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Summary Depression affects millions of U.S. adults over their lifetime, many of whom are parents with children. In a given year an estimated 7.5 million adults with depression have a child under the age of 18 living with them. It is estimated that at least 15 million children live in households with parents who have major or severe depression. The burden of depression and the barriers to quality of care for depressed adults are increasingly well under- stood, but the ways in which depression affects parenting, and children’s health and psychological functioning, are often ignored. Many factors are associated with depression, including co-occurring medical and psychiatric disorders (such as substance abuse), economic and social disadvantages, and conflicted or unsupportive relationships. These factors typically amplify stress and erode effective coping. For many adults (30–50 percent), depression becomes a chronic or recurrent disorder in a vicious cycle of stress and poor coping that exacts sustained individual, family, and societal costs. Effective screening tools and treatments for adult depression are avail- able and offer substantial promise for reducing the negative consequences of the disorder. However, not everyone benefits from even the treatments associated with the strongest evidence base, and individual, provider, and system-level barriers decrease access to these treatments. These institutional and sociocultural barriers both cause and sustain existing disparities in care for depressed adults. Furthermore, few opportunities exist to identify the vulnerable popu- lation of children (i.e., those at risk of adverse health and psychological functioning) living in households with one or more parents experiencing 

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depression or to offer prevention and treatment services that can improve the care of the depressed parent in a framework that also offers services for children. In addition to improving depression care for adults, therefore, is the need to develop and implement an identification, treatment, and prevention strategy that can respond to the parenting and caregiving roles of the affected parents and their children. Although depression has been documented as a major concern in multiple programs that serve families and children (e.g., Head Start; the Special Supplemental Nutrition Program for Women, Infants, and Children; Temporary Assistance for Needy Fami- lies), federal and state responses to this problem are diffuse and fragmented across multiple health and human service agencies. In short, parental depression is prevalent, but a comprehensive strategy to treat the depressed adults and to prevent problems in the children in their care is absent. National leadership, interagency collaboration, state- based linkage efforts, and collaboration with the private sector are what is lacking in the United States at this time to effectively support the develop- ment and evaluation of a framework that integrates health, mental health, public health, and parenting in a life-course framework, from pregnancy through adolescence. There is also a lack of support for public and profes- sional education, training, infrastructure development, and implementation efforts to improve the quality of services for affected families and vulner- able children. Likewise, funds rarely exist for research, data collection, or evaluation efforts that might lead to improved prevention and treatment services for this population. STUDY SCOPE AND APPROACH Scope The Committee on Depression, Parenting Practices, and the Healthy Development of Children was charged with reviewing the relevant literature on parental depression, its interaction with parenting practices, and its ef- fects on children and families. In conducting this study, the committee • clarified what is known about interactions among depression and its co-occurring conditions, parenting practices, and child health and development; • identified the findings, strengths, and limitations of the evidentiary base that support assessment, treatment, and prevention interven- tions for depressed parents and their children; • highlighted disparities in the prevalence, prevention, treatment, and outcomes of parental depression among different sociode-

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 SUMMARY mographic populations (e.g., racial/ethnic groups, socioeconomic groups); • examined strategies for widespread implementation of best prac- tice and promising practice programs given the large numbers of depressed parents; and • identified strategies that can foster the use of effective interventions in different service settings for diverse populations of children and families. Approach A variety of sources informed the committee’s work, including: five formal committee meetings, expert presentations, and a public workshop; a review of literature from a range of disciplines and sources; technical reviews on selected topics; and analyses of data and research on depression in adults and parents and its consequences for their children. The commit- tee considered research on the causes, comorbidities, and consequences of depression in adults (specifically including parenting and child health outcomes), various health and support services for depression care, the features of interventions and implementation strategies for depression care in diverse populations, and public policies related to implementing promis- ing interventions. The committee also visited two programs that provide a multifaceted approach to mental health services in substance abuse settings to underserved mothers and their families. Through our review of the literature and discussions with service providers, policy makers, and stakeholder organizations, the committee identified four major issues that are faced in attempting to address the problems associated with the care of depressed parents. These are the integration of knowledge regarding the dynamics of parental depression, parenting practices, and child outcomes so that it is transdisciplinary and links research to practice; the need to recognize the multigenerational di- mensions of the effects of depression in a parent so that the needs of both parent and the child are identified in research and practice; the application of a developmental framework in the study and evaluation of the effects of parental depression; and the need to acknowledge the presence of a constellation of risk factors, context, and correlates of parental depres- sion. These four themes pervade each area that the committee addressed, and they are essential to improving the quality of care for depressed par- ents and those who are affected. But many promising strategies identified here for screening, treatment, prevention, and policy interventions have emerged that deserve consideration to engage the large and diverse num- bers of families affected by depression.

