Preventive interventions for children of parents with depression: international perspectives

Depression is a public health problem of major proportions. In Australia, the prevalence rate for depression is over 15% in adults, and similar rates of illness have been reported around the world.1,2 Based on an analysis of a nationally representative data set in the United States,3 and assuming the same rates in Australia, there are about 1 million Australian children living with a parent who has experienced depression in the past year.

According to recent reviews,3-5 offspring of depressed parents have rates of depression that are between two and four times higher than their counterparts from homes without parental illness. These offspring also have an increased risk for a range of mental health disorders6 and associated difficulties, including deficits in academic performance, social relationships, and self-esteem. Because the risks for children of depressed parents have been recognised worldwide, several countries have implemented systematic national programs to assist these families. A recent meta-analysis of prevention trials has shown that prevention of offspring mental health problems is possible.7

Both specific (eg, having had a prior depression, having a depressed parent, genetic vulnerabilities) and non-specific (eg, poverty, exposure to violence) risk factors contribute to higher lifetime rates of depression in children of depressed parents. Goodman and Gotlib8 have proposed an integrative model to address the cross-generational transmission of risk, and this was the overall organising framework for the US Institute of Medicine3 report on depression in parenting. A recent review5 highlights key observations of the current research in this area:

• The impact of risk factors is bidirectional. That is, not only do parental behaviours influence child outcome, but children’s behaviours influence the parent.

• Both genetic and environmental factors are involved in the transmission of risk, and recent advances in understanding the heritability of depression and gene/environment influences (eg, whole-genome comparisons, molecular genetics) offer great promise for the future.9-11

• Parent–child interactions and parenting style have received significant attention as key factors in the transmission of depression risk from parent to child.12 Psychiatric treatment for parents as well as support for parenting can reduce the risk for children.13,14

• Although children of depressed parents are at increased risk for depression and other difficulties, many families cope well with these problems.15,16 In families with parental depression, Beardslee and Podorefsky17 found that children who do well have individual, family and community resources that enable them to accomplish age-appropriate developmental tasks, engage in relationships, and understand their surroundings despite the parent’s illness. Therefore, important opportunities for resilience promotion in children include supporting families to identify and build upon these resilient processes.

Selected preventive interventions targeted at parents with depression and measuring outcomes in children have a strong evidence base.4 A recent meta-analysis by Siegenthaler and colleagues of randomised controlled prevention trials7 showed that in studies reviewed, risk to offspring for the same mental disorder from which the parent suffered was reduced by 40%. This applied to internalising but not to externalising symptoms. There are a number of national selective prevention strategies designed specifically for children of parents with depression (see Box 1). These have in common a focus on strengthening parenting and addressing youth needs. We discuss two national programs in detail below.

Most parents who are seeking help for depression will present to primary care physicians. Key factors for physicians are (i) recognising depression; (ii) helping parents obtain treatment; (iii) understanding children’s concerns and developmental needs; (iv) offering psychoeducation; (v) providing parental guidance; and (vi) follow-up.

It is important for a primary care practitioner to ask parents if they have experienced depressive symptoms, particularly if they are in high-risk groups such as having had prior depression, recent losses or multiple risk factors (poverty and social isolation). In a number of countries, screening has been recommended for new parents, and parents in whom depression is suspected. Where screening tools are readily available and are paired with access to treatment, they can assist the practitioner. Evidence-based treatment for depression should be instituted. Assisting patients who are parents to obtain treatment when needed is essential.

Eliciting parent concerns is also important. Many parents are worried about possible long-term effects of depression on their children. Research demonstrates that depression in parents affects children differently, depending on the child’s developmental stage.3 Early in life, attachment between parent and child may be disrupted, and symptoms such as difficulties in establishing routines for the child, frequent doctor visits, and difficulties with feeding and sleeping may signal parental depression. In the preschool and school years, difficulties accomplishing developmental milestones may signal the presence of depression, and anxiety symptoms before puberty and depressive symptoms after puberty are very common in children of depressed parents. During adolescence, the rates of diagnosis of depression and anxiety in children of depressed parents increase markedly, and these should be identified and attended to as well.

Depression is not well understood either in society in general or by parents. Helping families to identify their own strengths and to focus on them, providing clear psychoeducation on what parents can do to support the children and helping them to access and use out-of-home resources has proved valuable in a wide array of settings. Depending on the local circumstances, parents might be able to turn to extended family, friends, non-government organisations and family services. They can learn to preserve essential parenting functions despite their illness (eg, supporting their child’s friendships and activities). In fact, children themselves place more emphasis on the importance of peer relationships as a form of support than do parents or mental health professionals.25,26 It is also important to emphasise that while there is increased risk, many children do well, and no child is irrevocably damaged.

Primary care mental health professionals are in an excellent position to provide long-term follow-up and ask periodically about the children of depressed parents. The Beardslee21 and Compas27,28 projects provided long-term follow-up, and the benefits of these interventions were revealed over time. We believe that follow-up with families with depressed parents is essential and can greatly strengthen the initial interventions. A list of resources for practitioners is provided in the Box.

Systematic approaches, such as those used in Finland and Australia, offer the best opportunity for large-scale impact, and there are important strategies that practitioners can employ directly with families.

Although many of us began this work in an expert role, we came to recognise that in working with families with parental depression, there are two types of experts: the parents and children who are experts on their own families, and the practitioner with expertise in the treatment of depression and the management of preventive interventions. In this sense, we came to develop partnerships with families and learned a great deal from them.