Individual and Combined Effects of Postpartum Depression in Mothers and

Fathers on Parenting Behavior

James F. Paulson, Sarah Dauber and Jenn A. Leiferman
Pediatrics 2006;118;659
DOI: 10.1542/peds.2005-2948

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/118/2/659.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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ARTICLE

Individual and Combined Effects of Postpartum

Depression in Mothers and Fathers on
Parenting Behavior
James F. Paulson, PhDa, Sarah Dauber, PhDa, Jenn A. Leiferman, PhDb
aCenter for Pediatric Research, Eastern Virginia Medical School, Norfolk, Virginia; bSchool of Medicine, University of Colorado Denver, Health Sciences Center, Denver,
Colorado

The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
BACKGROUND. Pediatric anticipatory guidance has been associated with parenting
behaviors that promote positive infant development. Maternal postpartum depression is known to negatively affect parenting and may prevent mothers from
following anticipatory guidance. The effects of postpartum depression in fathers on
parenting is understudied.
OBJECTIVE. Our purpose with this work was to examine the effects of maternal and

paternal depression on parenting behaviors consistent with anticipatory guidance

recommendations.
METHODS. The 9-month-old wave of data from a national study of children and their
families, the Early Childhood Longitudinal Study, provided data on 5089 2-parent
families. Depressive symptoms were measured with a short form of the Center for
Epidemiologic Studies Depression Scale. Interviews with both parents provided
data on parent health behaviors and parent-infant interactions. Logistic and linear
regression models were used to estimate the association between depression in
each parent and the parenting behaviors of interest. These models were adjusted
for demographic and socioeconomic status indicators.
RESULTS. In this national sample, 14% of mothers and 10% of fathers exhibited

levels of depressive symptoms on the Center for Epidemiologic Studies Depression

Scale that have been associated with clinical diagnoses, confirming other findings
of a high prevalence of postpartum maternal depression but highlighting that
postpartum depression is a significant issue for fathers as well. Mothers who were
depressed were 1.5 times more likely to engage in less healthy feeding and sleep
practices with their infant. In both mothers and fathers, depressive symptoms were
negatively associated with positive enrichment activity with the child (reading,
singing songs, and telling stories).

www.pediatrics.org/cgi/doi/10.1542/
peds.2005-2948
doi:10.1542/peds.2005-2948
Key Words
anticipatory guidance, parenting, fathers,
depression, child development
Abbreviations
ECLSEarly Childhood Longitudinal Study
BBirth Cohort
CES-DCenter For Epidemiologic Studies
Depression Scale
SESsocioeconomic status
OR odds ratio
CI condence interval
Accepted for publication Feb 23, 2006
Address correspondence to James F. Paulson,
PhD, Center for Pediatric Research, Eastern
Virginia Medical School, 855 W Brambleton
Ave, Norfolk, VA 23510. E-mail: paulsojf@evms.
edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2006 by the
American Academy of Pediatrics

CONCLUSIONS. Postpartum depression is a significant problem in both mothers and

fathers in the United States. It is associated with undesirable parent health behaviors and fewer positive parent-infant interactions.

PEDIATRICS Volume 118, Number 2, August 2006

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659

NOW SUBSTANTIAL body of literature documents

the negative effects of parental (in most cases maternal) depression.1 Much attention has been placed on
child outcomes, which have included decrements in social development, behavior problems, emotional difficulties, and a range of physical health problems.2 The longpresumed mechanism of these poor outcomes has been
impaired parenting practices (eg, decreased display of
emotion, involvement, and warmth), which result in
disrupted parent-child relationships and consequent
child difficulties. However, parenting-level mechanisms
for the translation of parental depression to poor child
outcomes have only recently undergone more systematic investigation.3
Anticipatory guidance for parenting infants is an area
that directly addresses these mechanisms and has an
established association with positive infant development. In a review article of health care services and
promotion of child development, Regalado and Halfon4
report that pediatric anticipatory guidance in areas such
as sleep habits, discipline, and reading effectively promotes child development in the first 3 years of life. More
specifically, studies have shown that anticipatory guidance provided by pediatricians is associated with better
infant sleep patterns, increased frequency of reading,
and improved quality of parent-child interactions.5 The
American Academy of Pediatrics anticipatory guidance
recommendations for parents of children ages birth to 1
year include breastfeeding, putting the infant to sleep on
its back, putting the infant to sleep awake, not putting
the infant to sleep with a bottle, and engaging in positive
interactive activities with the child.6 These interactive
activities include reading stories and playing together,
both of which have been found to promote language
development, as well as social and emotional development in young children.79
Given the documented positive effects of anticipatory
guidance on child development, it is important to examine factors that may prevent parents from following
these recommended practices. Parental postpartum depression may be one such factor, because it has been
linked to poor child health and development outcomes
and compromised parenting practices.10 Depression is
addressed variably in this literature and, although sometimes defined by a clinical diagnosis, is most often captured with self-report screening instruments on which
scores above a given threshold are associated with positive clinical diagnoses.2,11 Maternal postpartum depression is prevalent, with 8% to 25% of women experiencing subclinical depressive symptomatology sometime
during the first year postpartum.12 Several recent studies
have found similar rates of postpartum depression in
new fathers, particularly in families where the mother is
also experiencing depression.1316 However, to our
knowledge, no study exists that examines paternal depression in the first year postpartum in a large, nation-

