7
Prevention of Adverse Effects

SUMMARY

Prevention Interventions That Specifically Target Families with Depressed Parents

  • Studies of interventions that target families with depressed parents have shown the potential to prevent adverse outcomes in children across all developmental stages. These include interventions that prevent or treat depression in the parent, those that target the vulnerabilities of the children, and those that improve parent-child relationships and parenting practices. However, the evaluation of these interventions has rarely included large-scale trials or widespread implementation or dissemination.

Broadly Focused Prevention Interventions in Families with Depressed Parents

  • Some evidence suggests that prevention strategies that focus more broadly on parenting and child development can be effective even when there is a high rate of depression among parents. However, most evidence-based prevention strategies have not been evaluated for their relative effectiveness in families with depressed parents. Enhancements of these strategies with components targeted specifically to families with depressed parents have also rarely been evaluated.



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7 Prevention of Adverse Effects SUMMARY Prevention Interventions That Specifically Target Families with Depressed Parents • Studies of interventions that target families with depressed parents have shown the potential to prevent adverse outcomes in children across all developmental stages. These include interventions that prevent or treat depression in the parent, those that target the vulnerabilities of the children, and those that improve parent-child relationships and parenting practices. However, the evaluation of these interventions has rarely included large-scale trials or wide- spread implementation or dissemination. Broadly Focused Prevention Interventions in Families with Depressed Parents • Some evidence suggests that prevention strategies that focus more broadly on parenting and child development can be effective even when there is a high rate of depression among parents. However, most evidence-based prevention strategies have not been evaluated for their relative effectiveness in families with depressed parents. Enhancements of these strategies with components targeted spe- cifically to families with depressed parents have also rarely been evaluated. 2

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22 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN • Existing service programs for families, such as early childhood edu- cation and home visitation, often provide preventive services that focus more broadly on parenting and child development. These service programs often serve a large number of depressed parents. Although these programs offer opportunities to identify depression in parents and to integrate treatment and prevention services, few programs routinely do so. Prevention for Vulnerable Families • Some prevention programs targeted to families with depression have been shown to be effective in low-income families and in families from varied cultural and linguistic backgrounds. There is less evidence on the effectiveness of these programs in families with co-occurring conditions such as exposure to trauma and co-existing mental and substance abuse disorders. • A variety of existing service programs serve vulnerable families, such as social welfare programs and substance abuse services. Al- though these programs offer opportunities to identify depression in parents and to integrate treatment and prevention services, few programs routinely do so. ____________________ As described in this report, major depression is a highly prevalent disorder among adults of parenting age, and, as a consequence, millions of children in the United States are exposed every year to the risk associated with depression in a parent. Even more children are exposed to heightened levels of depressive symptoms in parents who do not meet diagnostic crite- ria; these children have also been demonstrated to be at increased risk. So far we have focused on identifying and treating depression in parents. This chapter focuses on efforts to prevent the effects that depression in parents can have on their families, as described in Chapter 4. The importance of preventive efforts is underscored by the scope of the problem and by the high percentage of adult depression, including parents, that goes untreated. Treating parental depression, attending to children’s needs, and assisting parenting are all necessary components to foster resilience, promote health, and prevent disorder in families in which parents are depressed. An important framework exists for understanding the available litera- ture. The National Academies recently published a report on the preven- tion of mental, emotional, and behavioral disorders among young people (National Research Council and Institute of Medicine, 2009). The com- mittee strongly supports the overall perspective on prevention presented in

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2 PREVENTION OF ADVERSE EFFECTS Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The report emphasizes several general points about prevention that apply to the prevention of depression in families: (1) prevention requires a shift to a public health focus from the traditional disease model, in which one waits for the occurrence of disease before action; (2) not only are the immediate needs of the child and family important but also their longer term needs; (3) mental health and physical health are inseparable and should be viewed as different aspects of the same underlying developmental processes; (4) mental, emotional, and behavioral disorders and their prevention are inherently developmental, and coordi- nated systems-level interventions are needed to address them. The preven- tion report emphasizes the need for a developmental perspective—just as this report does in considering the prevention of adverse outcomes of parental depression. The needs of children are quite different at ages 4, 8, or 12, so different interventions need to be tailored for children and their parents at different developmental stages. Studies of parental depression can involve different types of focus. In some studies, severely ill parents with depression are identified, and the interventions focus primarily on depression. In others, depression in par- ents often serves as the identifier of a constellation of adversities that may include poverty, minority status, living in low-resource, difficult neighbor- hoods, social isolation, and exposure to violence. Although parental depres- sion is an important condition to be addressed, comprehensive prevention efforts must also address these other factors. Additional risk factors that often need to be addressed systematically include comorbidity, divorce, and diminished social status. The committee reviewed the relevant literature in order to identify ex- amples of interventions or programs that target families with a depressed parent or that illustrate important conceptual principles for addressing the needs of these families, as well as to identify areas in which relatively little intervention research has been conducted. The committee did not seek to systematically identify all existing interventions and program evaluations. We drew on existing meta-analyses and systematic reviews whenever pos- sible and supplemented with additional literature searches to identify rel- evant evidence-based programs. Whenever possible, we limited our review to interventions that have been evaluated in at least one randomized trial. In some cases, nonrandomized studies are discussed if that was the best available evidence for an approach to families with a depressed parent. The chapter text focuses on concepts and major outcomes. A table at the end of the chapter summarizes methodological details, study population demographics, and outcome measures for interventions that target families with a depressed parent. The chapter begins with the available evidence on prevention of depres-

