Depression in Parents, Parenting, and Children Opportunities to Improve Identification, Treatment, and Prevention (2009) / Chapter Skim
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7 Prevention of Adverse Effects
7 Prevention of Adverse Effects
Pages 281-342
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From page 281... ...
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 • 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.
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From page 282... ...
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 • 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.
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From page 283... ...
The prevention report emphasizes the need for a developmental perspective -- just 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.
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From page 284... ...
Chapter 4 described evidence related to the first step in prevention research, reviewing a number of identified mechanisms that mediate the association between depression in parents and adverse outcomes in children, including biological, psychological, and interpersonal processes. This chapter considers preventive 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)
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From page 285... ...
The framework also distinguishes between preventive interventions delivered to the general population (called universal prevention) , to individuals exposed to known risk factors (selective prevention)
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From page 286... ...
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.
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From page 287... ...
Other interventions designed to prevent depression in the postpartum period through psychotherapeutic, psychoeducational, and social support 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 cognitivebehavioral therapy–based program targeted at mothers of very preterm infants (Hagan, Evans, and Pope, 2004)
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From page 288... ...
However, only a few investigations have examined the influence of antidepressants or psychotherapy 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.
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From page 289... ...
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 depression 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)
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From page 290... ...
However, these studies have not measured possible changes in parenting behaviors as a function of mothers' depression status, leaving unanswered at present the question of the role of possible improvements in parenting that are sufficient 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 developmental outcomes other than psychopathology.
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From page 291... ...
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)
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From page 292... ...
Given that maternal depression can interfere with the effectiveness of home visiting programs, and home visiting offers an opportunity to deliver 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 comprehensive health and social services have been shown to have a lasting impact on children's cognitive scores, behavioral development, school retention, and adult productivity (Nelson, Westhues, and MacLeod, 2003)
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From page 293... ...
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 depressed parents and referral for mental health services. In addition, because the combination of multiple risk factors was associated with worse outcomes, program enhancements to address other family needs, for example, income and educational needs, may also be warranted in order to maximize program outcomes.
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From page 294... ...
There is some evidence, however, on the relative effectiveness of parenting 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.
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From page 295... ...
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 interactions for mothers with depression (Field et al., 1996; Malphurs et al., 1996; Pelaez-Nogueras et al., 1996)
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From page 296... ...
TPP has been shown to increase attachment security and foster cognitive development in children of depressed mothers (Cicchetti, Rogosch, and Toth, 2000; Cicchetti, Toth, and Rogosch 1999)
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From page 297... ...
There is also some evidence that parental depression can reduce the effectiveness of some parenting programs, as was seen with the home visiting 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 children's aggression and behavioral problems, and to prevent them from developing conduct problems.
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From page 298... ...
. Combining Parent Training and Treatment of Depression Two randomized controlled trials have combined interventions to teach parenting skills with treatment for parents' depression and assessed the effects of the interventions on maternal depression and childhood behavioral problems (Sanders and McFarland, 2000; Verduyn et al., 2003)
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From page 299... ...
Family Talk Intervention Beardslee and colleagues have developed and evaluated a preventive intervention for children at risk for depression owing to their parents' depression. This intervention was designed so that it could be used with all families facing parental depression.
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From page 300... ...
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 parents and their children with two active components -- teaching parenting skills to parents and teaching children skills to cope with their parents' depression (Compas, Forehand, and Keller, 2009; Compas, Keller, and Forehand, in press)
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From page 301... ...
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 families, and very few programs have had rigorous evaluations.
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From page 302... ...
Although there is a lack of strong direct evidence for effects on maternal 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 programs 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.
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From page 303... ...
In some cases, interventions targeted at risk factors reduce depression in parents as well as improve parenting and child outcomes. In other cases, the presence of depression in a family can alter the effectiveness of the interventions.
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From page 304... ...
. Given the high prevalence of maternal depression in prevention programs 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 programmatic enrichment for the subpopulation of depressed parents.
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From page 305... ...
. However, based on available evidence, 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.
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From page 306... ...
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 development 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)
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From page 307... ...
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 factors 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)
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From page 308... ...
. Although rigorous data for child outcomes are not available, the two-generation approach that includes treatment interventions for the parent, parenting training, and preventive 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.
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From page 309... ...
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)
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From page 310... ...
, 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.
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From page 311... ...
to reduce adverse outcomes in children. For evidence-based preventive intervention strategies and preventionfocused service programs that are not specifically targeted to depressed families, future research needs to consider parental depression in intervention design, assess depression in families, and track outcomes in families with depression as a subgroup in their evaluations.
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From page 312... ...
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
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From page 313... ...
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)
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From page 314... ...
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
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From page 315... ...
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 months' postpartum (diagnosed by SCI-D) continued
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From page 316... ...
seven phone sessions Race/ethnicity: health starting at 2 81% Canadian; regions in weeks' 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.
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From page 317... ...
at in both groups at age 2 level) infant's 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 ≥ 13)
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From page 318... ...
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.
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From page 319... ...
were associated with decreases in maternal depression severity (HRSD) continued
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From page 320... ...
320 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1 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)
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From page 321... ...
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 (≥ symptoms (CBCL) in randomized 40% reduction children whose parents trial in baseline responded to treatment depressive symptoms on MADRS)
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From page 322... ...
322 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 7-1 Continued Population and Intervention Description Citation Demographics Setting Psychological Comparison of 3 Cooper et al. Depressed postpartum Home visits treatment of psychological (2003)
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From page 323... ...
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)
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From page 324... ...
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.
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From page 325... ...
(HRSD and and 18 BDI) Reduced parental months stress, but treated (parenting Greater rate depressed mothers and child of remission still had higher outcomes)
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From page 326... ...
Three home visits Race/ethnicity: took place between 68.9% European American ages 4–18 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.
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From page 327... ...
(BDI-II) No difference Improved Improved attachment 6 months Randomized in level of maternal-infant security (AQS)
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From page 328... ...
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
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From page 329... ...
Reduced Improved parent- Improved infant 6 months' Randomized depressive child interactions development at 6 and 12 (to 12 trial symptoms at 6 (Interaction months (Bayley Mental months' and 12 months' Rating Scale) at and Motor)
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From page 330... ...
: 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)
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From page 331... ...
maternal depressive depressive symptoms symptoms (BDI)
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From page 332... ...
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)
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From page 333... ...
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 parents' communication of parents' depression trials behaviors and parental (interview ratings) and attitudes attention to toward their children's depression experience (interview (interview ratings)
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From page 334... ...
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 interventions 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.
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From page 335... ...
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 children's 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)
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From page 336... ...
. Long-term effects from a randomized trial of two public health preventive interventions for parental depres sion.
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From page 337... ...
. A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents.
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From page 338... ...
. Change in child psychopathology with improve ment in parental depression: A systematic review.
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From page 339... ...
. Coping with the stress of parental depression II: Adolescent and parent reports of coping and adjustment.
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From page 340... ...
. Prevention of depression with primary care pa tients: A randomized controlled trial.
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From page 341... ...
. Improving mental health through parenting programmes: Block randomized controlled trial.
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From page 342... ...
. A randomized controlled trial of a home-visiting intervention aimed at preventing re lationship problems in depressed mothers and their infants.
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