. In both the first pilot study and a second larger trial, sustained changes were found in behaviors and attitudes toward the illness as well as reported increases in family communication and attention to the childrenâs experience in both groups, with a significantly greater change in the clinician-facilitated group (Beardslee et al., 1997, 2003). Analysis of the combined sample from the first two trials at 2.5 and 4.5 years after enrollment showed a sustained increase for both sets of intervention groups in the two main targets of intervention (behavior and attitudes toward the illness in the parents and understanding of parental illness in the children), with a significantly greater effect in the clinician-facilitated group. Parents who changed the most in behavior and attitude had children who increased the most in understanding (Beardslee et al., 2003, 2007). In addition, in both groups, there was a gradual increase in both parentsâ and childrenâs Family Relationship Inventory scores and a decline in scores on the Youth Self-Report Depression Subscale, but there were no significant differences between the clinician-facilitated group and the lecture comparison group. Recognition and treatment of depression when it occurred was also in-
300 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN creased in both intervention groups compared with the recognition of de- pression prior to enrollment (Beardslee et al., 2007). Similar effects were found in a third, small, randomized trial to evaluate an adaptation for use with single mothers who were members of minority groups (Podorefsky, McDonald-Dowdell, and Beardslee, 2001). The principles in this approach and the specific Family Talk Interven- tion have been used in a number of large-scale efforts to address children of the mentally ill and specifically children of parents with depression. For example, the lecture sessions were adapted for use in the state of Delaware by the Delaware Mental Health Association. The Family Talk Intervention has also been selected for use in several large-scale programs for children of the mentally ill in Holland and Finland (Beardslee et al., in press; Solantaus and Toikka, 2006). This large-scale implementation effort is discussed in more detail in Chapter 8. Family Cognitive-Behavioral and Parenting Skills Intervention Building on the work of Clarke and Beardslee, Compas and colleagues have developed and evaluated a preventive intervention for depressed par- ents and their children with two active componentsâteaching parenting skills to parents and teaching children skills to cope with their parentsâ de- pression (Compas, Forehand, and Keller, 2009; Compas, Keller, and Fore- hand, in press). This intervention model is based on evidence that parentsâ depression is associated with increased levels of withdrawn and irritable or intrusive parenting and that these patterns of parenting are associated with increased levels of childrenâs internalizing and externalizing problems (Jaser et al., 2005; Langrock et al., 2002). Conversely, childrenâs use of second- ary control coping (acceptance, cognitive reappraisal, distraction) to cope with these stressful interactions with their parents is associated with lower internalizing and externalizing problems (Langrock et al., 2002; Jaser et al., 2005, in press). An open-trial pilot study established the feasibility, acceptability, and initial effects of an earlier version of this family intervention (Compas, Keller, and Forehand, in press). A total of 34 families participated. Each family had a parent who had experienced at least one episode of depression during the lifetime of his or her children; half of the sample had a parent who met criteria for a current depressive episode at the time of assessment. After 10 small-group interventions, parentsâ reports of their childrenâs problems showed significant decreases in aggressive behavior problems, withdrawn behavior, total internalizing problems, and total externalizing problems. Significant effects were also found on self-reports of depression in the parents on the BDI-II. Initial findings from an ongoing, randomized clinical trial in a sample
PREVENTION OF ADVERSE EFFECTS 301 of 111 families further suggest that this is a promising approach to the prevention of adverse outcomes in children of depressed parents (Compas, Forehand, and Keller, 2009). Compared with a psychoeducational informa- tion comparison condition, significant effects have been found favoring the intervention group on adolescentsâ self-reports of their depressive symptoms and other internalizing and externalizing problems, as well as on parentsâ reports of adolescentsâ externalizing symptoms over the first 12 months af- ter the intervention. Furthermore, significantly greater reductions have been found in the group intervention on parentsâ depressive symptoms on the BDI-II at 2 months after enrollment; however, effects on parentsâ depressive symptoms were not sustained at 6- or 12-month follow-ups. These interventions demonstrate that a focus on parenting in combina- tion with several prevention approaches that address the needs of the chil- dren as well as the needs of parents with depression has great promise for addressing the adverse effects of depression on families. A comprehensive, two-generation approach to intervention design is directly related to the impairments in parenting described in Chapter 4, underscoring a strong theoretical basis. The examples described above offer a preliminary base of evidence in practice; however, further replication and larger scale studies are needed to evaluate the feasibility and effectiveness of implementing these kinds of programs in real-world settings in which parents can be reached. UNIVERSAL AND PUBLIC HEALTH APPROACHES Although not the focus of this chapter, it is worth noting that a poten- tially important part of any comprehensive approach to supporting families dealing with depression is a broad awareness of the need for universal public health strategies. Such efforts focus on wellness and mental health promotion as a way to reduce the incidence of depression for adults and adolescents, including those who are or may become parents. These efforts may include a focus on diet and nutrition, exercise, sleep, stress reduction, social support, and education. For pregnant women, these approaches also include quality prenatal care, adequate nutrition, and avoidance of harmful substances, all of which can improve health outcomes for both mothers and children (Bodnar and Wisner, 2005; Clapp, 2002; Honikman, 2002). Universal prevention and public health approaches are challenging to design. It can be very difficult to evaluate the extent to which they can lead to prevention of depression in parents and of adverse outcomes in children of depressed parents. There is a very limited evidence base for effects of universal prevention and public health approaches on depression in fami- lies, and very few programs have had rigorous evaluations. The work that has been done has centered around pregnancy and the postpartum period. Social support and education have commonly emerged