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN CONCLUSIONS The committee’s findings are broadly marshaled into the following conclusions that serve as the basis for seven recommendations. Depression Is a Common Condition and Is Attributed to Multiple Risk Factors and Mechanisms Depression is a common condition among adults, many of whom are parents. Despite its prevalence, differences exist in rates of depression among particular sociodemographic categories—sex, income level, marital status, race/ethnicity, employment status. Multiple biological mechanisms, genetic factors, environmental risk factors, personal vulnerabilities, and resilience factors for depression—as well as the co-occurrence of other dis- orders such as substance abuse and trauma—have been identified. Although gaps exist in knowledge of the relationship among multiple contributors to depression, the research clearly implicates stress and adversity, giving im- portant clues about personal vulnerabilities, protection, and resilience—all of which have implications for interventions to identify, treat, and prevent depression. Multiple Barriers Exist That Decrease the Quality of Depression Care for Adults Like a variety of other health services, access to care for depression may be influenced by geographic, physical, financial, sociocultural, and temporal barriers. Such barriers include transportation issues, physical disabilities, stigma, language barriers, a history of oppression, racism, discrimination, poverty, immigration status, cultural customs and beliefs, and health insur- ance coverage. A 2006 Institute of Medicine report entitled Improving the Quality of Health Care for Mental and Substance-Use Conditions points out that care for mental health and substance use problems is also distinct from health care generally. The distinctive features they describe include greater stigma associated with diagnoses, a less developed infrastructure for measuring and improving the quality of care, a need for a greater number of linkages among multiple clinicians, organizations and systems provid- ing care to patients with mental health conditions, less widespread use of information technology, a more educationally diverse workforce, and a differently structured marketplace for the purchase of mental health and substance use health care. Although reducing these barriers is essential to improving the quality of care for depressed adults, it is also important to note that these barriers focus on the individual. Additional barriers impose

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 SUMMARY constraints for those depressed adults who are parents and for addressing its effects on parenting and child health and development. Depression May Interfere with Parenting Quality and Put Children at Risk for Adverse Outcomes Depression in parents interferes with parenting quality and is associated with poor health and development (e.g., physical, psychological, behav- ioral, social development and mental health) in their children at all ages. Focusing on symptoms and diagnosis provides important yet incomplete information about the complete picture of depression. A narrow focus on symptoms and diagnosis ignores the larger possible impacts on family de- velopment (i.e., individual and social capital, resource allocation). While it is difficult to estimate the true costs of depression in parents, it is essential to consider not only the individual family members but also the family as a whole. Some questions remain regarding conditions that make these interactions stronger or weaker and the specific mechanisms or intermedi- ate steps through which depression in the parent becomes associated with parenting or with outcomes in children; however, the research has clear implications for developing interventions for depressed parents and mitigat- ing its consequences. Existing Screening and Treatment Interventions Are Safe and Effective for Depressed Adults But Are Rarely Integrated or Consider Their Parental Status or Its Impact on Their Child Effective screening tools are available to identify adults with depression in a variety of settings. However, current screening programs for depres- sion in adults generally do not consider whether the adult is a parent, and therefore they do not assess parental function or comorbid conditions, do not consider the impact of the parent’s mental health status on the health and development of their children, and are rarely integrated with further evaluation and treatment or other existing screening efforts. Community and clinical settings that serve parents at higher risk for depression do not routinely screen for depression. Safe and effective treatments and strategies to deliver them exist for adults with depression in a range of settings. However, treatment safety, efficacy, and delivery strategies have generally not assessed parental status, the impact of depression on parental functioning, or its effects on child outcomes, except during pregnancy and in mothers postpartum. Mod- els that incorporate multiple interventions (e.g., collaborative care) for adults appear to be a reasonable approach to delivering depression care, although such models have not been tested for their effectiveness in serving parents.

