Towards a better understanding of real-world home-visiting programs: a large-scale effectiveness study of parenting mechanisms in Brazil

BACKGROUND

The scale-up of parenting programmes to support early childhood development (ECD) is poorly understood. Little is known about how and when early interventions are most effective. Sustainability of ECD programming requires a better understanding of the mechanisms of real-world interventions. We examined the effects on caregiving practices of Primeira Infância Melhor (PIM), a state-wide home-visiting programme in Brazil.

METHODS

This propensity score matched, longitudinal, quasiexperimental study uses data from the 2015 Pelotas Birth Cohort. We matched children who received PIM at any age with other cohort children on 25 key covariates. Sensitivity, guidance and responsiveness were assessed using video-recorded play tasks. Coerciveness and the parent-child relationship were assessed using the Parenting and Family Adjustment Scales. All parenting outcomes were examined at age 4 years. Separate moderation analyses were conducted for each effect modifier: family income, child age and duration of participation.

RESULTS

Out of 4275 children in the cohort, 797 were enrolled in PIM up to age 4 years. 3018 children (70.6%) were included in the analytic sample, of whom 587 received PIM and 2431 were potential controls. We found a positive effect of PIM on responsiveness (β=0.08, 95% CIs 0.002 to 0.16) and sensitivity (β=0.10, 95% CIs 0.02 to 0.19). No effect was found for any secondary outcomes. Moderation analyses revealed a stronger positive effect on sensitivity for low-income parents (β=0.18, 95% CIs 0.03 to 0.34).

CONCLUSION

A state-wide, home-visiting programme in Brazil improved aspects of responsive caregiving. Effects were more pronounced for low-income families, suggesting benefits of purposeful targeting.

Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): report of a feasibility randomized controlled trial

BACKGROUND

We investigated the acceptability and feasibility of a new brief intervention for maternal prenatal anxiety within maternity services in London and Exeter, UK.

METHODS

One hundred fourteen pregnant individuals attending their 12-week scan at a prenatal clinic with elevated symptoms of anxiety (GAD-7 score of ≥7) were randomly assigned to either the ACORN intervention + Treatment as usual (TAU) (n = 57) or to usual care only (n = 57). The ACORN intervention consisted of 3 2-h group sessions, led by a midwife and psychological therapist, for pregnant individuals and their partners. The intervention included psychoeducation about anxiety, strategies for problem-sovling and tolerating uncertainty during pregnancy, including communicating about these with others, and mindfulness exercises.

RESULTS

Engagement rates with ACORN met or exceeded those in primary care services in England. In the intervention arm, 77% (n = 44) of participants attended at least one session, 51% (n = 29) were adherent, defined as attending two or more sessions. Feedback was positive, and participants in the ACORN treatment group demonstrated evidence of a larger drop in their levels of anxiety than the participants in the TAU-only group (Cohen's d = 0.42).

CONCLUSION

The ACORN intervention was acceptable to pregnant individuals and their partners and resulted in reductions in anxiety. With further evaluation in a larger-scale trial with child outcomes, there is significant potential for large scale public health benefit.

Can guidance during play enhance children's learning and development in educational contexts? A systematic review and meta-analysis

This systematic review and meta‐analysis considered evidence of guided play compared to direct instruction or free play to support children's learning and development. Interventions from 39 studies were reviewed (published 1977–2020); 17 were included in meta‐analysis (N_total = 3893; M_childage = 1–8 years; M_girls 49.8%; M_ethnicity White 41%, African American/Black 28%, Hispanic 19%). Guided play had a greater positive effect than direct instruction on early maths skills (g = 0.24), shape knowledge (g = 0.63), and task switching (g = 0.40); and than free play on spatial vocabulary (g = 0.93). Differences were not identified for other key outcomes. Narrative synthesis highlighted heterogeneity in the conceptualization and implementation of guided play across studies.

A Brief Home-Based Parenting Intervention to Reduce Behavior Problems in Young Children: A Pragmatic Randomized Clinical Trial

IMPORTANCE

Behavior problems are one of the most common mental health disorders in childhood and can undermine children's health, education, and employment outcomes into adulthood. There are few effective interventions for early childhood.

OBJECTIVE

To test the clinical effectiveness of a brief parenting intervention, the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD), in reducing behavior problems in children aged 12 to 36 months.

DESIGN, SETTING, AND PARTICIPANTS

The Healthy Start, Happy Start study was a 2-group, parallel-group, researcher-blind, multisite randomized clinical trial conducted via health visiting services in 6 National Health Service trusts in England. Baseline and 5-month follow-up data were collected between July 30, 2015, and April 27, 2018. Of 818 eligible families, 227 declined to participate, and 300 were randomized into the trial. Target participants were caregivers of children who scored in the top 20% for behavior problems on the Strengths and Difficulties Questionnaire. Participants were randomly allocated on a 1:1 basis to receive either VIPP-SD (n = 151) or usual care (n = 149), stratified by site and number of participating caregivers. Analysis was performed on an intention-to-treat basis. Statistical analysis was performed from September 5, 2019, to January 17, 2020.

INTERVENTIONS

All families continued to access usual care. Families allocated to VIPP-SD were offered 6 home-based video-feedback sessions of 1 to 2 hours' duration every 2 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was the score on an early childhood version of the Preschool Parental Account of Children's Symptoms, a semistructured interview of behavior symptoms, at 5 months after randomization. Secondary outcomes included caregiver-reported behavior problems on the Child Behavior Checklist and the Strengths and Difficulties Questionnaire.

RESULTS

Among 300 participating children (163 boys [54%]; mean [SD] age, 23.0 [6.7] months), primary outcome data were available for 140 of 151 VIPP-SD participants (93%) and 146 of 149 usual care participants (98%). There was a mean difference in the total Preschool Parental Account of Children's Symptoms score of 2.03 (95% CI, 0.06-4.01; P = .04; Cohen d = 0.20 [95% CI, 0.01-0.40]) between trial groups, with fewer behavior problems in the VIPP-SD group, particularly conduct symptoms (mean difference, 1.61 [95% CI, 0.44-2.78]; P = .007; d = 0.30 [95% CI, 0.08-0.51]). Other child behavior outcomes showed similar evidence favoring VIPP-SD. No treatment or trial-related adverse events were reported.

CONCLUSIONS AND RELEVANCE

This study found that VIPP-SD was effective in reducing symptoms of early behavior problems in young children when delivered in a routine health service context.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN58327365.

A rapid review of the impact of quarantine and restricted environments on children's play and the role of play in children's health

Amidst the coronavirus disease 2019 (COVID-19) pandemic, there is uncertainty regarding potential lasting impacts on children's health and educational outcomes. Play, a fundamental part of childhood, may be integral to children's health during crises. We undertook a rapid review of the impact of quarantine, isolation and other restrictive environments on play and whether play mitigates adverse effects of such restrictions. Fifteen peer-reviewed studies were identified, spanning hospitals, juvenile and immigration detention and refugee camps. We found evidence of changes in children's access to play in crises and quarantine. These studies indicated how play might support children enduring isolation but lacked robust investigations of play as an intervention in mitigating impacts of restriction. Studies pertaining to children in isolation due to infectious disease outbreaks were notably absent. It is important that the potential effects of changes to such a crucial aspect of childhood are better understood to support children in this and future crises.

Does a video clip enhance recruitment into a parenting trial? Learnings from a study within a trial

Background

Reaching recruitment targets in randomised controlled trials is a challenge. Media tools are increasingly used to engage participants, yet there is a paucity of research into the use of video to optimise recruitment. We therefore tested whether adding a participant information video clip to a standard participant information sheet improved recruitment into a parenting trial.