302 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN as possible avenues to reduce stress and other risks for depression and to increase awareness about depressive symptoms. One approach has been broad public awareness campaigns and strategies to institute universal education for expectant families about postpartum depression. These are discussed in more detail in Chapter 8. Elements of social support and education are also evident in interventions for pregnant and postpartum women that are both universally and selectively targeted, such as the pre- ventive interventions described earlier in this chapter for which there was greater success in programs targeted to high-risk mothers. This is consistent with a systematic review of randomized trials of postpartum support and education. Shaw et al. (2006) found that universal interventions delivered to unselected women did not result in statistically significant improvements in any outcomes related to maternal mental health, parenting, quality of life, or physical health. A more recent large multicommunity universal intervention effort in Australia called PRISM (Program of Resources, Infor- mation, and Support for Mothers) incorporated not only community-based education and supportive services for mothers but also training for health care providers with the aim of improving their recognition of maternal depression and their capacity to address it (Lumley et al., 2006). However, in a cluster randomized trial, the intervention was not effective in reducing depression at 6 months postpartum, a result that the authors attributed in part to the smaller than expected impact of education and training of the primary caregivers. Although there is a lack of strong direct evidence for effects on mater- nal depression, universal approaches focused on prenatal and postpartum support are an area of public health program design and implementation. Thus, like the areas of home visiting, early childhood, and parenting pro- grams described earlier, research is warranted to explore these programs as opportunities to rigorously evaluate embedded strategies to recognize parental depression and to enrich them with interventions specifically for depressed parents and referral for mental health services. For example, one emerging approach to universal supportive care in pregnancy is the group care model. The Centering Healthcare Institute offers two group care models, one for pregnant mothers (Centering Preg- nancy) and one for new mothers (Centering Parenting) (Agency for Health- care Research and Quality, 2008). Centering Pregnancy brings together groups of 8 to 12 pregnant women who are at a similar stage in their preg- nancy. The groups meet in 10 2-hour sessions in which participants receive physical assessment, education and skills building, and support through facilitated group discussion. This group care model has been shown in a randomized controlled trial to produce improved pregnancy and birth out- comes (Ickovics et al., 2007). Centering Parenting brings together 5 or 6 mother-baby pairs and follows a schedule according to well-baby visits. A
PREVENTION OF ADVERSE EFFECTS 303 notable benefit of this approach is that the care is billable and sustainable (as a part of prenatal care and well-baby care). Although results have not been published on the effects of this model of care on antepartum or post- partum depression, the program is currently being evaluated for its impact on psychosocial outcomes, including stress and depression (Ickovics, 2008, personal communication). PREVENTION FOR VULNERABLE FAMILIES Many factors contribute to a heightened risk for depression in fami- lies, including poverty, housing and employment insecurity, and distressed neighborhoods; minority and immigrant status; co-occurring conditions, such as substance abuse, trauma, child abuse, and domestic violence; and family stressors. Some prevention intervention evaluations have examined the moderating effects of these risk factors. There are also interventions that directly address some of these risk factors in families, but there is limited evidence for the effects of these interventions on depression in families or for their relative effectiveness in families with depression. Examples of in- terventions with some specific evidence or highly applicable principles are reviewed here. A recurring theme is that interventions for high-risk families can op- erate in many ways. In some cases, interventions targeted at risk factors reduce depression in parents as well as improve parenting and child out- comes. In other cases, the presence of depression in a family can alter the effectiveness of the interventions. Depression can sometimes decrease the effectiveness of the program, presumably by interfering with the quality of the familyâs participation. In other examples, programs are more effective for families with depression, presumably because the higher level of risk in these families at the outset makes them most amenable to improvement as a result of the intervention. Poverty and Related Risk Factors There is increasing awareness of the inseparability of poverty and both risk for depression and child developmental outcomes. The 2009 National Research Council and Institute of Medicine prevention report highlighted the risk that poverty can confer and emphasized that âthe future mental health of the nation depends crucially on how, collectively, the costly legacy of poverty is dealt withâ (National Research Council and Institute of Medi- cine, 2009, p. xv). Previous chapters of this report have emphasized how the study of parental depression strongly reinforces the need to address poverty and health disparities. As described earlier in this chapter, early childhood intervention pro-
304 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN grams, including Early Head Start and some home visitation programs, were targeted to low-income families, and the rates of depression were found to be very high. This has also been seen in other emerging approaches to improving outcomes for low-income mothers. For example, a pilot project in Chicago found high rates of depression in the participants in a program evaluating the use of a community-based doula (a new motherâs aid) for young mothers in low-income communities, which is now being implemented more broadly and is undergoing a randomized controlled, lon- gitudinal study (Altfeld, 2003; Robert Wood Johnson Foundation, 2008). Although, in most programs, evaluation is needed of the relative ef- fectiveness of these early childhood programs when a parent is depressed, the available evidence does indicate that interventions to prevent adverse effects of depression in parents can be effective in low-income families. For example, many of the effective interventions for families with depression described earlier in this chapter, especially in pregnancy, postpartum, and early childhood, were targeted to low-income families (e.g., ROSE and some parent-child interaction interventions). For interventions that focus on parent training, a recent meta-analysis of parent training interventions similarly found consistent evidence for positive outcomes for families in poverty (Reyno and McGrath, 2006). However, depressive symptoms in the parent were a significant threat to the success of many of these interventions, with the interpretation that depressive symptoms work against parentsâ motivation to attend and to consistently apply what is taught. As described earlier, however, depres- sive symptoms in parents can also correlate with greater improvement in response to an intervention. In an evaluation of the Incredible Years in low-income Head Start children, for example, increased parenting ca- pability reduced child behavior problems at home and in the classroom, and the level and duration of maternal participation were associated with positive child outcomes (Baydar, Reid, and Webster-Stratton, 2003; Reid, Webster-Stratton, and Baydar, 2004). Depressive symptoms did reduce ma- ternal engagement. Despite this, symptomatic mothers benefited from the intervention as much as, or more than, nonsymptomatic mothers, which was attributed to their poorer initial parenting skills (Baydar, Reid, and Webster-Stratton, 2003). Given the high prevalence of maternal depression in prevention pro- grams targeted to low-income families and the potential for depression to interfere with the effectiveness of programs in this vulnerable population, in order to maximize outcomes in these programs there is once again cause to consider developing and evaluating approaches to embed recognition of parental depression and referral for mental health services along with pro- grammatic enrichment for the subpopulation of depressed parents.