660

PAULSON et al

ally representative sample. Postpartum depression in

mothers has been linked with negative parenting behaviors associated with negative child outcomes.17,18 Studies
have also found links between paternal depression and
psychopathology in children and adolescents, but most
of these studies did not focus on the postpartum period.19
Very little research to date has been conducted on the
effects of paternal postpartum depression on fathers
parenting behaviors.
Several studies have examined the relationship between maternal postpartum depression and specific
health-related parenting behaviors recommended by pediatricians, such as infant sleep position and breastfeeding. However, many of these studies have been limited
by small samples and inconsistent definitions of health
behaviors. Several studies have found that infants and
young children of depressed mothers tend to have more
sleep-related problems than those of nondepressed
mothers.2022 It has been suggested that these sleep problems may be a result of depressed mothers use of ineffective sleep practices.23 In one study of mothers of
8-month-old infants, depressed mothers were more
likely to sleep with their infants and nurse them to sleep,
both behaviors that have been associated with later sleep
difficulties.22 In addition, a study of single, low-income
black women found that mothers with persistent depressive symptoms were less likely to use the back sleep
position for their infants.24 To our knowledge, no study
to date has examined the effects of paternal postpartum
depression on sleep-related parenting behaviors in parents of infants.
The relationship between depression and breastfeeding is understudied and equivocal to date.2527 Breastfeeding may positively influence a womans mental state
either through hormonal changes or emotional attachment. For example, hormonal fluctuations involving
oxytocin and cortisol have been linked to improved
mental health.28,29 Moreover, aspects of breastfeeding,
such as physical proximity and touching, influence a
mothers emotional attachment to her infant and may
attenuate mental distress.30,31 On the other hand, several
studies have found that maternal depression negatively
impacts breastfeeding. Specifically, depressed mothers
have been found to breastfeed for shorter durations, as
well as to experience breastfeeding more negatively than
nondepressed mothers.3234 Only 1 known study has examined the impact of paternal depression on breastfeeding.35 This study found no effect of paternal depression
on breastfeeding interruption; however, mothers who
felt that their husbands actively supported breastfeeding
had a longer duration of breastfeeding.
The existing literature suggests that depressed mothers may be less likely to follow anticipatory guidance
recommendations regarding infant sleep practices and
breastfeeding. In addition to these specific health behaviors, anticipatory guidance for parents of young children

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includes recommendations regarding positive parentchild interactions, such as reading and playing together.
A large body of literature has demonstrated negative
effects of maternal depression on the quality of motherchild interactions. In a meta-analysis of studies in this
area,3 depressed mothers of infants and young children
were found to be more irritable and hostile, to be more
disengaged from their child, and to have lower rates of
play and other positive social interactions with their
child. Very few studies have looked at the impact of
paternal depression on parenting practices related to
parent-child interaction. Moreover, little research has
examined the joint effects of maternal and paternal depression on parenting behaviors and on child outcomes.
One notable exception is a study by Mezulis et al,36
which found that paternal depression during the postpartum period exacerbated the effects of maternal depression on later child behavior problems only if the
father spent significant amounts of time caring for the
child in infancy. In addition, being exposed to a nondepressed father did not buffer the effects of maternal
depression even if they spent high amounts of time with
their infants. In general, these findings suggest that father involvement in the postpartum period generally
impacts children of depressed mothers but has little to no
impact on children of nondepressed mothers. Only 1
known study has examined the relations between maternal and paternal depression and specific types of interactions, such as reading, with very young children.16
This study of parents of children ages birth to 3 years in
a large national sample found that depressed mothers
were less likely to play with or read to their children
after controlling for social and demographic covariates.
Paternal depression did not affect fathers frequency of
interactions with their children after covariates were
controlled.
Overall, the current study intends to examine the
extent to which postpartum depression among parents
of infants influences their engagement in parenting behaviors that are consistent with anticipatory guidance
recommendations and that have been associated with a
stable household environment and child well-being.
This study extends past research by examining the individual and interactive effects of both mothers and fathers depressive symptoms on their parenting practices
during the postpartum period in a large, nationally representative sample. As in much of the previous literature, we define depression with a rating scale that
characterizes individuals both in terms of symptom severity and with an empirically driven cut point, above
which a respondent is likely to receive a clinical diagnosis of depression. On the basis of the findings of previous
studies, we expected that mothers and fathers depression would negatively impact their parenting behaviors,
such that parents who are depressed would be less likely
to engage in positive health behaviors, as well as enrich-