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Emerging Preventive Interventions Demonstrate Promise for Improving Outcomes for Families with Depressed Parents Emerging preventive interventions specifically for families with de- pressed parents and adaptations of other existing evidence-based parenting and child development interventions demonstrate promise for improving outcomes for these families. However, the data from most of these inter- ventions for families with depression are limited. Broader preventive in- terventions that support families and the healthy development of children also hold promise for improving parent and child outcomes, although such interventions have not been tested to demonstrate their effects in mitigating the consequences of a depressed parent within their families. Emerging Initiatives Highlight Opportunities and Challenges in Improving the Engagement and Delivery of Care to Diverse Families with a Depressed Parent The scope and compelling nature of depression in parents and its inter- action with parenting and healthy child development supports the need to develop or adopt strategies to meet the needs of a diverse number of families with a depressed parent. Ideally, the identification, treatment, and preven- tion of depression among adults would integrate mental and physical health services. In addition, for those who are parents, they would strengthen and support parent-child relationships, offer developmentally appropriate treat- ment and prevention interventions for children, and provide comprehensive resources and referrals for other comorbidities associated with depression (such as substance abuse and trauma). Such services would be available in multiple health care settings, including those that engage children and fami- lies. Furthermore, this system of care would use more proactive approaches for prevention or early intervention of depression in parents in the context of a two-generation model that is family-focused, culturally informed, and accessible to vulnerable populations. Existing health care and social services systems are far from achieving this goal in implementing this system of care for depressed parents and their families. But emerging initiatives at the community, state, and federal level as well as internationally have included key features of a service delivery model for depressed parents and their children and highlight opportunities and challenges to improve, implement, and disseminate more effective, ef- ficient, and equitable service delivery models. A wide range of settings offers opportunities to engage and deliver care to diverse families with a depressed parent. These adult health, child heath, and family support settings often lack linkages with other settings to offer integrated mental health, social support, and parenting interventions for these vulnerable populations.

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 SUMMARY Multiple Challenges Exist in Implementing and Disseminating Innovative Strategies Implementing innovative strategies requires addressing existing sys- temic, workforce, and fiscal barriers. In order for these strategies to be effective they should be flexible, efficient, inexpensive, and, above all, acceptable to the participants by having the ability to engage participants and reduce or overcome barriers to care. Furthermore, numerous oppor- tunities exist to continue to build a knowledge base that can enhance the development of future programs, policies, and professional practice. But overcoming systemic, workforce, and fiscal challenges and developing new knowledge to help in the design of innovative strategies are not sufficient to ensure its use in the routine efforts of service providers and practitioners to identify, treat, and prevent parental depression and to reduce the impact of this disorder on children. The application of evidence-based knowledge re- quires explicit attention to dissemination, implementation, and the creation of organizational infrastructure and cultures that are intentionally recep- tive to new research findings. Since the current research base points to no simple path for implementation and dissemination of innovative strategies, both conceptual principles and promising practices should guide large-scale efforts, but large-scale efforts should be undertaken in a staged, sequential fashion with each effort building on the knowledge from the proceeding stage. The ultimate goal should be to have system-wide programs for pa- rental depression that incorporate multiple points of entry, employ flexible strategies, and allow for the types and amounts of services and prevention to be tailored to individual needs and families. Aligning the work that sup- ports the development of innovative strategies with the efforts to implement and disseminate evidence-based programs in specific settings will help to clarify additional work that is needed to deliver care for particular groups and also how to extend these strategies to other populations and systems. RECOMMENDATIONS Improve Awareness and Understanding Sustained commitments will be needed from the federal and state gov- ernments to increase the basic knowledge and public awareness about de- pression in parents and its effects on the healthy development of children. This leadership is central to improve the care of depressed adults who are parents as well as to reduce adverse outcomes in their children. Recommendation 1: The Office of the U.S. Surgeon General should identify depression in parents and its effects on the healthy develop-