PREVENTION OF ADVERSE EFFECTS 305 Employment and Income Assistance Programs As just described, prevention interventions designed to improve out- comes for children and families can be effective in low-income families. In addition, programs that address poverty by increasing employment and in- come can have positive effects on parenting and on child outcomes (Morris, Duncan, and Clark-Kauffman, 2005). However, based on available evi- dence, it is not clear whether programs designed to address employment, poverty, and housing can also affect depression in parents or improve child outcomes specifically in families with depression, because few studies have directly addressed this question. A few examples of projects using random- ized designs that have included some evaluation of depression in parents, parenting, or child developmental outcomes are described below. New Hope Project:â The New Hope project in Milwaukee, Wisconsin, pro- vided income supplementation, job search assistance, and subsidized health insurance and child care in families that were primarily African American and Hispanic (Epps and Huston, 2007; Huston et al., 2005; Miller et al., 2008). The program increased parental employment and family income while the benefits were in place. There were significant improvements in childrenâs academic performance and positive social behavior as well as a decrease in problem behavior. There was little impact on parenting practices and parent-child relations or psychological well-being in parents. Minnesota Family Investment Program:â The Minnesota Family Invest- ment Program (MFIP) provided financial incentives to encourage work as well as employment-focused activities and services to predominantly non-Hispanic European Americans and African Americans in urban coun- ties in Minnesota (Gennetian and Miller, 2002). MFIP increased employ- ment, earnings, and income in families through 3 years after entry into the study. Children in families receiving the program were less likely to exhibit problem behaviors and more likely to perform better and be more engaged at school. The program reduced the incidence of mothers at high risk for depression (Center for Epidemiologic Studies Depression Scale [CESD] score of 24 or above) but did not have effects on the home environment and parenting, except for a significant increase in parental supervision of children. New Chance Project:â The New Chance demonstration project, which took place in 10 states, focused on young women who bore children as teenagers and were high school dropouts. The project provided adult education, occupational skills training, job assistance, health and family planning classes and services, group and individual counseling to address
306 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN problems in the mothersâ lives, parenting classes, and classes on life skills, such as communication and decision making (Quint, Bos, and Polit, 1997). Over half of the overall sample at the outset of the study were at risk of clinically significant depression based on CESD scores. The percentage at risk for depression decreased in both the experimental and control groups, but the intervention did not have a significant effect on depression relative to the control group. CESD scores improved more for mothers in the con- trol group than for mothers in the New Chance group, and, at 42-month follow-up, the mothers in the program group were at higher risk of depres- sion than those in the control group. This was hypothesized to result from the greater instability in living arrangements in the program group as well as from raised expectations for improvement that remained unmet. The program group also reported higher levels of parental stress and rated their children as having more behavior problems, an effect that was concentrated among those mothers who were at risk of depression at baseline. At the 18-month follow-up, children in the New Chance group did have more favorable home environments than the control group based on the Home Observation for Measurement of the Environment (HOME) scale, which evaluates aspects of the home environment, such as cognitive stimulation, safety, emotional support in mother-child interactions, and harshness of discipline. By the 42-month follow-up, however, this effect persisted only for the subset of mothers who were not at initial risk of depression. An in-depth examination of parenting behavior and child de- velopment in a subset of families, using coded videotaped observations of interactive tasks for the mother and child, showed that, at an average of 21 months after enrollment, the program had positive effects on parenting, but these were not accompanied by a difference in child developmental outcomes measures (Zaslow and Eldred, 1998). Moving to Opportunity:â In a randomized housing mobility experiment as part of a demonstration project called Moving to Opportunity, families living in high-poverty public housing projects in five U.S. cities were given vouchers and counseling to help them move to private housing in neighbor- hoods with lower levels of poverty. The study population was comprised predominantly of African American or Hispanic female heads of household with children. The families were offered housing vouchers, allowing them to move to neighborhoods that were safer and had significantly lower poverty rates than those of control families who were not offered vouch- ers. There were significant reductions in psychological distress and in the probability of a diagnosis of a major depressive episode, with systematically larger effect sizes for the group experiencing larger changes in neighbor- hood poverty rates (Kling et al., 2004; Kling, Liebman, and Katz, 2007). Taken together, these findings support the principle that policies and
PREVENTION OF ADVERSE EFFECTS 307 programs that target poverty and related risk factors, such as employment, income, and housing, have some potential for beneficial effects on child outcomes, parenting, and depression in families. However, the evidence in this area is mixed, and in some cases outcomes appear to be worse for families with depression or parents at high risk for depression. Therefore, further evaluation is needed, both of the effects of these programs on the subset of participating families with depression and, as noted in previous discussions, of enhancing the intervention to maximize the benefits for these high-risk families, such as incorporating access to mental health services and providing more intensive outreach, engagement, and support services to both parents and children in families with depression. Subsequent inter- vention research of this kind can be further informed by studies that have identified compensatory actions that parents can take to reduce the adverse effects of poverty and other social risk factors on children (e.g., Jarrett and Burton, 1999). The data on the effects of employment, income, and housing interven- tions in families with depression, although limited, are also sufficient to suggest that a complementary approach is also worth considering. Com- prehensive early childhood and parenting programs that are targeted to or serve low-income families with depression may benefit from designing and evaluating enhancements that offer income, employment, and housing support as a possible means to increase their effectiveness in this vulnerable population. Families with Co-occurring Conditions As described in this report, families with depression are more vulner- able to potential adverse outcomes when there is a co-occurrence of such conditions as substance abuse, trauma, child abuse, family conflict, and domestic violence. Although these coexisting risk factors are likely to play a role in the effectiveness of many of the interventions discussed in this chapter, there is very limited rigorous evidence to examine how these fac- tors interact with parental depression in approaches to preventing adverse outcomes in children. In the area of substance abuse, for example, there are programs that take a family-based approach to prevention of substance abuse in children and adolescents, such as the Strengthening Families Program (Spoth et al., 2002; Spoth, Redmond, and Shin, 2001). This is a highly regarded, evidence-based, family skills training program, but it is not targeted at families with parents with substance abuse or co-occurring depression. In addition, the relative effectiveness for such families is not known, although there is some indication that the intervention works equally well in high- risk and low-risk families, based on a broad measure of risk that includes