Methods

One hundred seven participants were randomised to receive either a participant information sheet (n = 51) or an informational video clip (n = 56) as part of an email contact following a screening phase. All participants went on to receive the information sheet as part of the existing consent procedure.

Results

The video condition did not increase the odds of recruitment into the trial, such that those in the video condition were significantly less likely to participate in the main trial (OR = 0.253, CI = 0.104–0.618, p = 0.003).

Conclusion

The introduction of a video clip into the recruitment stages of a parenting trial did not lead to an improvement in recruitment; however, the small sample size precludes definitive inferences. We offer reflections on challenges encountered in implementing the SWAT and suggestions for other researchers seeking to embed recruitment SWATs into similar trials.

Trial registration

Current controlled trials ISRCTN 58327365. Registered on 19 March 2015.

SWAT registration

SWAT 106; Effects of a video clip on recruitment into a randomised trial. Registered on 20 December 2016.

Association of Maternal and Paternal Depression in the Postnatal Period With Offspring Depression at Age 18 Years

Importance

Paternal depression during the postnatal period has been associated with adverse child outcomes. Family environment has been reported as a pathway for risk transmission from fathers to children. The influence of paternal depression during the postnatal period on offspring depression remains to be clarified.

Objective

To investigate the association between paternal depression in the postnatal period and offspring depression and explore potential mediating and moderating factors that influence any association between paternal and offspring depression.

Design, Setting, and Participants

This prospective study of a UK community-based birth cohort (the Avon Longitudinal Study of Parents and Children) of parents and their adolescent offspring investigated associations between paternal depression during the postnatal period and offspring depression at age 18 years. We tested a hypothesized moderator (ie, sex) and conducted path analysis to examine hypothesized mediators (ie, depression in the other parent, couple conflict, and paternal involvement and emotional problems, conduct problems, and hyperactivity in offspring at age 3.5 years) of the associations between both paternal and maternal depression and offspring depression. Data collection for the Avon Longitudinal Study of Parents and Children began in 1991 and is ongoing. Data analysis for this study was conducted from June 2015 to September 2018.

Exposures

Depression symptoms in fathers at 8 weeks after the birth of their children.

Main Outcomes and Measures

Offspring depression symptoms at age 18 years, using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

Results

A total of 3176 father-offspring pairs were analyzed; of the children, 1764 were girls (55.5%) and 1412 (44.5%) were boys. Paternal mean (SD) age at delivery was 29.6 (9.6) years. The offspring of fathers who had depression during the postnatal period were at increased risk of experiencing depression symptoms at age 18 years (β = 0.053 [95% CI, 0.02-0.09]). The association is mediated by maternal depression at 8 months after birth (β = 0.011 [95% CI, 0.0008-0.02]; 21% [0.011/0.053]) and conduct problems at 42 months after birth (β = 0.004; [95% CI , -0.00004 to 0.009]; 7.5% [0.004/0.053]). Couple conflict and paternal involvement do not mediate this association. The increased risk is seen in girls but not boys (interaction β = 0.095; P = .01).

Conclusions and Relevance

The association between paternal depression in the postnatal period and depression in girls at age 18 years is partially explained by maternal depression. Couple conflict and paternal involvement were not found to play a role in the risk of transmission; this contrasts with the role that couple conflict was found to play in the risk of childhood behavior problems. Conduct problems in childhood appear to be a pathway for risk transmission between paternal depression and subsequent depression in offspring at age 18 years.

Correction to: Salivary cortisol response to infant distress in pregnant women with depressive symptoms

The article Salivary cortisol response to infant distress in pregnant women with depressive symptoms, written by Susannah E. Murphy, Elizabeth C. Braithwaite, Isabelle Hubbard, Kate V. Williams, Elizabeth Tindall, Emily A. Holmes, and Paul G. Ramchandani, was originally published electronically.

Early childhood aggressive behaviour: Negative interactions with paternal antisocial behaviour and maternal postpartum depressive symptoms across two international cohorts

Background

Early childhood aggressive behaviour is a predictor of future violence. Therefore, identifying risk factors for children’s aggressive behaviour is important in understanding underlying mechanisms. Maternal postpartum depression is a known risk factor. However, little research has focused on the influence of paternal behaviour on early childhood aggression and its interaction with maternal postpartum depression.

Methods

This study was performed in two cohorts: the Fathers Project, in the United Kingdom (n = 143) and the Generation R Study, in The Netherlands (n = 549). In both cohorts, we related paternal antisocial personality (ASP) traits and maternal postpartum depressive (PPD) symptoms to childhood aggressive behaviour at age two (Fathers Project) and age three (Generation R Study). We additionally tested whether the presence of paternal ASP traits increased the association between maternal PPD–symptoms and early childhood aggression.

Results

The association between paternal ASP traits and early childhood aggressive behaviour, corrected for maternal PPD-symptoms, was similar in magnitude between the cohorts (Fathers Project: standardized β = 0.12, p = 0.146; Generation R: β = 0.14, p = 0.001), although the association was not statistically significant in the Fathers Project. Strikingly, and in contrast to our expectations, there was evidence of a negative interaction between paternal ASP traits and maternal PPD-symptoms on childhood aggressive behaviour (Fathers Project: β = −0.20, p = 0.020; Generation R: β = −0.09, p = 0.043) in both studies. This meant that with higher levels of paternal ASP traits the association between maternal PPD-symptoms and childhood aggressive behaviour was less and vice versa.

Conclusions

Our findings stress the importance of including both maternal and paternal psychopathology in future studies and interventions focusing on early childhood aggressive behaviour.

Depression and playfulness in fathers and young infants: A matched design comparison study

BACKGROUND

Depression in fathers in the postnatal period is associated with an increased risk of some adverse child developmental outcomes. One possible mechanism for the familial transmission of risk is through the negative effects of depression on parenting and the parent-child relationship. So far, evidence indicates that depressed fathers tend to be more withdrawn in their early interactions. However, the interaction dimensions studied to date may not be able to detect and accurately classify unique features of father-infant play - including physically stimulating and highly rousing episodes of play. Hence, in this matched design comparison study, we set out to examine, for the first time, links between diagnosed paternal depression in the postnatal period and playfulness in father-infant interactions.

METHODS

Fathers and their infants were assessed when the infants were 3 months old. Paternal depression was diagnosed using a structured psychiatric interview. Currently depressed (n = 19) and non-depressed (n = 19) fathers were individually matched on age and education. Fathers were filmed playing with their children. Four dimensions were coded for paternal playfulness during free-play: physicality, playful excitation, tactile stimulation and active engagement.

RESULTS

Depressed fathers, compared to non-depressed fathers, engaged in fewer episodes of playful excitation (mean scores: 0.71 vs.2.53, p = 0.005), less gentle touch (mean time: 38.57 vs. 53.37, p = 0.015) and less active engagement (mean scores: 2.29 vs 3.24, p = 0.044). When controlling for infant fretfulness, the findings remained largely unchanged.

LIMITATIONS

The sample size was small and the sample was limited to mostly white, well-educated fathers.

CONCLUSIONS

Playful paternal behaviours as early as 3 months differ between fathers with and without depression. These changes may help in understanding children's risk in relation to paternal psychopathology and could be a target for future family interventions.

Maternal prenatal stress and placental gene expression of NR3C1 and HSD11B2: The effects of maternal ethnicity

BACKGROUND

Prenatal stress is associated with altered fetal and infant development. Previous studies have suggested that these effects may be mediated in part via altered functioning of placental enzymes and receptors involved in the HPA-axis, including the glucocorticoid receptor (NR3C1) and HSD11B2, the enzyme which metabolises cortisol. However, previous studies have not examined the potential ethnicity effects on these associations. This study aimed to characterise the association between maternal prenatal stress and placental genes expression and subsequently, any potential effect of maternal ethnicity.