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN ment of children as part of its public health priorities focused on mental health and eliminating health disparities. To implement this recommendation, the U.S. Surgeon General should encourage individual agencies, particularly the National Institutes of Health, the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA), to support the Healthy People 2020 overarching goal of achieving health equity and eliminating health disparities by including the importance of identifica- tion, treatment, and prevention of depression and its potential impact on the healthy development of children of depressed parents. These agen- cies should pay particular attention to groups and populations that have historically and currently experience barriers in receiving quality health care, including for behavioral health. Efforts should be made to ensure that effective strategies are employed to increase the participation and en- gagement of these vulnerable populations in critical research studies and clinical trials. New research methods and innovative models that partner with vulnerable communities should be supported. Particular focus should be directed at prevention and early intervention efforts that are commu- nity-based and culturally appropriate so that the high burden of disability currently associated with depression in populations experiencing health disparities can be reduced. Recommendation 2: The Secretary of the U.S. Department of Health and Human Services, in coordination with state governors, should launch a national effort to further document the magnitude of the problem of depression in adults who are parents, prevent adverse ef- fects on children, and develop activities and materials to foster public education and awareness. To implement this recommendation the Secretary of the U.S. Depart- ment of Health and Human Services (HHS) should encourage individual agencies, particularly the National Institute of Mental Health (NIMH), HRSA, CDC, and the Agency for Healthcare Research and Quality, to iden- tify the parental status of adults and add reliable and valid measures of de- pression to ongoing longitudinal and cross-sectional studies of parents and children and national health surveys, in ways that will support analyses of prevalence, incidence, disparities, causes, and consequences. Second, CDC should develop guidelines to assist the states in their efforts to collect data on the incidence and prevalence of the number of depressed adults who are parents and the number of children at risk to adverse health and psy- chological outcomes. Finally, using this information, HHS should encour- age agencies, most notably HRSA, to develop a series of public education

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9 SUMMARY activities and materials that highlight what is known about the impact of depression in parents. These activities and materials should specifically tar- get the public and individuals who make decisions about care for a diverse population of depressed parents and their children in a variety of settings (e.g., state and county leadership, state health directors, state mental health agencies, and state maternal and child health services). Support Innovative Strategies To build on emerging community, state, and federal initiatives to im- prove the quality of care for depressed parents, further support is necessary to encourage the design and evaluation of innovative services in different settings for diverse populations of children and families. Recommendation 3: Congress should authorize the creation of a new national demonstration program in the U.S. Department of Health and Human Services that supports innovative efforts to design and evaluate strategies in a wide range of settings and populations to identify, treat, and prevent depression in parents and its adverse outcomes in their children. Such efforts should use a combination of components—in- cluding screening and treating the adult, identifying that the adult is a parent, enhancing parenting practices, and preventing adverse out- comes in the children. The results of the new demonstration program should be evaluated and, if warranted, Congress should subsequently fund a coordinated initiative to introduce these strategies in a variety of settings. To implement this recommendation, agencies in HHS should prepare a request for proposals for community-level demonstration projects. Such demonstration projects • should test ways to reduce barriers to care by using one or more empirically based strategies to identify, treat, and prevent depres- sion in parents in heterogeneous populations (i.e., race/ethnicity, income level), those in whom depression is typically underidenti- fied, and those with risk factors and co-occurring conditions (e.g., trauma, anxiety disorders, substance use disorders); • should call attention to effective interventions in which screening and assessment are linked to needed care of parents with depres- sion, that support training in positive parenting, and that encour- age strategies to prevent adverse outcomes in their children; • could identify multiple opportunities to engage parents who are depressed as well as to identify children (at all ages) who are at risk because their parents are depressed;