308 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN internalizing symptoms in parents (Guyll et al., 2004; Spoth et al., 2006). Several substance abuse prevention programs are specifically targeted to children growing up in homes in which caregivers have substance use dis- orders. For example, Alateen is a program for children of alcoholics based on the Alcoholics Anonymous 12-Step Program of Recovery, which has been widely adopted. However, at the present time, very few evaluation data on the effectiveness of Alateen are available. In general, a review of the prevention and intervention programs targeted to children of caregivers with alcohol or substance use disorders showed that they have not received enough rigorous evaluation to demonstrate prevention or reduction in alco- hol or drug use consumption (Emshoff and Price, 1999), and there are no data on the relative effectiveness for families also coping with depression in the parents. As described in Chapter 6, residential substance abuse programs for women and their children, such as those that are part of the Boston Public Health Commission and PROTOTYPES, take comprehensive, innovative approaches with potential for addressing the overlapping challenges of substance abuse, depression, and trauma (see Box 6-2). Although rigorous data for child outcomes are not available, the two-generation approach that includes treatment interventions for the parent, parenting training, and pre- ventive interventions for the children is a formula that warrants attention for further evaluation and as an informative model for the design of other intervention programs. Cultural and Linguistic Competence and Adaptation in Design and Implementation of Prevention Interventions The availability of culturally and linguistically appropriate interven- tions is an important element in addressing disparities in attention to de- pression in vulnerable populations. The discussion of issues of engagement and barriers to care in Chapter 6 applies as well to preventive interventions as it does for treatment. A crucial component in the effective implementation of programs to prevent the adverse outcomes of depression in vulnerable families is the cul- tural and linguistic appropriateness of the design and delivery of interven- tions to serve diverse populations. Van Vorhees and colleagues conducted a systematic review of the literature to identify modifiable mechanisms and effective interventions for the prevention of depression in the health care setting at the system, community, provider, and individual patient level (Van Voorhees et al., 2007; see also Chapter 6). From their review of the limited number of studies that examined potential effects of preventive interven- tions for adult depression on disparities, Van Vorhees and colleagues con- cluded that adapting standard preventive interventions to enhance cultural
PREVENTION OF ADVERSE EFFECTS 309 relevance to Hispanics (MuÃ±oz et al., 1995), African Americans (Napholz, 2005; Phillips, 2000), and American Indians (Manson and Brenneman, 1995) showed promising results. Similarly, many of the interventions de- scribed in this chapter, particularly those targeted to early childhood, were evaluated primarily in minority populations, and thus have demonstrated effectiveness in these groups. In other cases, such as the Family Talk Intervention, trials subsequent to the pilot study have focused on culturally specific adaptations for new populations. As described earlier, the Family Talk Intervention was adapted for use with inner-city, single-parent, minority families with positive results (Podorefsky, McDonald-Dowdell, and Beardslee, 2001). The intervention approach has also been recently adapted for use with Hispanic clients, and a manual for the conduct of the intervention in Spanish has been developed. The modifications include delivering the intervention both in English and Spanish, a focus on acculturation stress and the immigration experience as well as depression, flexibility in delivering the sessions, and careful attention to treating the families with respect. An open trial involving nine families with pre- and postassessment receiving the clinician-centered intervention has shown that it is safe and feasible and led to significant changes in be- haviors and attitudes toward the illness. The families also had high scores on a standard self-report rating of the parentsâ therapeutic alliance with the therapist providing the intervention (DâAngelo et al., 2009). Future work on interventions to serve families with depression can also draw on the example of successfully adapted interventions in related domains. For example, Beeber, Perreira, and Schwartz (2008) have adapted an intervention to increase social support for low-income mothers, includ- ing recently immigrated Latina women. The Incredible Years, a parenting program described earlier in this chapter, can also serve as an informative model for successful wide adaptation of a parenting intervention. PREVENTION APPROACHES IN COMMUNITY SETTINGS Community and faith-based organizations may offer an important setting for education and other prevention programs for families with depression, especially in some minority communities. In many rural and low-income communities, churches are the primary institutions of social support, and community settings may offer the most promise for access to needed interventions. However, there are important questions about capacity and whether organizations in these settings have the knowledge, education, and skilled staff necessary to implement programs. Schools have been a more common setting for preventive interventions for children, including some parenting and family-focused interventions (National Research Council and Institute of Medicine, 2009). However,
310 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN with the exception of the parenting interventions described above, few programs have been evaluated in school settings that target children of depressed parents in their program design or program evaluation. The Internet offers an emerging opportunity to deliver interventions to families, as described in Chapter 6. Web-based perinatal and postpartum depression interventions, for example, can be accessible in ways that make them well suited for the needs of expectant and new mothers. Although web-based programs and support sites are becoming available, there is very little evaluation of the effectiveness of these efforts. In one example, a pilot, randomized controlled trial is currently under way to evaluate a web-based version of the MamÃ¡s y BebÃ©s/Mothers and Babies course, a cognitive-behavioral and psychoeducational intervention for prevention of postpartum depression (MuÃ±oz et al., 2007; University of California, San Francisco, 2008). The lack of high-quality research interventions in community settings is a major research gap. This gap could be addressed by more studies to ex- amine the capacity for delivering interventions in these settings; to evaluate the implementation of existing evidence-based interventions not previously delivered in these settings; and to evaluate the effectiveness of programs already in place that have not been evaluated, taking into account that different measures are used to estimate depression in different community- based programs, which may lead to differences in the populations that are targeted and in outcomes. RESEARCH GAPS More research is needed on the prevention of adverse outcomes in families with depressed parents. Although there is preliminary support for interventions that prevent adverse effects for depressed parents and their children, most of these approaches need further evaluation, replication, and longitudinal studies before widespread implementation is warranted. Many of these studies target only a particular area (e.g., parenting or child development), and only a limited number of interventions have targeted both parents and their children. Additional research is needed to further support these existing preventive interventions for families with depressed parents. For the programs and practices that have already been found to be most promising in randomized trials, larger scale effectiveness studies and implementation and dissemination trials need to be pursued. In addition, there is a need to develop new interventions targeted at the comprehensive needs of families with depression as well as adaptations or enrichments of more broad intervention approaches to enhance their ef- fectiveness in these families. Because families with parental depression may present with depression as the primary problem or as part of a constella-