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN sion in parents, which is a first-line approach to preventing the adverse ef- fects on children. The main focus of the chapter, however, is on approaches to reduce adverse outcomes in children, with a special emphasis whenever possible on interventions that take a two-generation approach to addressing the parent’s depression, parenting, and child outcomes. The committee’s review revealed promising programs and important conceptual frameworks related to preventing the effects that depression in parents can have on families. These studies themselves and the broader con- text of prevention research indicate that there is a considerable promise to the approach and that current lines of investigation need expansion. How- ever, despite the immense costs of parental depression in many different areas of life, as yet there are no large-scale, widely implemented prevention programs within systems in the United States to address parental depres- sion. There is, therefore, a need to develop large-scale programs based on the existing knowledge base and on promising programs and, at the same time, to refine and evaluate these programs at various levels in order to determine the most effective and cost-effective preventive interventions. A FRAMEWORK FOR PREVENTIVE INTERVENTIONS Significant interest and a substantial knowledge base in the area of prevention have accumulated over the past 15 years. A broad framework for preventive interventions has been presented by the Institute of Medicine (IOM) report Reducing Risks for Mental Disorders (1994) and the previ- ously mentioned report Preventing Mental, Emotional, and Behavioral Dis- orders Among Young People (National Research Council and Institute of Medicine, 2009). As outlined in the these reports, the usual sequence lead- ing to the eventual widespread dissemination of preventive interventions is, first, the identification of risk factors and protective mechanisms, then the development of promising approaches and efficacy studies of preven- tive interventions, followed by large-scale effectiveness and dissemination studies, and finally the implementation of prevention programs. Chapter 4 described evidence related to the first step in prevention research, reviewing a number of identified mechanisms that mediate the association between de- pression in parents and adverse outcomes in children, including biological, psychological, and interpersonal processes. This chapter considers preven- tive interventions, with a focus on those that have been designed to directly address the source of risk for children by reducing parental depression through prevention or treatment and by targeting possible mechanisms of risk, including psychological vulnerabilities in children of depressed parents (e.g., Clarke et al., 2001), family relationships (e.g., Beardslee et al., 2007), and parenting and children’s ways of coping (e.g., Compas, Forehand, and Keller, 2009).

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2 PREVENTION OF ADVERSE EFFECTS The IOM framework defines prevention as intervening before the onset of a disorder in order to prevent or reduce risk for the disorder. This is distinct from treatment, which is targeted to individuals with a diagnos- able disorder and is intended to cure the disorder or reduce its symptoms or negative effects on that individual. The framework also distinguishes between preventive interventions delivered to the general population (called universal prevention), to individuals exposed to known risk factors (selec- tive prevention), and to individuals exhibiting signs or symptoms of a disorder (indicated prevention). By definition, interventions that target the children of parents with current or past depression are either selective or indicated: the target populations are identified by exposure to the risk of parental depression (selective prevention) and, in some cases, by the onset in the children and adolescents of symptoms of related adverse outcomes (indicated prevention). Preventive interventions have been delivered in a variety of contexts, including health care settings, early childhood settings, schools, and communities. Evaluating the effects of prevention programs is complex, as effects may not manifest for months or years after delivery of the intervention, and lasting preventive effects must be documented over long periods of time. PREVENTION OF DEPRESSION IN PARENTS Adults and Adolescents of Parenting Age A first-line approach to preventing the effects of depression in parents is prevention of depression in adults and adolescents of parenting age. This is an important aspect, along with treatment, of reducing the burden of disease and its effects on parenting and child development. A recent meta- analysis reviewed 19 studies that used a randomized design to examine whether prevention programs are capable of reducing the incidence of de- pression (Cuijpers et al., 2008). This review was not designed to examine depression in parents but did include some studies of parents or adults of parenting age. Of these 19 studies, 11 included interventions with adults and 7 involved adolescents. Of the 11 studies with adults, 4 involved inter- ventions delivered to pregnant women, 3 with women during the postpar- tum period, 1 with older adults, and 3 with adults in the typical parenting age range (ages 18–50). Interventions were delivered in a variety of settings using universal, selective, and indicated approaches. The mean incidence rate ratio was 0.78, indicating a reduction in incidence of depression by 22 percent, although the limited duration of follow-up in most studies makes it difficult to distinguish whether this reflects a true reduction in incidence or a delay in onset. Thus, as reflected in this meta-analysis, there is promising evidence that