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0 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN • could include the Healthy Start Program, the Head Start Program, the Nurse-Family Partnership, home visiting, schools, primary care, mental health and substance abuse treatment settings, and other programs that offer early childhood interventions; • would ideally use more than one strategy and could use funds to test state-based efforts that experiment with different service strate- gies and service settings and to strengthen the relationship between mental health services and parental support programs; • could test ways to reduce the stigma and biases frequently as- sociated with depression, address cultural and racial barriers and disparities in the mental health services system, and explore op- portunities to strengthen formal and informal supports for families that are consistent with cultural traditions and resources; and • should include state mental health agencies and local government (e.g., counties), at least in an advisory capacity. Finally, SAMHSA should promote interagency collaboration with other HHS agencies—CDC, HRSA, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, NIMH, the National Institute on Nursing Research, and the National Institute of Child Health and Human Development—to develop coordinated strategies that support the design and evaluation of these demonstration projects. SAMHSA could identify an interagency committee to pool information about programs that are affected by parents with depression, programs that offer opportunities to engage parents and children in the treatment and prevention of this dis- order, and research and evaluation studies that offer insight into effective interventions. SAMHSA could develop opportunities to introduce effective interventions in both community-based systems of care frameworks and in integrated behavioral and mental health services in a variety of settings including primary care and substance abuse treatment settings. Develop and Implement Systemic, Workforce, and Fiscal Policies Policies are intended to influence decisions and actions. Some policies provide protections for vulnerable populations, while others create condi- tions for a desirable future—business, health, or otherwise. Both call for the careful use of policies to foster the delivery of care for depressed parents and their children. Recommendation 4: State governors, in collaboration with the U.S. Department of Health and Human Services, should support an inter- agency task force within each state focused on depression in parents. This task force should develop local and regional strategies to support

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 SUMMARY collaboration and capacity building to prepare for the implementation of evidence-based practices, new service strategies, and promising pro- grams for the identification, treatment, and prevention of depression in parents and its effects in children. The wide variation in state resources and structures for providing mental health services and family support resources suggests that broad experimentation with different service strategies may be necessary to imple- ment two-generation interventions for the treatment and prevention of depression in parents, to support parenting practices, and to prevent physi- cal, behavioral, and mental health problems in youth. First, state governors should designate a joint task force of state and local agencies to coordinate local efforts (e.g., counties) and to build linkages and the infrastructure that can support a strategic planning process; refine service models and delivery systems through collaboration among diverse agencies; prepare to incorporate an array of programs for different sites, settings, and target populations; prepare model plans that include multiple entry points in a variety of service sectors; and prepare for a stepwise rollout with ongoing or interim evaluation. Second, the state strategies should include policy protocols and fiscal strategies that offer incentives across multiple systems (including health and education) to expand the state’s capacity to respond to parental depression through a family-focused lens. These protocols and strategies could be supported by the efforts funded and coordinated by HHS through agencies that include SAMHSA and HRSA. Third, the state strategies should offer flexible responses that can be adapted to the needs of urban and rural com- munities. Finally, states should be required to provide a biannual report to a designated office in HHS that describes their strategic plans as well as the challenges and barriers that affect their capacity to address depression in a family context for children of all ages. These reports should be shared to encourage states to learn from each other’s initiatives. Recommendation 5: The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, in collaboration with relevant professional organizations and accredit- ing bodies, should develop a national collaborative training program for primary, mental health care, and substance abuse treatment pro- viders to improve their capacity and competence to identify, treat, and prevent depression in parents and mitigate its effects on children of all ages. For this recommendation to be realized, the national collaborative training program should strengthen a workforce that is informed about