ment and play activities, with their infants than parents

who are not depressed. In addition, we expected to find
parenting behaviors to be the most compromised in
families where both parents were depressed.
METHODS
Data
This study used data from the first wave of the Early
Childhood Longitudinal Study (ECLS)-Birth Cohort
(B).37 The ECLS-B is a multisource, multimethod study,
conducted by the National Center for Education Statistics, designed to evaluate a range of influences on childrens early development. The population from which
the ECLS-B sample was extracted consisted of children
born in 2001, with an oversampling of specific ethnic
minority groups (eg, American Indian and Asian and
Pacific Islander infants), low birth weight infants, and
twins. Births were sampled within primary sampling
units from the National Center for Health Statistics vital
statistics system. The primary sampling units were stratified by geographical region, median household income,
proportion minority population, and metro versus nonmetro area. More than 14 000 births were sampled,
yielding a final sample of 10 688 completed parent respondent interviews at the 9-month data collection
point. This represents a response rate of 76.8%.
Sample Selection
Data were collected from mothers, resident fathers, nonresident fathers, and infants using a combination of
computer-assisted personal interviews, self-administered questionnaires, and direct developmental assessments of the infants. The current study used data from
the biological mother interviews and self-report questionnaires and resident father questionnaires. Because of
the nature of our research question, we limited our
sample to only those cases with complete mother and
father mental health data. Of the 10 688 completed parent interviews, 9447 had complete depression data available. Of these, we included only those cases where biological mothers were living with the target child (n
9327) and excluded 462 cases that were duplicate data
on twin infants, resulting in 8865 cases. We further
narrowed down the sample to include only those biological mothers with corresponding resident father data,
yielding a final sample size of 5089. Details on sample
demographics and depression data appear in Table 1.
Measures
Depression
Depression for both mothers and fathers was measured
by an abbreviated form of the Center for Epidemiologic
Studies Depression (CES-D) Scale.38 The CES-D short
form measures different depressive symptoms, including
depressed affect, positive affect, somatic symptoms, psyPEDIATRICS Volume 118, Number 2, August 2006

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661

TABLE 1 Demographics and Mean CES-D Scores for Mothers and Fathers With High and Low Depressive Symptoms (Total N 5089)
Variable

Mothers
Full
Sample,
N (Column %)

Age, y
20
2034
35
Race
White
Black
Hispanic
Asian/Pacic Islander
Other
Education
12th grade
High school graduate
Some college
Work status
Full-time
Part-time
Unemployed
Mean CES-D score (SD)

Low Depression
(N 4536),
N (Column %)

Fathers
High Depression
(N 733),
N (Column %)

High Depression
(N 522),
N (Column %)

151 (3.5)
3261 (74.9)
944 (21.7)

50 (6.8)
541 (73.8)
142 (19.4)

63 (1.2)
3291 (64.7)
1735 (34.1)

57 (1.2)
2925 (64.0)
1585 (34.7)

6 (1.1)
366 (70.1)
150 (28.7)

2853 (56.1)
372 (7.3)
732 (14.4)
808 (15.9)
318 (6.3)

2464 (56.6)
308 (7.1)
633 (14.6)
687 (15.8)
258 (5.9)

389 (53.1)
64 (8.7)
99 (13.5)
121 (16.5)
60 (8.2)

2915 (57.4)
419 (8.2)
737 (14.5)
725 (14.3)
286 (5.6)

2637 (57.8)
350 (7.7)
667 (14.6)
654 (14.3)
253 (5.5)

278 (53.4)
69 (13.2)
70 (13.4)
71 (13.6)
33 (6.3)

888 (17.4)
1046 (20.6)
3155 (62.0)

711 (16.3)
868 (19.9)
2777 (63.8)

177 (24.1)
178 (24.3)
378 (51.6)

742 (14.6)
1335 (26.2)
3012 (59.2)

633 (13.9)
1171 (25.6)
2763 (60.5)

109 (20.9)
164 (31.4)
249 (47.7)

1665 (32.8)
984 (19.4)
2432 (47.9)
4.58 (4.96)

1476 (33.9)
858 (19.7)
2015 (46.3)
2.96 (2.67)

189 (25.8)
126 (17.2)
417 (57.0)
14.19 (4.50)

4249 (86.1)
246 (5.0)
441 (8.9)
3.69 (4.67)

3866 (87.2)
208 (4.7)
360 (8.1)
2.45 (2.59)

383 (76.3)
38 (7.6)
81 (16.1)
14.53 (4.75)

Health Behaviors
Six items from the biological mother interview were
used to assess parental engagement in the following
health behaviors: putting the child to sleep on its back,
putting the child to bed without a bottle, putting the
child to sleep awake, and breastfeeding. Mothers were
asked to report the position in which they put their
infant to sleep as a newborn and as a 3-month-old.
PAULSON et al

