Screening for postpartum depression: Most caught at 2 months and teen fathers nowhere to be found

By Nestor Lopez-Duran PhD

I was reading through the last issue of the journal Pediatrics and encountered a study that made me think about a previous post I wrote concerning the effects of Fathers postpartum depression. This new study explored the increasing practice by pediatricians and family doctors of screening for postpartum depression during well-baby checkups.

This new study was conducted by a group of researchers at the University of Colorado at Denver.  The authors examined data from the Colorado Adolescent Maternity Program. This program was designed to provide care to 12 to 21-year-old mothers mostly from low income, under-served backgrounds.  The authors wanted to explore the prevalence and incidence of parental depression and the effectiveness of an electronic screening reminder system for clinicians. Specifically, during a well baby visit, an electronic cue appeared on the patients electronic record requesting the clinician to administer a postpartum depression screening instrument.

The results:

  1. The system provided 413 reminders and clinicians appropriately administered the depression screening 99% of the time.
  2. 20% of the mothers screened positive of depression and were referred for further evaluation
  3. The prevalence of positive screens was between 10 to 19% during a 2-week, 2-month, 4-month, and 6-month visit. Specifically, the prevalence was: for 2 week= 17%; 2-month= 16.5%; 4-month= 10%; and 6-month = 18.5%; Prevalence refers to the total number of current positive cases.  For example, at the 2-month visit, 16.5% of the mothers screened positive. However, at the 4-month visit only 10% of the mothers screened positive. There was no time-related trend in the prevalence of depression.
  4. The incidence however varied significantly with time. The incidence was about 17% during the 2-week and 2-month visit and then only 2.9% and 1.9% during the 4- and 6- month visit, respectively.  Incidence refers to the rate of new cases. Thus the risk of testing positive for postpartum depression for the first time during the 4-month and 6-month visit was very low. In fact, the authors reported that only 2 cases of depression would have been missed if the screening had taken place only during the 2-month visit.

Two thoughts:  Other studies have shown a 20% prevalence rate of postpartum depression, so these numbers are relatively in line with previous research. But I was actually surprised that the prevalence wasnt higher.  Remember these are adolescent mothers mostly with low SES and likely limited resources. I was expecting that these mothers were more at-risk not only because of their background, but also because depression rates increase dramatically in adolescence.  In fact, a previous investigation of postpartum depression among adolescent mothers found the prevalence rate much closer to 30% (see Birkeland et al., 2005 Adolescent Motherhood and Postpartum Depression. DOI 10.1207/s15374424jccp3402_8). So it is possible that these low rates reflect the effectiveness of the Colorado Adolescent Maternity Program. This is promising as it suggests that social programs that provide health care access to adolescent mothers may reduce the risk of developing postpartum depression in this at-risk population.

My second thought was what about the fathers? In my previous postpartum depression post I discussed the often neglected finding that fathers also experience postpartum depression at the same rate as mothers, and that it seems that fathers depression may have an even greater impact on the babys development.   Im not blaming the researchers.  The absence of fathers from the study reflected the fact that only in a small number of cases the mother was not the person who brought the baby for the check up. So this reflects our social tendency of fathers to be absent from these aspects of the parenting process. The problem goes beyond the implications for equality and gender roles.  The absence of fathers during the well baby visits also means that these fathers are not being screened for depression, greatly limiting our ability to identify and address this potential public health problem.

The Reference: Sheeder, J., Kabir, K., & Stafford, B. (2009). Screening for Postpartum Depression at Well-Child Visits: Is Once Enough During the First 6 Months of Life? PEDIATRICS, 123 (6) DOI: 10.1542/peds.2008-1160

An apology is more than a word: Effects of apologies on childrens emotions

By Nestor Lopez-Duran PhD

We recently discussed the role of shame and guilt in child depression,  and their link to two distinct discipline practices one that elicits negative views of the self (shame) while the other facilitates the childs understanding of the consequences of ones behaviors on others and the need for reparation and/or apologies (guilt). We discussed how guilt is associated with more positive outcomes while shame is associated with a number of negative consequences. Most of that discussion was focused on the effects of these factors on the transgressor. Bu what about the victim? What are the effects of receiving an apology or reparation from a wrongdoer?

In adults, receiving an apology is associated with forgiveness and feeling less vengeful (see Ohbuchi et al., 1989; see end of post for reference), but less is known about the effects of apologies in children. At the APS convention this past weekend, Craig Smith and Paul Harris from the Harvard Graduate School of Education presented a very clever and informative experimental study on the effects of apologies on childrens emotions and attributions.

The authors recruited75 children (42 girls) age 4 to 7 who were visiting the Boston Museum of Science. The children were told that they would receive a gift of very cool stickers from a child who lives in another city.  Then the children were randomly assigned to one of three groups.