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN it is feasible to reduce depression in adults and adolescents through preven- tive interventions, and these approaches could potentially be used to target parents of children at all developmental stages, starting with preconception. Although some of the existing interventions that have been rigorously tested were delivered to adults of parenting age, with the exception of strategies specifically targeting pregnant or postpartum women (see the next section), they were not designed specifically to prevent depression in parents, nor did they assess whether the subjects were parents or analyze outcomes for parents as a distinct subgroup. Indeed, just as there is a limited number of treatment studies analyzing outcomes in parents, there is a lack of evidence on effective prevention strategies targeted to parents and on the relative ef- fectiveness in parents of current prevention strategies devised for adults in general. Further evaluation of current preventive interventions is needed in which the parenting status of the participants is tracked and outcomes for parents are analyzed. In addition, evaluations are needed of new interven- tions or adaptations of existing interventions that incorporate approaches specifically targeted to adults or adolescents who are parents, including, for example, multigenerational approaches such as those described in this chapter. Pregnant and Postpartum Women Although broad intervention approaches to prevent depression in adults are generally not targeted to parents, there are prevention strategies specifically focusing on pregnancy and the postpartum period. A variety of approaches have been used in interventions designed to prevent depression in the postpartum period. These include psychotherapeutic approaches based on the same principles as approaches for the treatment of postpartum depression, including cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT), along with psychoeducation, social support, and other supportive services. Evidence from rigorous evaluations of prevention models is limited, and the results are mixed. Although a few programs have been shown to be promising, others fail to demonstrate significant effects on measures of depressive symptoms or a diagnosis of depression (Battle and Zlotnick, 2005; Dennis, 2005; Dennis and Creedy, 2004). A few examples of programs that have shown promise in at least one randomized trial are described below. In addition, most evaluations of interventions to prevent postpartum depression do not include measures of child outcomes, so the impact of these interventions on reducing adverse outcomes for children is not known. Further evaluation of these approaches in diverse populations of mothers and delivered in diverse settings is needed to determine if more widespread implementation would be warranted.

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2 PREVENTION OF ADVERSE EFFECTS The ROSE Program: Zlotnick conducted two randomized clinical trials of an interpersonal psychotherapy-based group intervention to prevent depres- sion in pregnant women receiving public assistance who were at high risk for depression (Zlotnick et al., 2001, 2006). Known as the ROSE Program (Reach Out, Stand Strong, Essentials for New Mothers), the intervention is designed to help an ethnically diverse group of mothers-to-be on public assistance improve close interpersonal relationships, build social support networks, and master their transition to motherhood. At 3 months’ post- partum, mothers in the intervention group were significantly less likely to have a diagnosis of postpartum depression. Telephone Peer Support: Using a different approach, Dennis et al. (2009) reported a large, randomized trial of an individualized, telephone-based peer support intervention. The participants were women receiving post- partum care in seven health regions in Canada who were identified as high risk for depression owing to elevated depressive symptoms. They were matched with trained peer volunteers who had recovered from postpartum depression and received a minimum of four peer-support phone sessions starting at 2 weeks’ postpartum. At 12 weeks’ postpartum, a significantly fewer number of the mothers in the intervention group had scores on the Edinburgh Postnatal Depression Scale (EPDS) consistent with postpartum depression. Other interventions designed to prevent depression in the postpar- tum period through psychotherapeutic, psychoeducational, and social sup- port approaches have been evaluated in randomized trials but have not demonstrated an effect. For example, some approaches that have not demonstrated similar success have included a six-session group cognitive- behavioral therapy–based program targeted at mothers of very preterm infants (Hagan, Evans, and Pope, 2004); a single, individual critical incident stress debriefing session after childbirth (Priest et al., 2003); and a series of six weekly prenatal and one postnatal group classes focused on cognitive and problem-solving approaches and enhancing social support (Brugha et al., 2000). This difference in outcomes may result from methodological differences and intervention design, but it may also be explained by the level of risk in the study population. The ROSE Program is distinct from these other trials because it targeted a high-risk population in terms of both demographics and depressive symptoms. The peer telephone support intervention was evaluated in a more general demographic population but was also targeted to women at high risk based on symptoms. Thus, there appears to be prom- ise for indicated prevention approaches to address postpartum depression in women at high risk, but universal approaches have not been as successful. Universal prevention is discussed later in this chapter.