Low Depression
(N 4567),
N (Column %)

201 (3.9)
3802 (74.7)
1086 (21.3)

chomotor retardation, and interpersonal activity and has

been used in past research studies39 and national health
survey collection efforts.40 The CES-D short form contains 12 items with each item coded on a 4-point scale
between 0 and 3. The range of total scores is 0 to 36, with
a total score between 10 and 14 representing moderate
depression and 15 representing severe depression.
Cronbachs for the study sample was .863 for the
mothers and .862 for the fathers. Note that the term
depression used throughout this article refers to individuals who report high levels of depressive symptomatology and is not intended to refer to individuals who
are diagnosed with clinical depression.
CES-D results were used in 2 different ways in this
study. For analyses using logistic regression, dichotomous depression scores for mothers and fathers were
created using cut points established by the ECLS research team based on previous research. For linear regressions, continuous scores on the CES-D for mothers
and fathers were used. This enabled us to examine the
impact of both the likely presence or absence of depression and the influence of the degree of depressive symptoms on outcomes.

662

Full Sample,
N (Column %)

Responses were combined into 1 item for sleep position

and coded as putting the child to sleep on the back at
both ages versus any other sleep position at either or
both ages. Putting the child to bed with a bottle and
putting the child to bed awake were both coded yes
versus no. Breastfeeding was coded on the basis of mothers responses to whether they had ever breastfed their
infant (yes versus no).
Parent-Child Interaction
Parent-child interactions were assessed with 7 items,
reported by both mothers and fathers. Parents were
asked how often in a typical week they read to their
child, tell their child stories, sing songs with their child,
and take their child on errands (not at all, once or twice,
3 6 times, or every day). These 4 items were dichotomized into every day versus less often. In addition, parents were asked how often in the past month they
played peekaboo with their child, tickled their child, or
took their child outside to walk or play (not at all, rarely,
a few times a month, a few times a week, about once a
day, or more than once a day). These 2 items were
dichotomized into a few times a week or more versus
less often. Similar methods for dichotomizing these
items have been used in previous studies.41 The first 4
items have been used in the National Household Education Survey, a large, population-based survey administered every 2 years from 1991 to 2001. The last 2 items
were used in the Early Head Start Research and Evaluation Project.40 All of the items except for tickle child
were used as dependent variables in the logistic regressions. Tickle child was excluded because of lack of suf-

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ficient variability in response: 99% of mothers and fathers reported tickling their child a few times a week or
more.
Because many of the items addressing parent-child
interactions were similar, exploratory factor analysis42
was used to determine whether a more parsimonious
approach to operationalizing parent-child interactions
was feasible. The principal components method with
varimax rotation was conducted on the 7 items described above for mothers and fathers separately. This
revealed 2 coherent factors of parent-child interactions
that were very similar for mothers and fathers. The
2-factor solution allows us to describe parent-child interactions with 2 variables rather than the original 7.
This approach explains 45.84% of variance for mothers
and 47.92% of variance for fathers. Factor 1 includes the
following 3 items, all of which measure enrichment
activities: read to child, tell stories to child, and sing
songs with child. Factor 2 includes the following 4 items,
which measure play activities: play peekaboo, tickle
child, take child on errands, and take child outside to
walk or play. Because of the logical consistency of their
constituent items, we named these factors enrichment
and play.
Demographic Covariates
A number of demographic variables known to be associated with the outcome variables were controlled for in
the analyses and operationalized as follows. Child gender was coded as male and female. Mother and father
age were trichotomized into the following groups: 20 to
34 years, 20 years, and 34 years. Mother and father
race were dichotomized into white and other racial
backgrounds. Mother and father education were coded

into 3 groups: some college or more, high school graduate or equivalent, and 12 years. Mother and father
work status were coded into full-time employment,
part-time employment, and unemployed. A composite
variable measuring socioeconomic status (SES) was derived by the authors of the ECLS-B on the basis of
household income, education, and occupation. This
variable was coded into 3 SES groups, representing highest, middle, and lowest. Child birth weight was coded as
normal or low, and birth status was coded as singleton or
multiple birth. Household income was included as a
continuous variable. Parity was coded as a continuous
variable as the number of additional children residing in
the household with the target child, which ranged from
0 to 6.
Data Analysis
Descriptive statistics for all of the outcome variables
were computed and compared for mother and father
depression groups using the 2 statistic (see Table 2).
Logistic regression was used to model the relationship
between maternal and paternal dichotomized depression
scores and categorical outcome variables.43 Unadjusted
and adjusted effects of depression were examined, and
the final results are displayed in Table 3. In the initial
adjusted model, all of the covariates described above
were entered; however, mother and father age, father
race, SES group, birth weight, and birth status (singleton
versus multiple) were not significant and were dropped
from additional analyses. All of the models were examined both with and without the interaction term
(mother depression father depression), and no differences in main effects were observed. Therefore, final
reported results include the interaction term. The final