Group 1: Children in this group received a gift envelope but the envelope didnt have any stickers. Instead, the envelope had an empty sticker backing paper and a note from the other child. The note said:

I used all the stickers before I mailed this

Group 2: In this group the children also received an envelope with only the empty sticker backing paper. However the note said:

I used all of the stickers before I mailed this. I am really sorry

Group 3:  The final group received an envelope with the cool stickers as promised and no note.

The authors then asked 3 questions:

  1. How did you feel after opening the envelope? (a 5-point sad to happy picture scale was used)
  2. Do you think the other boy/girl is nice or not-so-nice?
  3. What do you think the other boy/girl was feeling?

Finally, the authors also assessed the effects of the group assignment on the kids sharing behaviors. To this end, the kids were given 10 stickers and were told to share as many as they wanted with the other children.

The results:

  1. Regardless of age, children who didnt get the gift but received the apology reported feeling more positively than kids who didnt get the gift but didnt get the apology.
  2. 87% of the kids who received the apology rated the other child as nice compared to only 37% of the children who didnt get the apology.
  3. Children who received the apology were more likely than children who didnt receive the apology to rate the other kid as sad. In addition, those who didnt receive the apology rated the feelings of the other child at the same level as did children who received the sticker. That is, those who received the gift and those who didnt receive the gift but received no apology rated the other child (gift giver) as happy, while kids who received the apology rated the other child as sad.
  4. Given this last finding, the authors tested a mediator model of apology in which the perception of the other childs emotion (the emotions of the wrongdoer) explains the positive effects of apology.  The model was confirmed; indicating that receiving an apology makes the recipient feels better by affecting the recipients perception of the wrongdoers emotions. So for example, we feel better after an apology because the apology indicates that the other person feels sad about what they did.
  5. Finally, there was no effect of the apology on the likelihood of sharing. All children, regardless of condition (apology, no apology, or gift) shared an average of 3 stickers during the sharing phase of the experiment.

In summary, the study indicates that receiving an apology after a wrongdoing significantly improves the emotional reaction of the recipient, and this may be partly due to the recipients perception that the child who gave the apology feels bad about the action. Some may take a cynic view of this result, interpreting it as hmm so apologies makes us feel better only because it tells us that the other child feels bad, which satisfy our need for vengeance.  But it is likely that apologies work because the apology and our perception of the other childs sadness tell us something about how fair and predictable is our world. That is, thinking that the other child feels sad: 1) may affect our attributions so that we may no longer think that the other child is mean or did it on purpose, or at least not without realizing that it was the wrong thing to do. 2) knowing that the other person agrees that it was the wrong thing to do reaffirms our view of the world as just and predictable, since the others sadness tells us that people in general dont do things like this, because after all, it was the wrong thing to do.

The references:

Smith, C. E., & Harris, P. L. (2009) The effects of apology on childrens emotions and attributions. Poster presented at the Annual Convention of the Association for Psychological Science. San Francisco. May, 2009.

Ohbuchi, K., Kameda, M., & Agarie, N. (1989). Apology as aggression control: its role in mediating appraisal of and response to harm Journal of Personality and Social Psychology, 56 (2), 219-227 DOI: 2926625

Father-daughter bond affects the daughters’ romantic relationships

By Nestor Lopez-Duran PhD

Researchers have noted for decades that children view their home environment and relationship with their parents as models, and that this is usually reflected in how these children interact in new environments in the future. For example, children who are exposed to highly aggressive parenting are in turn more likely to use hostility and aggression as means to attain their own goals (see our review of Hoevet et al. 2009 meta-analysis on parenting and delinquency). Children also model positive behaviors. For example, children who see parents reach amicable resolutions to conflicts are also more likely to learn better conflict resolution skills.

Following this line of research, some investigators have examined whether child exposure to specific bonding or attachment styles are also likely to affect how these children act in their own close relationships later on. To answer this question, a research group from Rider University examined the role of the quality of father-daughter bond in the development of positive romantic relationships during young adulthood.

The authors studied 78 teens and young adults (average age 19), who reported on the quality of their relationship with their fathers and their current boyfriends. Three specific relationship domains were examined, namely:  communication, trust, and time spent with their boyfriends/fathers.

The results:

  1. Girls with good communication with their fathers also had significantly better communication with their boyfriends when compared to girls with low communication with their fathers.
  2. Girls with high levels of trust with their fathers also had significantly better communication and trust with their boyfriends.
  3. Finally, time spent with their fathers was not associated with communication, trust or time spent with their boyfriends.

At first glance, the data seem to show that the quality of bond between daughters and fathers, specifically communication and trust (albeit not time), predicts better communication and trust with their boyfriends. One interpretation is that these girls learn to create secure attachments with their dads, which allow them to then have more positive relationships with their boyfriends (more trust and better communication). It is also possible that fathers contribute to the modeling/development of good communication skills and trust, which affect how these girls interact with their boyfriends. However, it is also possible that this reflects an individual characteristic of the girls themselves and is not necessarily a reflection of the quality of the father-daughter bond. That is, it is possible that girls who have good communication with their fathers simply have a specific temperament or communication styles/skills that facilitate the development of good father-daughter communication, and it is this individual characteristic that also leads to better communication with their boyfriends. But more than likely a combination of individual characteristics and child-parent relationships is driving this effect, which would be in line with previous research on the effects of adolescent-parent relationships in later romantic relationships. For example, Donnellan et al. (2005) found that both personality traits and parenting experiences during adolescents predicted the quality of romantic relationships in young adulthood.