METHOD

Pregnant women(n=83) were recruited prior to elective caesarean section and assessed for trait anxiety, depression and life events. Placentas were collected and placental gene expression of NR3C1 and HSD11B2 were analysed. We examined associations between maternal prenatal stress and placental gene expression, and the tested for a possible moderating effect of maternal ethnicity(59.0% Caucasian;41.0% non-Caucasian:12.0% South Asian;6.0% African/African-American;14.4% Other;8.4% Mixed).

RESULTS

Analyses demonstrated a trend in the association between both maternal trait anxiety and depression symptoms with placental gene expression of NR3C1(adj.β=0.220,p=0.067;adj.β=0.212,p=0.064 respectively). We found a significant interaction with maternal ethnicity(β=0.249;p=0.033). In Caucasian women only prenatal trait anxiety and depressive symptoms were associated with an increase in placental NR3C1 expression(adj.β=0.389,p=0.010;adj.β=0.294;p=0.047 respectively). Prenatal life events were associated with a down regulation of HSD11B2(adj.β=0.381;p=0.008), but only in Caucasians.

CONCLUSION

These results support previous findings of an association between maternal prenatal stress and the expression of placental genes associated with the HPA-axis, but only in Caucasians. These ethnic specific findings are novel and require replication in different populations.

Associations between biological markers of prenatal stress and infant negative emotionality are specific to sex

PURPOSE

Fetal programming is the idea that environmental stimuli can alter the development of the fetus, which may have a long-term effect on the child. We have recently reported that maternal prenatal cortisol predicts infant negative emotionality in a sex-dependent manner: high prenatal cortisol was associated with increased negative emotionality in females, and decreased negative emotionality in males. This study aims to test for this sex-specific effect in a different cohort, and investigate whether sex differences in fetal programming may be specific to glucocorticoid mechanisms by also examining a maternal salivary alpha-amylase (sAA) by sex interaction.

METHODS

88 pregnant women (mean gestational age=27.4 weeks, SD=7.4) collected saliva samples at home over two working days to be assayed for the hormone cortisol (range=0.13-88.22nmol/l) and the enzyme alpha-amylase (range=4.57-554.8units/ml). Samples were collected at waking, 30-min post-waking and 12h post-waking. Two months after birth participants reported infant negative emotionality using the distress to limits subscale of the Infant Behavior Questionnaire.

RESULTS

The interaction between maternal prenatal cortisol and infant sex to predict distress to limits approached significance (p=0.067). In line with our previous finding there was a positive association between prenatal cortisol and negative emotionality in females, and a negative association in males. The interaction between sAA and sex to predict distress was significant (p=0.025), and the direction of effect was the same as for the cortisol data; high sAA associated with increased negative emotionality in females and reduced negative emotionality in males.

CONCLUSIONS

In line with our previous findings, this research adds to an emerging body of literature, which suggests that fetal programming mechanisms may be sex-dependent. This is the first study to demonstrate that maternal prenatal sAA may be an important biomarker for infant behavior, and the findings have implications for understanding sex differences in developmental psychopathology.

Preventing enduring behavioural problems in young children through early psychological intervention (Healthy Start, Happy Start): study protocol for a randomized controlled trial

BACKGROUND

Behavioural problems are common in early childhood, and can result in enduring costs to the individual and society, including an increased risk of mental and physical illness, criminality, educational failure and drug and alcohol misuse. Most previous research has examined the impact of interventions targeting older children when difficulties are more established and harder to change, and have rarely included fathers. We are conducting a trial of a psychological intervention delivered to families with very young children, engaging both parents where possible.

METHODS

This study is a two-arm, parallel group, researcher-blind, randomized controlled trial, to test the clinical effectiveness and cost-effectiveness of a parenting intervention, Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) for parents of young children (12-36 months) at risk of behavioural difficulties. VIPP-SD is an evidence-based parenting intervention developed at Leiden University in the Netherlands which uses a video-feedback approach to support parents, particularly by enhancing parental sensitivity and sensitive discipline in caring for children. The trial will involve 300 families, who will be randomly allocated into either an intervention group, who will receive the video-feedback intervention (n = 150), or a control group, who will receive treatment as usual (n = 150). The trial will evaluate whether VIPP-SD, compared to treatment as usual, leads to lower levels of behavioural problems in young children who are at high risk of developing these difficulties. Assessments will be conducted at baseline, and 5 and 24 months post-randomization. The primary outcome measure is a modified version of the Preschool Parental Account of Child Symptoms (Pre-PACS), a structured clinical interview of behavioural symptoms. Secondary outcomes include caregiver-reported behavioural difficulties, parenting behaviours, parental sensitivity, parental mood and anxiety and parental relationship adjustment. An economic evaluation will also be carried out to assess the cost-effectiveness of the intervention compared to treatment as usual.

DISCUSSION

If shown to be effective, the intervention could be delivered widely to parents and caregivers of young children at risk of behavioural problems as part of community based services.

TRIAL REGISTRATION

ISRCTN Registry: ISRCTN58327365 . Registered 19 March 2015.

Adapting and developing a video-feedback intervention for co-parents of infants at risk of externalising behaviour problems (VIPP-Co): A feasibility study

BACKGROUND

Recent research on early interventions with parents of infants at risk of externalising behaviour problems indicates that focusing on co-parenting and involving fathers in treatment may enhance effectiveness. This article reports the development and preliminary evaluation of a brief intervention: video-feedback intervention to promote positive parenting and sensitive discipline for co-parents (VIPP-Co).

METHODS

Families who reported to be struggling with their infant's behaviour were recruited from the community and received six home-based sessions of VIPP-Co. The primary outcome was feasibility of the adapted intervention, assessed using semi-structured questionnaires and interviews post-intervention. Preliminary clinical outcome measures were also recorded.

RESULTS

In total, five families with infants between 10 and 24 months completed the intervention. Feedback data documented high rates of acceptability and feasibility. All fathers and mothers completing the intervention reported that it positively impacted their understanding of their child's thoughts and feelings, as well as their approach to individual parenting and co-parenting. Additional preliminary outcome data indicated positive changes in parent-chid interaction and a positive trend was found for infant behaviour, parental well-being and parent relationship adjustment across the intervention.

CONCLUSIONS

The overall results of this study are encouraging, but VIPP-Co must be evaluated with larger samples to explore its efficacy.

FATHER-CHILD INTERACTIONS AT 3 MONTHS AND 24 MONTHS: CONTRIBUTIONS TO CHILDREN'S COGNITIVE DEVELOPMENT AT 24 MONTHS

The quality of father–child interactions has become a focus of increasing research in the field of child development. We examined the potential contribution of father–child interactions at both 3 months and 24 months to children's cognitive development at 24 months. Observational measures of father–child interactions at 3 and 24 months were used to assess the quality of fathers’ parenting (n = 192). At 24 months, the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development, Second Edition (N. Bayley, 1993) measured cognitive functioning. The association between interactions and cognitive development was examined using multiple linear regression analyses, adjusting for paternal age, education and depression, infant age, and maternal sensitivity. Children whose fathers displayed more withdrawn and depressive behaviors in father–infant interactions at 3 months scored lower on the MDI at 24 months. At 24 months, children whose fathers were more engaged and sensitive as well as those whose fathers were less controlling in their interactions scored higher on the MDI. These findings were independent of the effects of maternal sensitivity. Results indicate that father–child interactions, even from a very young age (i.e., 3 months) may influence children's cognitive development. They highlight the potential significance of interventions to promote positive parenting by fathers and policies that encourage fathers to spend more time with their young children.