TABLE 2 Descriptive Statistics: Mother and Father Depression and Outcome Variables
Variable

Full
Sample,
N (%)

Both Not
Depressed,
N (%)

Mother
Depressed,
N (%)

Father
Depressed,
N (%)

Both
Depressed,
N (%)

Back sleep position

Child ever breastfed
Child to bed without bottle
Child to bed awake
M read to child every day
M tell stories every day
M sing songs every day
M take child on errands every day
M play peekaboo a few times a week or more
M tickle child a few times a week or more
M play outside a few times a week or more
F read to child every day
F tell stories every day
F sing songs every day
F take child on errands every day
F play peekaboo a few times a week or more
F tickle child a few times a week or more
F play outside a few times a week or more

2685 (52.8)
3784 (74.4)
3816 (75.1)
3100 (61.1)
1695 (33.3)
1375 (27)
3785 (74.4)
2946 (57.9)
4635 (91.1)
5033 (98.9)
3780 (74.3)
409 (8.2)
534 (10.8)
1731 (34.9)
1177 (23.4)
4354 (87.7)
4937 (98.8)
3006 (60.4)

2163 (54.4)
3021 (75.9)
3064 (77.1)
2402 (60.4)
1384 (34.8)
1126 (28.3)
2991 (75.2)
2298 (57.8)
3656 (91.9)
3942 (99.1)
2986 (75.1)
331 (8.4)
422 (10.9)
1379 (35.7)
911 (23.2)
3421 (88.2)
3864 (98.9)
2387 (61.3)

259 (44.2)
403 (68.8)
391 (66.7)
368 (63.3)
157 (26.8)
127 (21.7)
417 (71.2)
342 (58.4)
517 (88.2)
578 (98.6)
421 (71.8)
41 (7.1)
60 (10.4)
180 (31.3)
134 (23.0)
497 (87.2)
568 (98.8)
338 (59.0)

203 (54.1)
266 (70.9)
270 (72.0)
250 (66.7)
107 (28.5)
86 (22.9)
267 (71.2)
219 (58.4)
336 (89.6)
369 (98.4)
271 (72.3)
29 (7.9)
38 (10.4)
130 (35.6)
101 (27.2)
315 (84.9)
366 (98.9)
206 (55.5)

60 (40.8)
94 (63.9)
91 (61.9)
80 (54.4)
47 (32.0)
36 (24.5)
110 (74.8)
87 (59.2)
126 (85.7)
144 (98.0)
102 (69.4)
8 (5.6)
14 (10.0)
42 (29.0)
31 (21.2)
121 (85.2)
139 (97.2)
75 (52.8)

.001
.001
.001
.05
.001
.01
.10
NS
.01
NS
NS
NS
NS
.10
NS
NS
NS
.05

M indicates mother; F, father; NS, not signicant.

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663

TABLE 3 Adjusted Effects of Maternal and Paternal Depression on Outcomes

Depression No Yes OR (95% CI)

Variable
Sleep position back other
Ever breastfed yes no
Bed with bottle no yes
Bed awake yes no
Mother read every day less often
Mother tell stories every day less often
Mother sing songs every day less often
Mother errands every day less often
Mother peekaboo few times a week
less often
Mother play outside few times a
week less often
Father read every day less often
Father tell stories every day less often
Father sing songs every day less often
Father errands every day less often
Father peekaboo few times a week
less often
Father play outside few times a
week less often

MD

FD

MD FD

1.40 (1.111.76)a
1.48 (1.131.94)a
1.53 (1.162.02)a
0.75 (0.551.02)b
1.24 (0.971.60)
1.42 (1.081.86)c
1.12 (0.851.47)
1.10 (0.891.35)
1.57 (1.082.28)c

0.80 (0.601.06)
0.98 (0.681.41)
0.99 (0.681.45)
0.66 (0.470.91)c
1.04 (0.741.47)
1.40 (1.011.94)c
1.16 (0.831.62)
1.20 (0.891.63)
1.12 (0.661.92)

0.74 (0.421.30)
0.92 (0.382.21)
1.08 (0.542.16)
2.73 (1.236.06)c
0.59 (0.311.14)
0.54 (0.251.17)
0.60 (0.271.37)
0.72 (0.431.20)
1.11 (0.403.11)

1.29 (0.941.75)

1.26 (0.931.71)

0.87 (0.501.49)

1.55 (0.942.53)
0.99 (0.691.42)
1.39 (1.061.83)c
1.06 (0.761.47)
1.00 (0.681.49)

1.04 (0.581.86)
1.23 (0.752.01)
0.92 (0.681.25)
1.15 (0.791.67)
1.28 (0.812.03)

0.90 (0.272.98)
0.76 (0.301.91)
0.85 (0.431.69)
1.37 (0.583.22)
0.50 (0.201.25)

1.23 (0.981.55)

1.42 (1.101.85)a

0.71 (0.371.36)