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN and prepared to address parenting issues associated with depression and the effects of adult disorders on children in a diverse society. This program should explore opportunities to enhance attention to interactions between depression and parenting in ongoing mental health and primary care train- ing and continuing education programs, such as activities funded by Title VII and Title VIII of section 747 of the Public Health Service Act. Training efforts should include an emphasis on developmental issues, exploring the impact of depression and the combination of depression and its commonly co-occurring disorders (e.g., anxiety disorders, parental substance use dis- orders) on children of different ages, from pregnancy through adolescent development. Options for such training programs could include cross- disciplinary training with an emphasis on parental depression, parent - ing, and developmentally based family-focused concerns that arise in the treatment of depression. Such training programs should call attention to identifying children at risk to adverse health and psychological outcomes. Training programs should also include efforts to build a more diverse and culturally competent workforce. Recommendation 6: Public and private payers—such as the Centers for Medicare and Medicaid Services, managed care plans, health mainte- nance organizations, health insurers, and employers—should improve current service coverage and reimbursement strategies to support the implementation of research-informed practices, structures, and settings that improve the quality of care for parents who are depressed and their children. Public and private payers should consider the following options for implementing this recommendation: • The Centers for Medicare and Medicaid Services (CMS) could ex- tend services and coverage of mothers to 24 months postpartum, which includes a critical period of early child development when interaction with parental care is especially important. Long-term coverage for parents would be optimal. CMS could remove re- strictions on Medicaid’s rehabilitation option and other payment options (including targeted case management and home visitation programs) that could reimburse services and supports in nonclini- cal settings and enhance access to quality care; allow same-day visit reimbursement for mental health and primary care services; reimburse primary care providers for mental health services; and remove prohibitions on serving children without medical diagno- ses, thereby covering health promotion services for children at risk before diagnosis.

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 SUMMARY • States could work with CMS to implement financing mechanisms to support access to treatment and supportive services for de- pressed parents through clarifying existing coverage, billing codes, or encouraging use of research-informed practices. This would complement local and regional strategies developed by the states. Similarly, private health plans and self-insured employers could cover parental depression screening and treatment and support the implementation of effective models. Promote and Support Research Knowledge is the basis of effective action and progress, yet current resources are limited and fragmented to expand the knowledge base and encourage the development, implementation, and dissemination of innova- tive evidence-based strategies for depressed parents and their families. Recommendation 7: Federal agencies, including the National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration, should support a collaborative, multiagency research agenda to increase the understanding of risk and protective factors of depression in adults who are parents and the in- teraction of depression and its co-occurring conditions, parenting prac- tices, and child outcomes across developmental stages. This research agenda should include the development and evaluation of empirically based strategies for screening, treatment, and prevention of depressed parents and the effects on their children and improve widespread dis- semination and implementation of these strategies in different services settings for diverse populations of children and their families. In carrying out this recommendation, these federal agencies should consider partnerships with private organizations, employers, and payers to support this research agenda. FINAL THOUGHTS Depression in adults is a prevalent and impairing problem and rarely occurs alone. The study of depression illustrates a larger set of issues, in- cluding other illnesses (e.g., anxiety, substance use disorders) and general stresses and risk factors (e.g., poverty). Screening tools, treatments, and delivery strategies available are effective for many with this disorder, espe- cially if identified early, but it remains underrecognized and undertreated. The problem of depression in adults is compounded when those adults are

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN parents because of its potential impact on parenting as well as the impact on the well-being of their children. Although there is significant and important research literature both about adults who are depressed and about parents facing adversity, there is remarkably little systematic examination of depres- sion in parents. Ultimately depression is a good and effectively identified indicator of problems that could trigger a system of care that intervenes not only in treating depression in the parent, but also in enhancing parent- ing skills, in alleviating other stresses, co-occurring conditions, and social contexts, and in identifying and intervening with children at risk. Although little research has been focused on improving care for de- pressed parents and their children, there are both conceptual principles and promising practices that could guide large-scale efforts in a deliberate sequential approach for family-centered care. Remarkable advances in re- search continue and need to be supported; it is therefore also important to build mechanisms to incorporate new findings into service settings as they become available. As with other areas in mental health and physical health, there are significant infrastructure, workforce, and fiscal problems that need to be addressed to build a system of family-centered care for depression in parents. It is the committee’s hope that this report will inspire policy makers and community leaders and practitioners to consider the value of long-term commitments to reducing parental depression and its effects on children. Only then can the knowledge base highlighted in this report be used well to promote access to appropriate services, reduce stigma, and reduce the costs of depression to adults, the children in their care, and society as a whole.