Fathers, fathering and child psychopathology

The last few years have seen a steady increase in research addressing the potential influence of fathers on their children's development. There has also been a clearer acknowledgement of the need to study families as a complex system, rather than just focusing on individual aspects of functioning in one or other parent. Increased father involvement and more engaged styles of father-infant interactions are associated with more positive outcomes for children. Studies of paternal depression and other psychopathology have begun to elucidate some of the key mechanisms by which fathers can influence their children's development. These lessons are now being incorporated into thinking about engaging both mothers and fathers in effective interventions to optimise their children's health and development.

Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries

Studies examining mechanisms underlying associations between maternal depression and adverse child outcomes (including behaviour, socioemotional adjustment, and emotion regulation) indicate that during pregnancy, maternal depression could affect child outcomes through altered placental function, epigenetic changes in the child, and stress reactivity. Infection and dietary deficiencies in the mother and the child, together with the child's genetic vulnerability, might also affect outcome. Postnatally, associations between maternal depression and child outcome are influenced by altered mother-child interactions, sociodemographic or environmental influences, and social support. Knowledge is scarce on mechanisms in low-income and middle-income countries where maternal depression is highly prevalent, and stressful factors that influence the development of perinatal maternal depression and adverse child outcome (eg, food insecurity, perinatal infections, crowded or rural living conditions, and interpersonal violence) are both more intense and more common than in high-income countries. We reviewed evidence and use the biopsychosocial model to illustrate risk factors, mediators and moderators underlying associations between maternal depression and child outcomes in low-income and middle-income countries.

Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): study protocol for a randomised controlled trial

BACKGROUND

National guidelines in the UK, United States of America, Canada, and Australia have recently stressed the importance of identifying and treating antenatal anxiety and depression. However, there is little research into the most effective and acceptable ways of helping women manage their symptoms of anxiety and stress during pregnancy. Research indicates the necessity to consider the unique needs and concerns of perinatal populations to ensure treatment engagement, highlighting the need to develop specialised treatments which could be integrated within routine antenatal healthcare services. This trial aims to develop a brief intervention for antenatal anxiety, with a focus on embedding the delivery of the treatment within routine antenatal care.

METHODS/DESIGN

This study is a two-phase feasibility trial. In phase 1 we will develop and pilot a brief intervention for antenatal anxiety, blended with group support, to be led by midwives. This intervention will draw on cognitive behavioural principles and wider learning from existing interventions that have been used to reduce anxiety in expectant mothers. The intervention will then be tested in a pilot randomised controlled trial in phase 2. The following outcomes will be assessed: (1) number of participants meeting eligibility criteria, (2) number of participants consenting to the study, (3) number of participants randomised, (4) number of sessions completed by those in the intervention arm, and (5) number of participants completing the post-intervention outcome measures. Secondary outcomes comprise: detailed feedback on acceptability, which will guide further development of the intervention; and outcome data on symptoms of maternal and paternal anxiety and depression, maternal quality of life, quality of couple relationship, mother-child bonding, infant temperament and infant sleep.

DISCUSSION

The study will provide important data to inform the design of a future full-scale randomised controlled trial of a brief intervention for anxiety during pregnancy. This will include information on its acceptability and feasibility regarding implementation within current antenatal services, which will inform whether ultimately this provision could be rolled out widely in healthcare settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95282830 . Registered on 29 October 2014.

Maternal prenatal depressive symptoms predict infant NR3C1 1F and BDNF IV DNA methylation

Prenatal maternal psychological distress increases risk for adverse infant outcomes. However, the biological mechanisms underlying this association remain unclear. Prenatal stress can impact fetal epigenetic regulation that could underlie changes in infant stress responses. It has been suggested that maternal glucocorticoids may mediate this epigenetic effect. We examined this hypothesis by determining the impact of maternal cortisol and depressive symptoms during pregnancy on infant NR3C1 and BDNF DNA methylation. Fifty-seven pregnant women were recruited during the second or third trimester. Participants self-reported depressive symptoms and salivary cortisol samples were collected diurnally and in response to a stressor. Buccal swabs for DNA extraction and DNA methylation analysis were collected from each infant at 2 months of age, and mothers were assessed for postnatal depressive symptoms. Prenatal depressive symptoms significantly predicted increased NR3C1 1F DNA methylation in male infants (β = 2.147, P = 0.044). Prenatal depressive symptoms also significantly predicted decreased BDNF IV DNA methylation in both male and female infants (β = -3.244, P = 0.013). No measure of maternal cortisol during pregnancy predicted infant NR3C1 1F or BDNF promoter IV DNA methylation. Our findings highlight the susceptibility of males to changes in NR3C1 DNA methylation and present novel evidence for altered BDNF IV DNA methylation in response to maternal depression during pregnancy. The lack of association between maternal cortisol and infant DNA methylation suggests that effects of maternal depression may not be mediated directly by glucocorticoids. Future studies should consider other potential mediating mechanisms in the link between maternal mood and infant outcomes.

Effects of prenatal depressive symptoms on maternal and infant cortisol reactivity

Prenatal depression is associated with adverse offspring outcomes, and the prevailing mechanistic theory to account for mood-associated effects implicates alterations of the maternal and foetal hypothalamic-pituitary adrenal (HPA) axes. Recent research suggests that depression may be associated with a failure to attenuate cortisol reactivity during early pregnancy. The aim of the current study is to investigate whether this effect continues into mid and late gestation. A further aim is to test whether maternal prenatal cortisol reactivity directly predicts infant cortisol reactivity. One hundred three pregnant women were recruited during either the second or third trimester. Depressive symptoms were assessed by self-report, and maternal salivary cortisol responses to a stressor (infant distress film) were measured. Approximately 2 months after birth, mothers (n = 88) reported postnatal depression and infant salivary cortisol responses to inoculation were measured. Prenatal depression was not associated with cortisol reactivity to acute stress in mid and late pregnancy. Similarly, neither prenatal depression nor maternal prenatal cortisol reactivity predicted infant cortisol reactivity to inoculation at 2 months. If the effects of prenatal depression on foetal and infant development are mediated by alterations of the maternal and foetal HPA axes, then early pregnancy may be a particularly vulnerable period. Alternatively, changes to HPA reactivity may not be as central to this association as previously thought.

Are female children more vulnerable to the long-term effects of maternal depression during pregnancy?

BACKGROUND

Female fetuses are more vulnerable to high levels of maternal glucocorticoids. We examined whether exposure to prenatal maternal depression, a condition associated with high glucocorticoids, carries greater risk for depression at 12 and 18 years in girls.

METHODS

Our sample comprised 7959 mothers and children from the Avon Longitudinal Study of Parents and Children following imputation for missing data. Maternal depression was assessed pre-and post-natally, and offspring depression at ages 12 and 18. We used logistic regression models to examine the relationship between exposure to prenatal and postnatal depression and offspring depression at 18 and 12 and interactions with gender.

RESULTS

There was an interaction between prenatal depression and gender (P=0.027) and between postnatal depression and gender (P=0.027) for offspring depression at 18. Following adjustment in pre-natally depressed mothers, the odds ratio for offspring depression at 18 was 1.55 (95% c.i. 1.03-2.34) for girls and 0.54 (0.23-1.26) for boys. In post-natally depressed mothers, the odds ratio for offspring depression at 18 was 1.15 (0.70-1.89) in girls and 3.13 (1.52-6.45) in boys. However there was no evidence for interaction between prenatal or postnatal depression and gender (P=0.559 and 0.780 respectively) for offspring depression at 12.