The following covariates were controlled: child gender, household income, mother race, mother and father employment, mother and father
education, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction between
mother and father depression. Brackets indicate reference group. Source: ECLS-B.
a P .01.
b P .10.
c P .05.

results are reported in the form of odds ratios (ORs),

allowing for ease of interpretation. All estimates are
presented with 95% confidence intervals (CIs). All of the
analyses were conducted using Stata 8 computer software (Stata Corp, College Station, TX),44 and adjustments were made to account for the sampling design
used in the ECLS.
Following the logistic regressions described above, an
additional set of analyses was conducted to examine
whether the degree of maternal and paternal depression
(measured continuously) might influence the degree of
parent-child interaction measured by the 4 factor scores
described above. Linear regressions were run on these
variables to determine whether the degree of mother
and father depression (measured using the continuous
scale score on the CES-D) impacted the degree of parent-

child interaction. These analyses used the continuous

CES-D scores for mothers and fathers as the independent
variables and the factor scores described above as the
dependent variables. Both unadjusted and adjusted effects were examined, following the same format described above for the logistic regressions (see Table 4).
All of the results discussed below are the results from the
adjusted models.
RESULTS
Depression in Mothers and Fathers: Descriptive Statistics
On the basis of the dichotomous depression scores, 14%
of mothers and 10% of fathers had moderate or severe
depressive symptoms. On the continuous CES-D scores,
mothers had a mean score of 4.58 (SD: 4.96) and fathers

TABLE 4 Adjusted Effects of Degree of Maternal and Paternal Depression on Degree of Parental
Engagement in Enrichment and Play Activities
Variable

Mother enrichment activities

Mother play activities
Father enrichment activities
Father play activities

Depression B (SE)
MD

FD

.008 (.003)a
.007 (.004)
.005 (.004)
.003 (.004)

.007 (.005)
.000 (.005)
.010 (.004)a
.005 (.004)

MD FD
.001 (.001)a
.001 (.001)
.000 (.001)
.000 (.001)

The following covariates were controlled: child gender, household income, mother race, mother and father employment, mother and father
education, and number of children in the household. MD indicates mother depression; FD, father depression; MD FD, interaction between
mother and father depression. Brackets indicate reference group. Source: ECLS-B.
a P .05.

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PAULSON et al

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had a mean score of 3.69 (SD: 4.67). Both mothers and

fathers continuous scores on the CES-D ranged from 0
to 36. 2 analyses were conducted to examine simple
associations among maternal and paternal depression
and the outcome variables. For the purpose of these
analyses, the sample was divided into the following 4
groups, on the basis of mother and father depression
status using the dichotomized CES-D scores: neither parent depressed (N 3981; 78.2%), mother only depressed (N 586; 11.5%), father only depressed (N
375; 7.4%), and both parents depressed (N 147;
2.9%).
Maternal and Paternal Depression and Health Behaviors
Descriptive Statistics Based on 2 Analyses
Significant differences were found for all of the health
behaviors, with anticipatory guidance recommendations
most likely to be followed when neither parent suffered
depressive symptoms and least likely to be followed
when both parents were depressed (see Table 2). Specifically, when both parents were depressed, the child
was less likely to be put to sleep on his/her back (2 [3]
30.16; P .001), was less likely to have ever been
breastfed (2 [3] 25.39; P .001), and was more likely
to be put to bed with a bottle (2 [3] 45.74; P .001).
One exception to this pattern was found for putting the
child to bed awake, which was most likely to occur when
fathers only were depressed (2 [3] 9.62; P .05).
Logistic Regressions
After adjusting for covariates, several effects of parental
depression on health behaviors were found in the logistic regressions (see Table 2). Depressed mothers were
less likely to put their infants to sleep on their backs (OR:
1.40; P .01), less likely to have ever breastfed their
infants (OR: 1.48; P .01), and more likely to put their
infants to bed with a bottle (OR: 1.53; P .01). Depressed fathers were more likely to put their infants to
bed awake (OR: 0.66; P .05). In addition, a significant
interaction between maternal and paternal depression
was found for putting the infant to bed awake, suggesting that when both parents were depressed, the infant
was less likely to be put to bed awake.
Maternal and Paternal Depression and Parent-Child
Interaction Behaviors
Descriptive Statistics Based on 2 Analyses
On the basis of the 2 analyses, significant or trend-level
differences were found for 4 mother-reported parentchild interaction behaviors, with mothers being overall
more engaged with their children when neither they nor
their spouse suffered depressive symptoms. Interestingly, mothers were least likely to read to their child (2
[3] 19.06; P .001), tell stories (2 [3] 15.45; P
.01), or sing songs (2 [3] 6.50; P .10) when either

they or the childs father (but not both) was depressed.