PREVENTION OF ADVERSE EFFECTS 311 tion of risk factors, more research is needed on identifying, engaging, and providing appropriate preventive interventions to such families not only in mental health services but in the variety of settings in which they may seek services. This is particularly relevant to low-income and ethnic-minority populations given that they are at increased risk for depression but are less likely to seek mental health services (Aguilar-Gaxiola et al., 2008). Although these targeted approaches are likely to be most promising, more evidence is also needed to determine whether universal programs focused on wellness and mental health promotion can lead to reductions in depression in parents and the subsequent adverse effects in children. The following types of programs need more research with attention to depression in parents: â¢ programs targeted at preventing depression in parents with chil- dren at all developmental stages; â¢ prevention programs targeted at improving parenting; â¢ prevention programs targeted at enhancing protective factors and reducing risk in children; â¢ multigenerational and multicomponent programs; â¢ prevention programs in settings in which families with depression and their children are readily accessed, such as schools and com- munities; and â¢ policy and social welfare interventions and other broad-based pro- grams targeted at vulnerable families and children. In all of these programmatic approaches, prevention research for fami- lies with parental depression needs to incorporate three major principles: (1) recognition and treatment of parental depression, (2) enhancement and support for parenting, and (3) a focus on the developmental outcomes of children. A number of areas of focus are needed in these research efforts. First, programs designed to assist children when parents are depressed need to focus not only on symptoms and diagnoses in children but also on strength- based strategies that help them accomplish appropriate developmental tasks (staying in school, relationships, acquiring skills). In addition, intervention research is needed that can serve to identify the characteristics of parenting by depressed parents that is of sufficient quality (e.g., sufficient levels of warmth and structure) to reduce adverse outcomes in children. For evidence-based preventive intervention strategies and prevention- focused service programs that are not specifically targeted to depressed families, future research needs to consider parental depression in interven- tion design, assess depression in families, and track outcomes in families with depression as a subgroup in their evaluations. Whenever possible,
312 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN these interventions should examine effects on parental depression, on par- enting, and on child outcomes. Additional research is also needed on the effectiveness of including specific intervention components to enrich the overall program for depressed parents. This research will elucidate how the effects of these interventions differ in families with depression and what adaptations or enhancements are needed to maximize the effectiveness of interventions for them. Although attention to prevention is warranted for children of depressed parents at all developmental stages, because of the rapid course of brain development during the first 5 years of life, increased focus is needed on evaluations and implementation trials of interventions during this stage of development. This can include interventions in pregnancy and the post- partum period, parent-child interaction interventions in infancy and early childhood, home visitation, and early childhood education. Finally, given the considerable evidence about the social determinants of health in general and its effects on parental depression in particular, it is important that intervention research to address depression in parents should assess relative effectiveness in low-income families, families in high- risk neighborhoods, families with unstable housing, and families from varied cultural and linguistic backgrounds as well as adaptations or en- hancements to target these vulnerable populations. In addition, it is impor- tant to consider the effectiveness and possible adaptations or enhancements of interventions in families with co-occurring conditions, such as marital conflict, domestic violence, and exposure to trauma and coexisting mental and substance abuse disorders. Even when interventions are not designed to address these populations, population and socioeconomic demograph- ics should be clearly reported so that studies can be placed in the proper context, the amount of risk properly assessed, and analyses of relative ef- fectiveness in high-risk subpopulations conducted. Trials are also needed of specific ways to offer identification, outreach, engagement, and treatment and prevention services to vulnerable families who face multiple risks. This research will help elucidate the need to address these interrelated factors to successfully intervene to prevent and treat depression and improve parent- ing and child outcomes as well as the need to make other interventions for these vulnerable families more successful. CONCLUSION Given the high prevalence of depression in parents and the evidence for the effects of depression on parenting quality and on child outcomes, there is a pressing need to maximize the ability to improve outcomes for both depressed parents and their children. Approaches are needed that not only offer treatment of depression in the parent but also support parenting
PREVENTION OF ADVERSE EFFECTS 313 and healthy child development. The most effective prevention strategies are therefore likely to be those that incorporate multiple components and target both generations. This conceptual basis has preliminary support from a small number of interventions that have targeted families with depressed parents and have demonstrated promise for improving outcomes for these families in at least one randomized trial (summarized in Table 7-1). They include interven- tions that prevent or improve depression in the parent, those that target the vulnerabilities of children of depressed parents, and those that improve parent-child relationships and parenting practices. In some promising interventions, a two-generation approach is used to target both the parents and their children, and in some cases treatment of the parent has been combined with interventions targeted at parenting or child development. However, the data from most of these interventions designed for families with depression are limited, with mixed results for some intervention approaches, a limited number of trials, small sample sizes, a lack of outcome measures for both the parent and the child, and little longitudinal follow-up to demonstrate sustained effects. There is, however, a broader and more robust evidence base for pre- ventive interventions to support families and the healthy development of children, which has been reviewed in detail elsewhere (National Research Council and Institute of Medicine, 2009). Multiple safe and effective in- terventions are currently available that are targeted more generally at im- proving parent-child relations, teaching parenting skills, or supporting the healthy development of children. These interventions (or elements of these interventions) have the potential to be incorporated into multiple settings and to serve multiple populations across development, from pregnancy through childhood and adolescence. Few of these broader prevention interventions specifically address fami- lies with depression. Nonetheless, these broadly robust prevention strategies hold promise for families with depression because, given the high preva- lence of depression in parents, most prevention strategies that have been shown to be effective were evaluated in a population that probably included families with depression, even if there was no assessment of parentsâ mental health status. Several approaches described in this chapter, both those targeted to families with parental depression and those more broadly targeted to pre- vention interventions, have already been demonstrated to be safe and ef- fective. Therefore, they stand ready for evaluations to determine whether selected components of these interventions, in combination with approaches to identify and treat depression in parents, can be effective when delivered in a variety of real-world service settings as part of integrated, two-genera- tion approaches to meet the needs of families with a depressed parent.