LIMITATIONS

As expected with this large cohort spanning over 18 years, there was loss-to-follow-up.

CONCLUSIONS

This is the first evidence in humans that increased vulnerability of female fetuses to maternal stress responses during pregnancy persists into adolescence. One explanation for gender differences emerging later is more depressive symptomatology is attributed to heritable risk at 12, whereas biological processes involved in brain development at 18 may be influenced by foetal programming. If replicated, this study has potential to help understand intergenerational transmission of depression, a leading cause of morbidity worldwide.

Parents' Prenatal Mental Health and Emotional, Behavioral and Social Development in Their Children

This study examines the association between expectant parents' psychological distress and children's development at 36 months old. This is a prospective population study based on the Norwegian Mother and Child Cohort Study, N = 31,663. Logistic regression models were used to assess whether high scores (cutoff ≥ 2.00) on the symptom checklist-5 in parents predicted higher levels (cutoff ≥ 90 percentile) of developmental problems in their children. The risk of emotional and behavioral problems were significantly increased in children when both parents were affected by psychological distress during pregnancy, fully adjusted OR 2.35 (95% CI 1.36, 4.07) and OR 2.65 (96% CI 1.564.48), respectively. The risk was higher when mothers reported high level of psychological distress than when only the fathers did, but the risk of emotional difficulties in children was highest when both parents presented high levels of psychological distress, indicating an additive effect of parental psychological distress.

Infant outcomes following treatment of antenatal depression: Findings from a pilot randomized controlled trial

INTRODUCTION

Maternal antenatal depression is associated with an increased risk of emotional and behavioural problems in children. More recently antenatal depression has been associated with shorter sleep duration, higher number of awakenings and sleep problems in infants. Examining the effect of treatment of depression on child development is the next step in unravelling the complex association between antenatal depression and offspring development.

METHODS

We used data from a pilot RCT of women with antenatal depression who received either Cognitive Behavioural Therapy (CBT) or Treatment as Usual (TAU), to examine infant sleep duration and temperament two months postpartum. Data was available for n=14 in the CBT group and n=11 in the TAU group.

RESULTS

No differences by treatment arm were evident. Improvement in depression scores during pregnancy was associated with easier temperament (β=-.45, p=.024) and shorter nocturnal sleep duration (β=-.58, p=.003). The findings were more pronounced in the CBT group compared to the TAU group.

LIMITATIONS

This was a pilot RCT and as such the sample size was small and there was some loss to follow up between the baseline and postnatal assessment.

CONCLUSION

Improvement in antenatal depressive symptoms may have beneficial effects for the infant; whether these are directly through effects on foetal development or indirectly through changes in the postnatal mother-infant relationship remains to be determined.

Associations of maternal and paternal antenatal mood with offspring anxiety disorder at age 18 years

OBJECTIVE

Maternal antenatal depression and anxiety are associated with increased risk of childhood behavioural and emotional problems in offspring; it remains unclear to what extent this is due to a maternal biological impact on foetal development. Here, we compare associations between maternal and paternal antenatal depression and anxiety with offspring anxiety disorders, thus controlling for some genetic and shared environmental factors.

METHODS

We used data from the ALSPAC population cohort including measures of antenatal parental depression and anxiety. At 18 years, offspring completed the CIS-R interview, yielding diagnoses for anxiety disorders. Results were adjusted for confounding variables including parental postnatal depression and anxiety.

RESULTS

Children of women with antenatal depression (18 weeks gestation), had an increased risk of anxiety disorders at 18 years of age (11.1% vs. 6.2%; adj. OR 1.75 (1.19, 2.58); p=0.01). Children of women with antenatal anxiety had increased risk of co-morbid anxiety and depression (adj. OR 1.39 (1.06, 1.82); p=0.02). No such associations were found with paternal antenatal depression or anxiety.

LIMITATIONS

There was a high attrition rate from the original cohort to the CIS-R completion at 18 years postpartum. Parental mood was only assessed together at one time point during the antenatal period.

CONCLUSIONS

The differences in the association between maternal and paternal mood during pregnancy and child outcomes supports the hypothesis that foetal programming may account, at least in part, for this association. We highlight the potential opportunity for preventative intervention by optimising antenatal mental health.

Foetal exposure to maternal depression predicts cortisol responses in infants: findings from rural South India

BACKGROUND

Maternal depression during pregnancy is associated with an increased risk of adverse child outcomes. One potential mechanism is the influence of antenatal depression on the foetal hypothalamic-pituitary-adrenal axis. This can be observed as disturbances in baseline cortisol secretion during childhood. The influence of antenatal depression on infant cortisol reactivity to a stressor may provide further insight into this association. In addition, the dose-response relationship between foetal exposure to antenatal depression and infant cortisol reactivity is unclear.

METHODS

A consecutive sample of 133 pregnant women in their third trimester was recruited from an antenatal clinic in Karnataka, South India. Women were assessed for depression before and after birth on the Edinburgh Postnatal Depression Scale (EPDS) and the Kessler 10 Scale. Salivary cortisol response to immunization was measured in 58 infants at 2 months of age. We aimed (i) to investigate the association between antenatal depression and infant cortisol reactivity to immunization and (ii) to explore whether the relationship is dose-dependent.

RESULTS

Exposure to antenatal depression independently predicted elevated infant cortisol responses to immunization (β = 0.53, P = 0.04). The association was found to be U-shaped, for antenatal depression measured on the EPDS, with the infants exposed to the highest and lowest levels of maternal antenatal EPDS scores during intra-uterine life showing elevated cortisol responses to immunization (R(2) = 0.20, P = 0.02). Infants exposed to moderate levels of maternal antenatal depression showed the lowest cortisol response to immunization.

CONCLUSIONS

These findings suggest that the association between antenatal depression and infant cortisol reactivity is dose-dependent and U-shaped, implying that infants exposed to both low and high levels of maternal depression showed greater reactivity. The study provides the first evidence of such an association from a low-income setting.

Associations between postnatal maternal depression and psychological outcomes in adolescent offspring: a systematic review

Postnatal depression (PND) affects approximately 10-20 % of new mothers in developed countries, with accumulating research documenting its adverse impact on not only the mother but also the wider family. Longitudinal studies assessing potential effects of maternal PND on offspring are mounting, and it is therefore timely to investigate the long-term psychological outcomes for adolescent offspring who were exposed to PND in infancy. PsycINFO, Medline, and Embase databases were searched with key terms for English language abstracts. Papers of 16 were identified that examined associations between PND and internalising problems, externalising problems, psychopathology, psychosocial, and cognitive outcomes of adolescent offspring. Impaired offspring cognitive outcomes reflected some of the most consistent findings. Conflicting evidence was found for an effect of PND on adolescent offspring internalising and externalising problems and overall psychopathology. Psychosocial outcomes in offspring adolescents indicated a specific adverse effect, although based on only two studies. Significant gender differences across outcomes were found. It was concluded that PND possibly increases risk vulnerability in the presence of recurrent, concurrent, and antenatal maternal depression but that these latter factors alone may be the stronger specific predictors. Limitations of the review are discussed as well as implications for future research and clinical practice.