All in all, the results are nonetheless very interesting in showing how the quality of father-daughter relationships may affect how daughters experience their relationships with their boyfriends.

The references:

Nemeth, Ansary, Seiden, & Keith (2009). Father-Daughter bonds and the quality of daughters romantic relationships: Are the two significantly linked? Poster presented at the Annual Convention of the Association for Psychological Science. San Francisco, May, 2009. Dr. Nadia Ansary is at Rider University.

Donnellan, M., Larsen-Rife, D., & Conger, R. (2005). Personality, Family History, and Competence in Early Adult Romantic Relationships. Journal of Personality and Social Psychology, 88 (3), 562-576 DOI: 10.1037/0022-3514.88.3.562
Hoeve, M., Dubas, J., Eichelsheim, V., Laan, P., Smeenk, W., & Gerris, J. (2009). The Relationship Between Parenting and Delinquency: A Meta-analysis Journal of Abnormal Child Psychology DOI: 10.1007/s10802-009-9310-8

Depressed preschool children: The role of shame and guilt.

By Nestor Lopez-Duran PhD

Dr. Joan Luby is one of the worlds leading experts in early childhood depression. Her work has shown that children as young as 3 can become clinically depressed. She is not just redefining sadness in young kids and calling it depression. Instead, she has demonstrated that some young children can, and do, experience clinical depression with the same constellation of symptoms and severity as the type of depression observed in adults.

A review of: Luby, J., Belden, A., Sullivan, J., Hayen, R., McCadney, A., Spitznagel, E. (2009). Shame and guilt in preschool depression: evidence for elevations in self-conscious emotions in depression as early as age 3 Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2009.02077.x

Dr. Luby and her colleagues at the Washington University in St. Louis just published an examination of complex self-conscious emotions among young children with clinical depression. Just as once we wrongly believed that children could not experience depression, we also once believed that young children did not have the capacity to experience complex self-conscious emotions, such as guilt, shame, and pride. However, recent research have shown that children in early childhood have a well developed sense of self and readily experience these emotions. Actually, after reading this study I shared the findings with a colleague and she replied Do you mean to tell me that developmentalists once didnt believe 4-year-olds couldnt feel shame and pride? All you have to do is toilet train a kid and you will see both!

The examination of shame and maladaptive guilt in depressed children is highly relevant because theories of depression indicate that these complex emotions play an important role in maintaining depressogenic states. Shame is usually viewed as a maladaptive emotion. Shame refers to a negative focus on aspects of the self in response to a wrongdoing (Im a horrible person for doing that). In contrast, guilt can be adaptive or maladaptive. Guilt refers to a focus on the wrongdoing which, in adaptive guilt, leads to reparation (e.g., I feel bad for what I did and I should apologize).

In order to explore the presence of guilt and shame in depressed kids, the authors examined 75 clinically depressed preschool children, 39 children with anxiety but not depression, 40 children with disruptive problems, and 146 healthy children. The children underwent a series of laboratory games intended to elicit responses of shame or guilt in reaction to specific vignettes. The vignettes consisted of short stories that the children had to complete, such as You are at the grocery store with your mom and you have lost your favorite teddy bear, show me what happens next. The parents of these children also completed a questionnaire that assesses feelings of guilt and guilt reparation.

The results:

Depression was significantly associated with high levels of shame themes expressed by the children during the stories. However, depression was not associated with guilt themes during the stories. This is consistent with the idea that shame is usually a maladaptive emotion associated with depression, while guilt can be adaptive if it is accompanied by reparation. However, the story became a bit more complex after examining the parental reports. As you can see in the graphic below, depressed kids showed high levels of guilt feelings but low levels of guilt reparation. This pattern was the opposite of what was observed in the healthy children. So it is possible that the parent-reported measure was more sensitive to the presence of more maladaptive guilt (high levels of guilt feelings without reparation) than the vignettes.

In sum, the findings suggest that the presentation of depression in early childhood, at least concerning the presence of guilt and shame, appears to be very similar to adult depression. The authors indicated that the examination of shame and guilt should be part of the clinical assessment of depression in young children, and that early intervention strategies should target these complex emotions.

On a final unrelated note, I was intrigued by the pattern of guilt presented by the kids with disruptive behaviors (see graph above). These children had very low levels of guilt and guilt reparation. The lack of guilt, and especially adaptive guilt, by children with disruptive behavior problems is one common predictor of negative outcomes. Children with conduct disorders show a pattern consistent with psychopathy with limited emotional reactions in response to the distress of others. Following on this theme, tomorrow I will review a study examining one possible mechanism by which these troubled kids are unable to respond to the distress of others.