314 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Examples of Interventions Specifically Targeted to Depression in Parents Population and Intervention Description Citation Demographics Setting Prevention of Parentsâ Depression ROSE Program Interpersonal Zlotnick Nondepressed pregnant Prenatal (Reach Out, psychotherapy- et al. (2001, women with at least one clinic Stand Strong, based group 2006) risk factor for depression Essentials for intervention (assessed by risk survey) New Mothers) Four weekly 60- First trial minute group n = 35 sessions delivered Age: 23.4 (mean) during pregnancy. Race/ethnicity: Second trial 46% Caucasian included a 50- 54% Non-Caucasian minute booster SES: Receiving public session after assistance delivery Single-parent: 77% Exclusion/inclusion criteria not reported Second trial n = 99 Age: 22.4 (mean) Race/ethnicity: 28% Caucasian 44% Hispanic 17% African American 2% Asian 8% Other SES: Receiving public assistance Single-parent: 67% Excluded: Substance abuse disorder; any current mental health treatment
PREVENTION OF ADVERSE EFFECTS 315 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Fewer episodes Not assessed Not assessed 3 months Randomized of major trials depression at 3 monthsâ postpartum (diagnosed by SCI-D) continued
316 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Peer support Individualized Dennis et al. Nondepressed women in the Telephone- telephone-based (2009) first 2 weeksâ postpartum based peer-support at high risk for depression (Identified intervention (EPDS > 9) in standard postpartum Minimum of four n = 701 care in peer-support Age: <20 â >35 (range) seven phone sessions Race/ethnicity: health starting at 2 81% Canadian; regions in weeksâ postpartum 19% Other Canada) delivered by peer SES: Mixed volunteers who Single-parent: 8% had recovered Excluded: Non-English from postpartum speaking; currently depression taking antidepressant or antipsychotic medications Infant Sleep Behavior- Hiscock Mothers reporting a problem Maternal modification et al. with their infantsâ sleep at and Child program to (2007, 7 months Health improve infant 2008) centers in sleep n = 49 centers and 328 Australia mother/infant pairs One-time Age (mothers): 33 (mean) consultation Age (children): 8 months delivered by Race/ethnicity: Not reported well-child nurses SES: Mixed low, middle, and to mothers at high infant ages 8 Single-parent: 3% months to develop Excluded: Non-English individualized speaking sleep management plan with one follow-up visit after 2 weeks
PREVENTION OF ADVERSE EFFECTS 317 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Fewer mothers Not assessed Not assessed 12 weeks Randomized with EPDS trial scores consistent with postpartum depression (EPDS > 12) Lower levels No differences Reduced infant sleep 2 months, Randomized of depression in parenting problems at ages 10 4 months, trial symptoms practices months and 12 months; and 18 (randomized (mean EPDS sleep problems resolved months at center scores) at in both groups at age 2 level) infantâs age 10 years months, 12 months, and 2 No differences in child years mental health Lower rates of EPDS scores consistent with postpartum depression (using EPDS > 9 and EPDS â¥ 13) at age 2 years continued
318 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Treatment of Parentsâ Depression STAR*D: Assessment of Pilowsky Depressed mothers Primary Pharmaco- children of et al. participating in a treatment care and logical depressed mothers (2008) trial and their children psychiatric treatment participating Weissman outpatient in a trial of et al. n = 151 mother/child pairs clinics pharmacological (2006) entered in study treatment for depression n = 123 mother/child pairs completed child assessments during 1 year of follow-up Age (mothers): 37.7 (mean); 24â52 (range) Age (children): 11.7 years (mean); 6â17 years (range) Race/ethnicity: 37% African American 42% White 18% Hispanic 3% Other SES: Mixed but with a large proportion of low-income Single-parent: 56% Excluded: Adults with bipolar disorder, schizophrenia, or schizoaffective disorders; adults with any medical condition contraindicating one of the study medications
PREVENTION OF ADVERSE EFFECTS 319 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method 33% of mothers Not assessed 32% of children had 3 monthsâ Ancillary had remission current DSM-IV intervals study of a of depression diagnosis at baseline up to 1 random- (HRSD â¤ 7) by year ized trial 3 months and At 3 months: Larger 57% by 1 year decrease in childrenâs diagnoses (K-SADS) and symptoms (CBCL) for mothers whose depression remitted; higher levels of maternal response to treatment (% change on HRSD compared to baseline) were associated with larger decrease in rates of childrenâs diagnoses and symptoms At 1 year: Larger decrease in childrenâs symptoms (K-SADS) for mothers whose depression remitted; during the year following initiation of maternal treatment, decreases in childrenâs psychiatric symptoms (K-SADS) were associated with decreases in maternal depression severity (HRSD) continued
320 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Treatment of Assessment of Browne Parents with dysthymia Suburban dysthymia children of et al. participating in a treatment primary parents (2002) trial and their children care group participating Byrne et al. practice in in a trial of (2006) n = 353 children entered in Canada pharmacotherapy, study at baseline interpersonal n = 145 parents and 260 psychotherapy, children with assessments or a combination at 2-year follow-up for treatment of dysthymia Age (parents): 41.1 (mean) Age (children): 10.3 years (mean); 4â16 years (range) Race/ethnicity: Not reported SES: Mixed Single-parent: 22.1% Excluded: Acute suicide risk; bipolar disorder; schizophrenia or any psychotic disorder; clinically significant and unstable medical conditions
PREVENTION OF ADVERSE EFFECTS 321 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method 66.9% of parents Not assessed Improved emotional 2 years Ancillary responded to and behavioral study of a treatment (â¥ symptoms (CBCL) in randomized 40% reduction children whose parents trial in baseline responded to treatment depressive symptoms on MADRS) continued
322 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Psychological Comparison of 3 Cooper et al. Depressed postpartum Home visits treatment of psychological (2003) women after their first postpartum treatments Murray et al. pregnancy and their depression (nondirective (2003) children counseling, cognitive- n = 190 mother/child pairs behavioral therapy, Age (mothers): 27.7 (mean); psychodynamic 17â42 (range) therapy) or routine Race/ethnicity: Not reported primary care SES: Mixed; 21% high social disadvantage Weekly therapy from Single-parent: 12% 8 to 18 weeksâ Excluded: Premature postpartum delivery; congenital abnormality; English not first language
PREVENTION OF ADVERSE EFFECTS 323 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Improved Reduced maternal Better infant emotional 4.5, 9, and Randomized maternal mood reports of early and behavioral rating 18 months trial with all three difficulties in at 18 months with and 5 treatments at relationships with nondirective counseling years 4.5 monthsâ infants with all (BSQ) postpartum three treatments (EPDS) at 4.5 months No persistent impact on (maternal self- childhood attachment Reduced rate report scale) and cognitive outcomes of depression at 5 years diagnosis More sensitive (increased rate early mother- of remission) infant relations at 4.5 months with nondirective with psycho- counseling in dynamic mothers with high therapy (SCI- social adversity D); effects not at 4.5 months maintained; (global rating no benefit of scale assessment any treatment of videotaped after 9 monthsâ interactions) postpartum No persistent impact on parent- child relationship or behavioral management at 5 years continued
324 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Psychological Interpersonal Forman et al. Depressed postpartum Clinic treatment of psychotherapy (2007) women and their children postpartum OâHara et al. depression Weekly 1-hour (2000) n = 120 sessions for 12 Age (mothers): 29.6 (mean) weeks Age (infants): 6 months Race/ethnicity: Predominantly White SES: Not reported Single-parent: 0% Excluded: Single parent; psychotic depression; history of bipolar disorder, schizophrenia, organic brain syndrome, mental retardation, or antisocial personality disorder; current diagnosis of alcohol or substance abuse, panic disorder, somatization disorder, 3 or more schizo-typal features, serious eating disorder, or obsessive-compulsive disorders Interventions for Children of Depressed Parents Group CBT Group cognitive- Clarke et al. Children of depressed HMO behavioral (2001) parents (current episode clinic preventive or past 12 months) with intervention for subdiagnostic depressive youth at high risk symptoms (symptoms of depression insufficient to meet DSM- III-R diagnostic criteria or 15 1-hour group CESD > 24) sessions delivered by masterâs-level n = 94 therapist Age (parent): 41.4 (mean) Age (children): 14.6 years (mean); 13â18 years (range) Race/ethnicity: not reported SES: Not reported Single-parent: 35% Excluded: Current and past psychiatric disorders were not excluded.