Paternal Depression in the Postnatal Period and Early Father-Infant Interactions

Objective. Paternal depressive disorder is associated with adverse effects on child development. One possible mechanism for this is through the effects of the disorder on parenting capacities. The link between paternal depression and father-infant interactions was investigated at three-months postpartum. Design. Major depressive disorder was assessed in N = 192 fathers using a structured clinical interview (SCID). Altogether, 54 fathers met criteria for depression, and 99 fathers were categorized as non-depressed. Observational assessments of face-to-face father-infant interactions were conducted in an infant-seat setting and a floor-mat setting. Associations between paternal depression and father-infant interactions were analyzed. Results. Paternal depression is associated with more withdrawn parental behavior in interactions on the floor-mat. There were few other differences in observed interaction between depressed and non-depressed fathers. Conclusions. Fathers with depression may be more withdrawn, displaying less verbal and behavioral stimulation during interactions with their young infants. They may initiate a pattern of parenting that remains compromised, potentially affecting their children's development.

Salivary cortisol response to infant distress in pregnant women with depressive symptoms

The Hypothalamic-Pituitary-Adrenal (HPA) axis has been proposed as a potential underlying biological mechanism linking prenatal depression with adverse offspring outcomes. However, it is unknown whether the reactivity of this system to stress is altered in pregnant women experiencing depression. The objective of this study was to investigate whether salivary cortisol response to a distressed infant film is enhanced in pregnant women with symptoms of depression compared with non-depressed controls. Salivary cortisol and subjective mood responses to the film were measured in 53 primiparous women, between 11 and 18 weeks gestation. Both groups showed similar increases in state anxiety in response to the film, but there was a significantly increased cortisol response in women experiencing symptoms of depression. Depression during pregnancy is associated with increased reactivity of the HPA axis. This is consistent with altered HPA axis functioning being a key mechanism by which prenatal mood disturbance can impact upon fetal development.

Postnatal depressive symptoms and child psychological development at 10 years: a prospective study of longitudinal data from the South African Birth to Twenty cohort

BACKGROUND

In high-income countries, maternal postnatal depression is associated with adverse outcomes in the child. However, few studies have investigated this relation in countries of low and middle income. Furthermore, to our knowledge, no studies have followed up cohorts into later childhood. We aimed to investigate whether maternal depression 6 months after birth is associated with psychological difficulties in a socioeconomically disadvantaged South African cohort of children at age 10 years.

METHODS

Birth to Twenty is a prospective, longitudinal, birth-cohort study based in the Soweto area of Johannesburg, South Africa. Mothers and children in this cohort have been followed up at timepoints ranging from before birth to age 10 years. Maternal mood was measured at 6 months with the Pitt depression inventory and at 10 years with the Centre for Epidemiologic Studies depression scale (CES-D). Child psychological functioning was assessed at 10 years with the South African child assessment schedule (SACAS). Our primary outcome was psychological development of children at age 10 years, measured by total score on the SACAS. Secondary outcomes were scores on externalising and internalising subscales of the SACAS. We used t tests to compare psychological outcomes between children whose mother had postnatal depression at 6 months and those whose mother did not have postnatal depression. We examined associations between maternal postnatal depression and child psychological outcomes by multivariate linear-regression analysis, adjusting for socioeconomic status and maternal depression at 10 years, and we used logistic regression to provide odds ratios for associations identified by linear regression.

FINDINGS

1866 mothers completed the Pitt depression inventory 6 months after the birth of their child; of these, 453 (24%) had symptoms of postnatal depression. At the 10-year assessment, 1012 mothers completed the CES-D questionnaire, of whom 747 (74%) were judged to have depression. Sociodemographic characteristics did not differ between mothers with and without depression at both 6 months and 10 years. After adjusting for socioeconomic status and maternal depression at 10 years, children whose mothers had postnatal depression at 6 months were more than twice as likely to have significant psychological difficulties 10 years later compared with children whose mothers did not have postnatal depression at 6 months (adjusted odds ratio 2·26, 95% CI 1·23-4·16).

INTERPRETATION

Maternal postnatal depression is associated with adverse psychological outcomes in children up to 10 years later in countries of low and middle income. In view of the increased prevalence of postnatal depression in these settings, this finding has important implications for policy and interventions for children and their mothers.

FUNDING

Wellcome Trust (UK), Medical Research Council of South Africa, Human Science Research Council (South Africa), University of the Witwatersrand.

Does paternal mental health in pregnancy predict physically aggressive behavior in children?

The aim was to study the association between paternal mental health and physically aggressive behavior in children. This study is based on 19,580 father-child dyads from the Norwegian Mother and Child Cohort Study (MoBa). Fathers' mental health was assessed by self-report (Symptom Checklist-5, SCL-5) in week 17 or 18 of gestation. Children's behavior (hitting others) was obtained by mothers' reports. A multinomial logistic regression model was performed. Expectant fathers' high level of psychological distress was found to be a significant risk factor only for girls hitting, adjusted OR = 1.46 (1.01-2.12), p = 0.043, but not for boys. High levels of mental distress in fathers predict their daughters' hitting at 5 years of age.

Expressed emotion as an assessment of family environment with mothers and fathers of 1-year-old children

BACKGROUND

High levels of expressed emotion (EE) in parents have been found to put children at risk for emotional and behavioural problems. However, the majority of existing studies have focused on mothers of school-aged children and adolescents rather than younger children, and have only rarely included fathers.

METHODS

The present study examined the reliability of EE in mothers and fathers of 1-year old children. It also investigated whether depression and marital problems in the postnatal period predicted EE toward the child at 12 months. EE was assessed with the Preschool Five Minute Speech Sample in 163 families.

RESULTS

The rater-interrater and code-recode reliability was high for most EE dimensions. Mothers and fathers were found to display quite similar EE scores. Regression analyses showed that depression and couple relationship significantly predicted EE in mothers, but not fathers.

CONCLUSIONS

The findings suggest that EE provides a reliable and useful assessment of the family environment in families of young children.

No moderating effect of 5-HTTLPR on associations between antenatal anxiety and infant behavior

OBJECTIVE

Maternal antenatal anxiety is associated with an increased risk of behavioral disturbances in offspring. Recent work has suggested that the effect of maternal antenatal anxiety on infant temperament at 6 months is moderated by the serotonin transporter polymorphism 5-HTTLPR, with carriers of the short allele more susceptible to the adverse behavioral outcomes of maternal antenatal anxiety. These findings, however, are yet to be replicated and extended beyond infancy. The aim of the current study was to assess this same potential moderator (5-HTTLPR) in a large population-based cohort study, and to determine whether or not the effects persist into childhood and early adolescence.

METHOD

Data from the Avon Longitudinal Study of Children and Parents (ALSPAC) cohort (N = 3,946) were used to assess whether the 5-HTTLPR genotype moderated the association between self-reported maternal antenatal anxiety (Crown Crisp Index) in pregnancy, and child temperament at 6 months (Infant Temperament Questionnaire), and also later behavioral and emotional problems on the Strengths and Difficulties Questionnaire from age 4 to 13 years.

RESULTS

We found no evidence to suggest that the 5-HTTLPR polymorphism moderated the effects of maternal antenatal anxiety on infant temperament at 6 months or infant behavioral and emotional problems from childhood through to adolescence.

CONCLUSION

Our results, based on a large prospective community sample that assessed children from infancy to early adolescence, provide a thorough test of, but no evidence for, a genetic moderation of the effects of maternal antenatal anxiety by 5-HTTLPR.

Parental depression and the challenge of preventing mental illness in children

Parental depression is a risk factor for psychiatric problems in children and adolescents. Exciting scientific developments have elucidated potential early mechanisms of intergenerational risk transmission and new models of intervention may help to prevent some childhood problems. However, caution is needed in interpreting such associations as causal and in targeting interventions appropriately.

Paternal mental health and socioemotional and behavioral development in their children

OBJECTIVE

To examine the association between symptoms of psychological distress in expectant fathers and socioemotional and behavioral outcomes in their children at age 36 months.