As expected, mothers were least likely to play peekaboo
with their infants when both parents were depressed (2
[3] 15.50; P .01). No significant differences were
found for mother-reported taking the child on errands,
tickling the child, or playing outside with the child.
For father-reported enrichment/play activities, only 1
significant (play outside) and 1 trend-level (sing songs)
difference was found. Fathers were most likely to play
outside with their children when neither parent was
depressed and least likely to do so when both parents
were depressed (2 [3] 8.94; P .05). In addition,
fathers were most likely to sing songs with their infants
when neither parent was depressed or when only the
mother was depressed and were least likely to sing songs
when both parents were depressed (2 [3] 6.66; P
.10).
Logistic Regressions
After adjusting for covariates, several significant effects
of maternal and paternal depression on parent-child interaction activities were found. Specifically, depressed
mothers were less likely to tell their child stories every
day (OR: 1.42; P .05) and played peekaboo less often
(OR: 1.57; P .05). When mothers were depressed,
fathers were less likely to sing songs with their children
every day. Two significant effects of paternal depression
were found: when fathers were depressed, mothers were
less likely to tell stories to their child every day, and
depressed fathers played outside less often with their
children (OR: 1.42; P .01). No significant interactions
were found.
Linear Regressions
After adjusting for covariates, mother enrichment activities was predicted by maternal depression, as well as by
a significant interaction between mother and father depression. A further analysis of this interaction revealed a
stronger negative effect of maternal depression on
mother enrichment activities when the father was not
depressed than when the father was also depressed.
Father depression predicted father enrichment activities,
such that fathers who were more depressed engaged in
less enrichment activities with their infants. No significant effects of maternal or paternal depression were
found on mother and father play activities.
DISCUSSION
The effects of maternal and paternal depression on parenting practices related to positive child health and development has undergone very little investigation to
date. The present study was among the first to examine
the individual and combined effects of postpartum depression in mothers and fathers in a large, nationally
representative sample of 2-caregiver families with
9-month-old children across the United States. ParentPEDIATRICS Volume 118, Number 2, August 2006

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665

ing behaviors that are emphasized in anticipatory guidance by pediatricians were the particular focus of this
study. We predicted that both maternal and paternal
depression would be negatively associated with parent
health behaviors and positive interactions that are recommended in anticipatory guidance. Moreover, we predicted that maternal and paternal depression, together,
would have a greater negative impact than just 1 parent
being depressed. The findings that are discussed below
are those that were observed after controlling for child
gender, parental work, education, race, household income, and number of children.
The prevalence of postpartum depression in mothers
(14%) reported in our study was consistent with other
research and national estimates.12 Postpartum depression in fathers was strikingly high (10%) and more than
twice as common than in the general adult male population in the United States.45 This finding is similar to the
1 previous national finding on this topic16 in that higher
than expected rates of depression were found among
fathers in the early parenting years. It adds to the body
of knowledge, however, in that Lyons-Ruth et al16 included parents of children birth to age 3 years, and the
current study focused on the postpartum period only.
Because the first year of a childs life is particularly
sensitive to parent-level influences, our current findings
suggest the call for increased awareness of postpartum
depression in men.
In support of the maternal depression component of
our hypothesis, maternal depression had a strong association, overall, with fewer desirable health behaviors,
including putting the infant to sleep in the back position
less often, a lower likelihood of ever breastfeeding, and
putting the child to bed with a bottle more often. These
findings are consistent with past research showing that
depressed mothers are less likely to engage in preventive
health behaviors.17,18 In addition, these findings suggest
that maternal postpartum depression may prevent
mothers of infants from adhering to anticipatory guidance recommendations.
Contrary to our expectations, paternal depression was
significantly associated only with a greater likelihood of
the child being put to bed awake, which is consistent
with anticipatory guidance for promoting good sleep
habits in children. There was a similar trend for maternal
depression. These counterintuitive findings (parental depression seems here to be associated with a desirable
caregiving behavior) does not necessarily suggest that
depressed parents attend more carefully to anticipatory
guidance recommendations but may rather be an artifact
of other behaviors in parents that are associated with
paternal depression (eg, 1 parent puts child to bed awake
to tend to the depressed parents needs). Contrasting
this, an interaction was observed between maternal and
paternal depression on putting a child to bed awake,
such that when both parents were depressed, the child
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PAULSON et al