PREVENTION OF ADVERSE EFFECTS 325 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Greater decrease No impact on No impact on child 12 weeks Randomized in depressive parent-child outcomes (all trial symptoms relationship outcomes) (HRSD and and 18 BDI) Reduced parental months stress, but treated (parenting Greater rate depressed mothers and child of remission still had higher outcomes) (HRSD â¤ 6; levels of parental BDI â¤ 9; no stress than longer meeting nondepressed DSM-IV mothers (PSI) criteria for major depressive disorder) Not assessed Not assessed Fewer symptoms of 2 years Randomized depression (CESD) trial Lower rate of major depression diagnoses at 12 months (K-SADS-E); this effect diminished by 24 months continued
326 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Interventions Targeted to ParentâChild Relationship or Parenting Skills Interaction Coached behavioral Horowitz Mothers with depressive Home Coaching for intervention et al. (2001) symptoms (EPDS â¥ 10) visitation At-risk Parents to promote and their infants (ICAP) maternal-infant responsiveness n = 117 as an addition Age (mothers): 31 (mean); to home visiting 17â41 (range) services Age (children): 4â8 weeks (range) Three home visits Race/ethnicity: took place between 68.9% European American ages 4â18 weeks or White 7.4% African American or Black 7.4% Latina or Hispanic 7.4% Mixed background 4% Other 3.3% Asian or Pacific Islander 1.6% Native American SES: Mixed Single-parent: Not reported Excluded: Not reported Mother-baby Mother-baby Van Doesum Depressed mothers receiving Home interaction intervention et al. (2008) outpatient treatment and visitation delivered by their infant children masterâs-level home visitors n = 71 with training in Age (mothers): 30 years prevention or (mean) health education Age (children): 5.5 months (mean); 1â12 months Program components: (range) modeling of Race/ethnicity: parenting; cognitive 85% Dutch (Caucasian) restructuring; 11% Other (Turkish, practical Moroccan, Surinamese, pedagogical Portuguese, Australian) support; and infant SES: Mixed massage Single-parent: 8% Excluded: Psychotic 8â10 home visits disorder; manic depression; lasting 60â90 substance dependence minutes on average
PREVENTION OF ADVERSE EFFECTS 327 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method No difference Improved Not assessed 10 weeks Randomized in level of maternal-infant trial depressive responsiveness symptoms (Dyadic Mutuality (decreased Code) equally in intervention group and control group) (BDI-II) No difference Improved Improved attachment 6 months Randomized in level of maternal-infant security (AQS) and trial depressive interaction, for socioemotional symptoms four dimensions: competence; no (decreased maternal difference on equally in sensitivity, externalizing, intervention maternal internalizing, or group and structuring, child dysregulation measures control group) responsiveness, (ITSEA) (BDI) child involvement (EAS) continued
328 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Motherâs Weekly assessments Hart, Field, Depressed mothers Mothers Assessment of of infantâs behavior and Nearing (CESD â¥ 16) and their trained in the Behavior by the mother for (1998) newborn infants hospital of her Infant 1 month maternity (MABI) n = 27 unit Age (mothers): 21.6 (mean); followed 15â30 (range) by use of Age (children): Newborn assessment Race/ethnicity: instrument 68% Hispanic at home 30% African American 2% White SES: Low income Single-parent: Not reported Excluded: Not reported Parent-child Multicomponent Field et al. Adolescent mothers with Public focused intervention (2000) depressive symptoms vocational comprehensive delivered over 3 selected based on predictor high school program months variables and their infants; Intervention predictor variables: low included day care interaction scores and for the infants; elevated norepinephrine, social, educational, serotonin, and cortisol at and vocational neonatal stage; increased programs for right frontal EEG and low the mothers; vagal tone at 3 monthsâ mood induction postpartum interventions for the mothers; infant n = 160 mother/infant massage therapy; pairs (96 selected for and mother- randomization) infant interaction Age (mothers): 17.3 (mean) coaching Age (children): 3 months Race/ethnicity: 60.9% African American 24.3% Hispanic 14.8% Non-Hispanic White SES: Low income Single-parent: Not reported Excluded: Not reported
PREVENTION OF ADVERSE EFFECTS 329 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method No effect on Not assessed Improvements in social 1 month Randomized maternal interaction and state trial depression organization (Neonatal (CESD) Behavioural Assessment Scale) Reduced Improved parent- Improved infant 6 monthsâ Randomized depressive child interactions development at 6 and 12 (to 12 trial symptoms at 6 (Interaction months (Bayley Mental monthsâ and 12 monthsâ Rating Scale) at and Motor); improved post- postpartum post-intervention. responding and initiating partum) (BDI) at 12 months (Early Social Communication Scales) continued
330 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1â Continued Population and Intervention Description Citation Demographics Setting Toddler-parent Joint therapy Cicchetti, Mothers with at least one Research psychotherapy sessions for Toth, and major depressive episode university (TPP) mothers and Rogosch since the birth of their their toddlers (2004) toddler to improve the Toth et al. mother-child (2006) n = 130 interaction Age (mothers): 31.68 and maternal (mean); 21â41 (range) responsivity Age (children): 20.34 months (mean) Average of 45 Race/ethnicity: sessions delivered 92.9% European American over an average of SES: Middle to high 58 weeks Single-parent: 12.1% Excluded: Bipolar disorder; low socioeconomic status Interventions That Combine Components for Treating Parents, Improving Parenting, and/or Supporting Child Development CBT family Cognitive therapy Sanders and Families with depressed 8 clinic intervention strategies to McFarland mothers (DSM-IV sessions treat depression (2000) diagnosis) and children and 4 integrated with with conduct disorder feedback teaching of or oppositional-defiant sessions parenting skills disorder delivered in compared with a homes behavioral family n = 47 intervention for Age (parents): 34.3 years treatment of (mean) oppositional and Age (children): 4.39 years disruptive behavior (mean); 3â9 years (range) in children Race/ethnicity: Not reported SES: Mixed 12 weekly sessions Single-parent: 32% delivered by Excluded: Not reported trained therapists