METHODS

The current study is based on data from the Norwegian Mother and Child Cohort Study on 31 663 children. Information about fathers' mental health was obtained by self-report (Hopkins Symptom Checklist) in week 17 or 18 of gestation. Information about mothers' pre- and postnatal mental health and children's socioemotional and behavioral development at 36 months of age was obtained from parent-report questionnaires. Linear multiple regression and logistic regression models were performed while controlling for demographics, lifestyle variables, and mothers' mental health.

RESULTS

Three percent of the fathers had high levels of psychological distress. Using linear regression models, we found a small positive association between fathers' psychological distress and children's behavioral difficulties, B = 0.19 (95% confidence interval [CI] = 0.15-0.23); emotional difficulties, B = 0.22 (95% CI = 0.18-0.26); and social functioning, B = 0.12 (95% CI = 0.07-0.16). The associations did not change when adjusted for relevant confounders. Children whose fathers had high levels of psychological distress had higher levels of emotional and behavioral problems.

CONCLUSIONS

This study suggests that some risk of future child emotional, behavioral, and social problems can be identified during pregnancy. The findings are of importance for clinicians and policy makers in their planning of health care in the perinatal period because this represents a significant opportunity for preventive intervention.

Do early father-infant interactions predict the onset of externalising behaviours in young children? Findings from a longitudinal cohort study

BACKGROUND

Factors related to parents and parenting capacities are important predictors of the development of behavioural problems in children. Recently, there has been an increasing research focus in this field on the earliest years of life, however, relatively few studies have addressed the role of fathers, despite this appearing to be particularly pertinent to child behavioural development. This study aimed to examine whether father-infant interactions at age 3 months independently predicted child behavioural problems at 1 year of age.

METHOD

A sample of 192 families was recruited from two maternity units in the United Kingdom. Father-infant interactions were assessed in the family home and coded using the global rating scales. Child behaviour problems were assessed by maternal report. Hierarchical and logistic regression analyses were used to examine associations between father-infant interaction and the development of behavioural problems.

RESULTS

Disengaged and remote interactions between fathers and their infants were found to predict externalising behavioural problems at the age of 1 year. The children of the most disengaged fathers had an increased risk of developing early externalising behavioural problems [disengaged (nonintrusive) interactions--adjusted odds ratio 5.33 (95% confidence interval; 1.39, 20.40): remote interactions adj. OR 3.32 (0.92, 12.05)].

CONCLUSIONS

Disengaged interactions of fathers with their infants, as early as the third month of life, predict early behavioural problems in children. These interactions may be critical factors to address, from a very early age in the child's life, and offer a potential opportunity for preventive intervention.

Using video feedback to improve early father-infant interaction: a pilot study

Preventive interventions with parents of infants have tended to focus on mothers. Recent research focused on fathers suggests that their involvement in interventions might enhance effectiveness. One effective approach with mothers is the brief, home-based Video-feedback Intervention to promote Positive Parenting (VIPP). This paper is a report of a pilot study of VIPP with fathers to assess its feasibility. Five fathers were recruited from an existing longitudinal study of parents. The primary outcome was acceptability, assessed using a semi-structured questionnaire after completion of the intervention. All fathers completed all sessions of the intervention. Fathers rated the intervention as having had a significant impact on their understanding of their child's thoughts and feelings, and as having improved their communication and relationship with their baby. Fathers' feedback was generally positive. The flexibility to conduct sessions at home (or at fathers' places of work) and the flexible timing of sessions were identified as fundamental to successful delivery. The results of this pilot study are encouraging, as VIPP with fathers was feasible. In light of the modest sample size, and the use of a non-clinical sample, the intervention must be evaluated with larger, clinical samples to evaluate its efficacy with fathers.

Depressed fathers' speech to their 3-month-old infants: a study of cognitive and mentalizing features in paternal speech

BACKGROUND

Depression in fathers in the postnatal period is associated with an increased risk of child behaviour problems. A key potential pathway of risk transmission is exposure of the child to negative cognitions and affect in the context of early parenting. This study examines paternal speech during face-to-face father-infant interactions at 3 months.

METHOD

Currently depressed (n=19) and non-depressed (n=19) fathers were individually matched on age and education. Speech was coded for cognitive biases and mentalizing statements using a modified version of previous measures of maternal speech. Paternal depression was diagnosed using a structured psychiatric interview.

RESULTS

Depression in fathers was associated with more speech focused on the paternal experience and less on the infants' experience. Depressed fathers' speech comprised more negative and critical utterances, compared with non-depressed fathers.

CONCLUSIONS

Important differences emerge in the speech of fathers who experience depression. Examining negative cognitions in the speech of these fathers as early as 3 months may help in understanding children's risk in relation to paternal psychopathology.

Disruption to the development of maternal responsiveness? The impact of prenatal depression on mother-infant interactions

Both prenatal and postnatal maternal depression are independently associated with an increased risk of adverse infant development. The impact of postnatal depression on infants may be mediated through the effect of depression in reducing maternal responsiveness. However, the mechanisms underlying the effect of prenatal depression are unclear. Using longitudinal data from over 900 mother-infant pairs in a UK birth cohort (ALSPAC), we found that women with high depressive symptom scores during mid pregnancy, but NOT when their infants were 8 months, had a 30% increased risk of low maternal responsiveness when the infant was 12 months compared to women with consistently low depression. This may provide a mechanism to explain the independent association between prenatal depression and poorer infant development.

Prevalence of child mental health problems in sub-Saharan Africa: a systematic review

OBJECTIVE

To assess the prevalence of child mental health problems in community settings in sub-Saharan Africa.

DATA SOURCES

A systematic search of MEDLINE, EMBASE, and PsychInfo, supplemented by tracking of references from identified articles and personal communications with local researchers.

STUDY SELECTION

Only community-based studies in sub-Saharan Africa that assessed the general psychopathology of children aged 0 to 16 years were included. For each eligible study, the following information was extracted: year of publication, country, population sampled, area type (rural or urban), sampling method and sample size (percentage boys), age range, assessment instrument, informant, diagnostic criteria, and prevalence rates of general psychopathology.

MAIN OUTCOME MEASURE

Pooled prevalence rate of psychopathology in children, identified by questionnaire and, specifically, by clinical diagnostic instruments.

RESULTS

Eleven studies met the inclusion criteria, 10 of which were included in the meta-analysis. The 10 studies provided data for 9713 children from 6 countries, with substantial variation in assessment methods. Overall, 14.3% (95% CI, 13.6%-15.0%) of children were identified as having psychopathology. Studies using screening questionnaires reported higher prevalence rates (19.8%; 95% CI, 18.8%-20.7%) than did studies using clinical diagnostic instruments (9.5%; 8.4%-10.5%).

CONCLUSIONS

Evidence suggests that considerable levels of mental health problems exist among children and adolescents in sub-Saharan Africa. One in 7 children and adolescents have significant difficulties, with 1 in 10 (9.5%) having a specific psychiatric disorder. There are clear sociodemographic correlates of psychopathology that may place children in areas of greatest deprivation at greatest risk.

Healthcare costs of paternal depression in the postnatal period

BACKGROUND

There is growing evidence that fathers experience depressive symptoms following the birth of a child. The aim of this study was to estimate the healthcare costs of paternal postnatal depression, thereby informing research into cost-effective preventative and treatment interventions for the condition.

METHODS

Data on healthcare resource-use over the first 12 months postpartum was collected from 192 fathers recruited from two postnatal wards in southern England. Three groups of fathers were identified: fathers with depression (n=31), fathers at high risk of developing depression (n=67) and fathers without depression (n=94).