was 3 times more likely to be put to bed asleep. This

finding is consistent with past literature that suggests
that negative effects of parental depression may be exacerbated when both parents are depressed.36
Overall, these findings suggest that higher levels of
depressive symptoms in parents, particularly mothers,
are associated with parenting practices that are inconsistent with anticipatory guidance recommendations and
that have been linked to poorer health outcomes in
children. Mothers who are distressed and experiencing
the cognitive and psychosomatic symptoms of depression may be less able to attend to recommendations for
even simple preventive measures. Although the general
lack of significant association between paternal depression and health behaviors does not support paternal
depression as a risk factor, our study is limited by the
availability of only mother report for health behaviors.
In terms of the effects of parental depression on parent-child interaction, we found that maternal depression
was associated with a lower likelihood of the mother
regularly telling stories and playing peekaboo with the
child. Maternal depression was also associated with a
decreased likelihood of the father singing songs to the
child every day. Paternal depression was associated with
a lower likelihood of the father playing with the child
outside regularly and a lower likelihood of the mother
telling the child stories every day. These findings are of
particular interest, because they suggest that maternal
and paternal depression, in addition to negatively impacting the positive interactions of the suffering parent,
have an impact on the other parents interactions with
their child.
Overall, our results suggest that where day-to-day
interactions are concerned, depressed mothers and fathers engage in less positive interaction with their children, with a particular reduction in the degree of enrichment interactions, including reading, telling stories, and
singing songs. These findings support the existing literature linking maternal depression to impaired parentchild interaction3 and extend the findings to include
fathers as well. These findings are concerning, because
they suggest that the pathway from positive parent-child
interaction to developmental success46 may be jeopardized by depression in either parent. The moderation
effect of paternal depression on mother enrichment behavior is unusual and has not, to our reading, been
reported in previous literature. The effect is small and
should be interpreted cautiously, but it is suggestive of a
family compensatory model in which maternal depression maintains a negative association with enrichment
when paternal depression is not pronounced, but this
relationship goes to 0 when fathers are more depressed.
As such, mothers ignore their depression to interact at
baseline levels with their children when fathers might be
more impaired by their own depression.
This study has several limitations. First, data from the

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9-month wave of the ECLS are cross-sectional and permit inferences about association but not causation. With
future waves of the ECLS birth cohort, however, prospective analysis and stronger causal assessments of the
role of parental depression will become possible. In addition, this study used the CES-D to assess parental
depression, a measure that does not provide an affirmed
clinical diagnosis. CES-D scores reflect a range of depressive symptoms that, when above an empirically determined threshold, are strongly associated with a diagnosis
of depression. Nevertheless, scores above the CES-D
threshold are not fully analogous to clinically verified
depression. Our measures of parenting behaviors are
similarly limited in that they rely on parent self-report
alone. Although parent report of behaviors has been
found to correspond fairly well with observational measures, our data on health behaviors (ie, breastfeeding,
sleep position, and sleep practices) only represent
mother report, one possible reason why paternal depression seemed to have a largely negligible effect on these
behaviors. Furthermore, the narrow range of response
options given to parents may provide a generally weak
measure of the association between depression and caregiving and/or parenting style. It is also important to note
that depression and parenting behaviors were measured
by self-report from the same source. Future studies
should take these limitations into account and make use
of more detailed parenting style and behavior instruments that are available47 and/or use supplementary
observational or diary methods. Finally, this study did
not measure whether parents actually received anticipatory guidance from their pediatricians on the relevant
topics. Given the increased emphasis on anticipatory
guidance in the American Academy of Pediatrics, it is
reasonable to assume that most parents in the study did
receive some information from their pediatricians. However, future studies are warranted that examine the
relationship of parental depression to adherence to anticipatory guidance while considering amount of anticipatory guidance actually received. The overwhelming
strength of this study was its careful sampling to allow
for inference to the general population of the United
States. Because the ECLS is an ongoing prospective
study, additional waves of data will allow this study to be
extended incrementally to provide a stronger picture of
the role of depression in parenting behavior over time.
PRACTICE IMPLICATIONS
The primary practical application of these findings relates to identification and management of postpartum
depression in both parents. Some attention (albeit insufficient) has been paid to the identification of and treatment for depression in mothers, particularly in the perinatal period. Our findings suggest that postpartum
depression in both parents can interfere with the successful adherence to anticipatory guidance. Research has

shown that pediatricians are increasingly delivering anticipatory guidance to parents of infants during wellchild visits, although many parents report areas of unmet needs.48 Our findings suggest that postpartum
depression in parents may be one factor that prevents
parents from successfully applying their pediatricians
recommendations. Thus, whereas the message may be
delivered to parents, it is not necessarily received. This
supports the call for pediatricians to take more responsibility for the identification of depressive symptoms in
mothers of young children.4951 Training pediatricians in
the diagnosis of depression may enhance their ability to
recognize parental depression.49 Moreover, some research has supported the use of brief screening tools in
pediatric settings in identifying mothers with depressive
symptoms who may benefit from treatment.52 Considering the present findings here regarding the effect of
depression on a fathers parenting behavior, such efforts
may bear investigation for both parents. Also, although
the research on the effects of paternal depression on
child outcomes is limited,19 current knowledge indicates
that depressed fathers tend to have children with higher
levels of physical and mental health difficulties, enhancing the urgency of catching this problem in families at
the earliest opportunity.

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Individual and Combined Effects of Postpartum Depression in Mothers and

Fathers on Parenting Behavior
James F. Paulson, Sarah Dauber and Jenn A. Leiferman
Pediatrics 2006;118;659
DOI: 10.1542/peds.2005-2948
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