PREVENTION OF ADVERSE EFFECTS 331 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method No effect on Not assessed More secure attachment To age 3 Randomized mothersâ (strange situation) years trial depression At 6 months: No difference At 6 months: greater 6 months Randomized better between groups concurrent change in trial maintenance child disruptive behavior of reduced (PDR) maternal depressive depressive symptoms symptoms (BDI) (BDI); greater concurrent change in depressive symptoms (BDI) amd child disruptive behavior (PDR) continued
332 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Population and Intervention Description Citation Demographics Setting Family Talk 7-session (average) Beardslee Parents with a history Most Intervention clinician-facilitated et al. of depression and their families family intervention (1997, children recruited for parents and 2003, from HMO their children 2007) Pilot families plus first trial or referred delivered by families plus additional from licensed social families combined for mental workers or clinical long-term follow-up: health psychologists n = 105 families providers compared to Age (parents): 43 (mean) 2-session lecture Age (children): 12 years group discussion (mean); 8â15 years (range) with parents Race/ethnicity: Predominantly White SES: Predominantly middle-class Single-parent: 19% Excluded: Parents acutely psychotic, acutely abusing substances, or in the midst of a divorce; or marital crisis. Children acutely depressed or with a history of depression; other psychiatric diagnoses not excluded Family Talk Adaptation of Podorefsky, Parents with a history Most Intervention Family Talk McDonald- of depression and their families Intervention for McDowdell, children recruited single, minority and from mothers Beardslee n = 16 families health and (2001) Age (parents): Not reported community Age (children): Not reported centers Race/ethnicity: 100% minority SES: Predominantly low-income Single-parent: 100% Excluded: Not reported
PREVENTION OF ADVERSE EFFECTS 333 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Changes in Increased family Increased understanding 4.5 years Randomized parentsâ communication of parentsâ depression trials behaviors and parental (interview ratings) and attitudes attention to toward their childrenâs depression experience (interview (interview ratings) ratings) Changes in Increased parental Post-inter- Randomized parentsâ attention vention trial behaviors to children and report of (interview ratings) global benefit of intervention (interview ratings) continued
334 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Population and Intervention Description Citation Demographics Setting Parenting and Cognitive- Compas, Depressed parents (current Academic child coping behavioral Forehand, or history of during the research skills intervention; and Keller lifetime of their child) and setting parenting skills (presented their children training for at the parents and Society n = 111 families (155 teaching children for children) skills to cope with Research Age (parents): 42.8 (mean) their parentsâ on Child Age (children): 11.4 years depression Develop- (mean); 9â15 years (range) ment in Race/ethnicity: 2009) 79% European American 7.7% African American 3.2% Asian American 1.3% Hispanic 7.7% Mixed ethnicity SES: Mixed with high levels of low-income families Single-parent: 36% Excluded: Parent with history of bipolar I, schizophrenia, or schizoaffective disorder; children with history of autism spectrum disorders, mental retardation, bipolar I disorder or schizophrenia or who met criteria for conduct disorder or substance/alcohol abuse or dependence NOTES: The committee did not seek to systematically identify every study on existing inter- ventions and program evaluations that target families with a depressed parent or that illustrate important conceptual principles for addressing these needs of these families; instead, whenever possible, the committee drew on existing meta-analyses and systematic reviews and whenever possible reviewed interventions that have been evaluated in at least one randomized trial. All outcomes reported in table are statistically significant. AQS = Attachment Q Sort Version 3; BSQ = Behavioral Screening Questionnaire; BSID = Bailey Scale of Infant Development; BDI = Beck Depression Inventory; CBCL = Child Be- havior Checklist; CBT = cognitive-behavioral therapy; CESD = Center for Epidemiologic Studies Depression Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth edition; EAS = Emotional Availability Scale, Infancy to Early Childhood Version; EEG = electroencephalogram; EPDS = Edinburgh Postnatal Depression Scale; HMO = health maintenance organization; HRSD = Hamilton Rating Scale for Depression; ITSEA = Infant Toddler Social and Emotional Assessment; KSADS = Kiddie-Schedule for Affective Disorders and Schizophrenia; KSADS-E = K-SADS, Epidemiological Version; MADRS = Montgomery Asberg Depression Rating Scale; PDR = Parent Daily Report; PSI = Parenting Stress Index; SCI-D = Structured Clinical Interview for DSM-IV; SES = socioeconomic status.
PREVENTION OF ADVERSE EFFECTS 335 Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Reduced Not assessed At 12 months: improved 12 months Randomized depressive childrenâs self-reports trial symptoms of depressive symptoms at 2 months and other internalizing (BDI-II); not and externalizing sustained at 6 problems (CESD and or 12 months Youth Self-Report); improved parentsâ reports of adolescentsâ externalizing symptoms (CBCL)
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