RESULTS

Mean father-child dyad costs were estimated at £ 1103.51, £ 1075.06 and £ 945.03 (£ sterling, 2008 prices) in these three groups, respectively (P=0.796). After controlling for potentially confounding factors, paternal depression was associated with significantly higher community care costs.

CONCLUSION

This study provides useful preliminary insights into the healthcare costs associated with paternal depression during the postnatal period.

LIMITATION

The small sample size may, in part, account for the failure to detect statistically significant differences in mean costs between study groups for most cost categories.

The association between observed non-verbal maternal responses at 12 months and later infant development at 18 months and IQ at 4 years: a longitudinal study

BACKGROUND

An infant's early environment has an important influence on their development. For example, the sensitivity and warmth of a mother's responses towards her infant is associated with the infant's later socio-emotional development. However, it is less clear whether maternal responses are associated with the infant's later cognitive development.

METHOD

We used data from a large UK cohort study to investigate the association between non-verbal maternal responses and later infant development and IQ. Maternal responses were rated at 12 months during an observed mother-infant interaction. Infant development was assessed using the Griffiths scales at 18 months and IQ at 4 years was assessed using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI). Data on the infant's developmental level at 6 months (prior to the maternal response ratings) was also available. The complete case sample comprised 732 mother-infant pairs.

RESULTS

There was evidence for an association between positive maternal responses and infant development at 18 months. After adjusting for infant developmental level at 6 months and other confounders, we found a difference of 0.25 standard deviations (coef 2.0, 95% CI (0.8-3.2), p=0.002) on the Griffiths scales between infant's whose mothers showed positive compared to neutral non-verbal responses at 12 months. However, an association between positive maternal responses and IQ at 4 years diminished following adjustment for maternal educational attainment.

CONCLUSION

The results provide evidence that positive maternal responses are associated with improved development in infants at 18 months. However, the association between maternal response and IQ at 4 years may be explained by higher educational attainment in mothers who show positive responses. Future studies are needed to explore the influence of maternal responses on different aspects of infant development as well as the role of maternal factors such as education.

Assessing prenatal depression in the rural developing world: a comparison of two screening measures

Significant levels of prenatal depression are reported from the Indian subcontinent (25–45%). A wide variety of measures have been used to screen for prenatal depression in western research. However, little evidence exists on the use of such measures in the context of the developing world. The objective of this study was to assess the validity of the Edinburgh Postnatal Depression Scale (EPDS) and the Kessler 10 Scale of Psychological Distress (K10) as screening measures for prenatal depression in rural South India. One hundred ninety-four women in their third trimester of pregnancy were assessed at a rural prenatal clinic in Karnataka, South India, using the EPDS, the K10 (scored 0–40) and a structured diagnostic psychiatric interview to establish a DSM-IV diagnosis of depression. Depressed women scored significantly higher on the EPDS and K-10 than controls. A receiver-operating characteristic analyses showed both scales to be good screening instruments for prenatal depression in rural South India at a cut-off of ≥13 on the EPDS (sensitivity = 100%, specificity = 84.90%, and area under the curve = 0.95) and ≥6 on the K10 (sensitivity = 100%, specificity = 81.30%, and area under the curve = 0.95). The EPDS and K10 have thus been shown to have equally good sensitivity and specificity in rural settings in the developing world at a cut-off score of ≥13 and ≥6, respectively. This study demonstrates the validity of the EPDS and K10 in screening pregnant women for depression during their prenatal check-ups.

Paternal depression: an examination of its links with father, child and family functioning in the postnatal period

BACKGROUND

Maternal depression is common and is known to affect both maternal and child health. One of the mechanisms by which maternal depression exerts its effects on child health is through an increased rate of parental disharmony. Fathers also experience depression, but the impact of this on family functioning has been less studied. The aim of this study was to investigate the association between paternal depressive disorder and family and child functioning, in the first 3 months of a child's life.

METHODS

A controlled study comparing individual and familial outcomes in fathers with (n = 54) and without diagnosed depressive disorder (n = 99). Parental couple functioning and child temperament were assessed by both paternal and maternal report.

RESULTS

Depression in fathers is associated with an increased risk of disharmony in partner relationships, reported by both fathers and their partners, controlling for maternal depression. Few differences in infant's reported temperament were found in the early postnatal period.

CONCLUSIONS

These findings emphasize the importance of considering the potential for men, as well as women, to experience depression in the postnatal period. Paternal symptoms hold the potential to impact upon fathers, their partners, and their children.

Differential susceptibility to fathers' care and involvement: The moderating effect of infant reactivity

The differential susceptibility hypothesis suggests that children differ in their susceptibility to the influence of both positive and negative environmental factors. Children with reactive temperaments are hypothesised to be particularly susceptible to environmental influences, both for better and for worse. The present study sought to investigate whether infant temperament moderates the influence of fathers on child prosocial and problem behaviours. In a large prospective population study (Avon Longitudinal Study of Parents and Children), 5064 children were followed between the ages of six and 81 months (6¾ years). Infant temperament, child behaviours, and fathers' involvement and depression were assessed.Although no overall moderating effect of reactive temperament was found for father involvement or depression, there was an interaction between reactivity, child gender, and father involvement. Girls with reactive temperaments were more susceptible to father involvement, showing significantly fewer problem behaviours and more prosocial behaviours when fathers were more involved, and more problem behaviours and fewer prosocial behaviours with less father involvement. The findings provide some support for the differential susceptibility hypothesis and extend existing findings to include effects of fathers' involvement on positive and negative behavioural outcomes.

An investigation of health anxiety in families where children have recurrent abdominal pain

OBJECTIVES

To explore health anxiety in children with recurrent abdominal pain (RAP) using a symbolic play assessment.

METHODS

Children with RAP and two control groups (with asthma and well children) were recruited. Eighty-four families completed play and questionnaire assessments of health anxiety and psychological functioning.

RESULTS

Children with RAP demonstrated less use of psychological descriptions for feelings than control children, and were more likely to represent serious outcomes to health scenarios than well children, but not children with asthma. Mothers of children with RAP had higher levels of health anxiety, and rated their children as having more physical symptoms and anxiety.

CONCLUSIONS

The symbolic play paradigm provided discriminating insights into health anxiety in children. The findings suggest that childhood RAP may be associated with higher levels of parental health anxiety. These aspects of family functioning might usefully be explored in families where a child has RAP.

Depression in fathers in the postnatal period: assessment of the Edinburgh Postnatal Depression Scale as a screening measure

BACKGROUND

Postnatal depression commonly affects women after the birth of a child, and is associated with an increased risk of adverse outcomes for their children. A wide variety of measures have been used to screen for depression in the postnatal period but little research has investigated such measures with men. However depression can also affect men at this time, and this is associated with an independently increased risk of adverse child outcomes. The present study aimed to determine whether a reliable cut off point for the Edinburgh Postnatal Depression Scale (EPDS) can be established to screen fathers.

METHOD

A sample of fathers was sent the EPDS at 7 weeks after the birth of their child. A structured clinical interview was conducted with 192 men to determine whether they were suffering from depression.

RESULTS

Fathers with depression scored significantly higher on the EPDS than non-depressed fathers. A score of greater than 10 was found to be the optimal cut off point for screening for depression, with a sensitivity of 89.5% and a specificity of 78.2%.

LIMITATIONS

The relatively modest participation rate means the results may not be fully generalisable to the whole population.

CONCLUSION

The EPDS is shown to have reasonable sensitivity and specificity at a cut off score of over 10. The study shows that it is possible to screen fathers for depression in the postnatal period and it may be valuable to administer this measure to new fathers.