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Infant Sleep: Maternal depression has been associated with infant sleep problems (Bayer et al., 2007), and a recent randomized trial tested the ef- fects of an infant sleep intervention on depression in mothers. A behavior modification program designed to improve infant sleep was delivered by well-child nurses to 8-month-old infants in well-child care centers in Aus- tralia with mothers reporting a problem with their infants’ sleep (Hiscock et al., 2007, 2008). Infant sleep problems were significantly reduced at 10 and 12 months compared with the control group, maternal depressive symptoms were also significantly reduced for the sleep intervention group, and the EPDS scores of the intervention group improved consistent with a reduction in postpartum depression. Parenting practices were also assessed using the Parent Behavior Checklist, as was child mental health using the Child Behavior Checklist. Neither measure differed markedly between the intervention and control groups (Hiscock et al., 2008). This trial was conducted in a more generalized population of mothers and suggests that targeting infant sleep problems may be an additional promising approach to preventing postpartum depression. PREVENTION OF ADVERSE OUTCOMES IN CHILDREN There are at least six potential models preventive interventions for chil- dren of depressed parents: (1) treatment of depression in adults (including parents), (2) early childhood interventions, (3) teaching parenting skills, (4) cognitive-behavioral interventions to address the children’s risk factors, (5) interventions to strengthen family functioning, and (6) family cognitive- behavioral interventions to teach both parenting skills to depressed parents and coping skills to their children. Research on these approaches is at vari- ous stages of maturity. Treatment of Parents’ Depression Arguably the most direct method of prevention of adverse outcomes in children of depressed parents would involve the treatment of parents’ depression to remission and prevention of relapse. However, only a few investigations have examined the influence of antidepressants or psycho- therapy on parenting or child outcomes. Therefore, key questions remain about the effects of treatment on families and the role of treatment in the prevention of adverse outcomes for children of depressed parents. Gunlicks and Weissman (2008) reviewed the findings of 10 studies that examined the association between improvement in parents’ depres- sion and their children’s psychopathology. They conclude that, although there is some evidence that successful treatment of parents’ depression has

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29 PREVENTION OF ADVERSE EFFECTS been associated with improvement in children’s symptoms and functioning, treatment may not be sufficient for improving cognitive and other aspects of child development. However, they note that research on the effects of treating parents’ depression as a means of preventing adverse outcomes in children is in its early stages and that further study is needed. This review was not limited to interventions evaluated in randomized trials. It includes some randomized trials of interventions focused specifically on treatment for the parent (included in the examples described immediately below) as well as interventions that included components targeting parent-child inter- action (described in the later section on parenting interventions). Findings from the child component of the Sequence Treatment Alter- natives to Relieve Depression (STAR*D) trial are illustrative of the status of research on the effects of treatment of parents’ depression on children’s mental health (Weissman et al., 2006). The study found that successful pharmacological treatment of mothers’ depression to remission over 3 months was associated with significant reductions in mental health prob- lems in their children compared with baseline. During the year following initiation of treatment for maternal major depressive disorder, decreases in the children’s psychiatric symptoms were significantly associated with decreases in maternal depression severity (Pilowsky et al., 2008). An ad- ditional analysis of the STAR*D trial examined the fates of single mothers: investigators found that this population was much less likely to complete treatment and less likely to remit if they remained in treatment (Talati et al., 2007). The impact of the single mother’s remission on her children was less dramatic than that found with two-parent households, but these results failed to achieve statistical significance. Two other studies examined the familial impact of successfully treating dysthymia, a persistent form of low-grade depressive illness (Browne et al., 2002; Byrne et al., 2006). The authors reported a decrease in emotional . and behavioral symptoms for children whose parents had successfully re- sponded to pharmacotherapy (sertraline), interpersonal psychotherapy, or a combination thereof. Other studies have focused specifically on treatment of postpartum de- pression. A study reported by Murray et al. (2003) and Cooper et al. (2003) investigated the effects of three different psychological treatments delivered by home visits for depressed postnatal women on maternal and childhood outcomes. They measured immediate and long-term maternal mood and depression as well as child and parenting outcomes. Although there were initial benefits at 4.5 months postpartum, the effects on maternal depres- sion did not persist after 9 months, and they found no persistent impact of parental treatment on behavioral management, childhood attachment, or cognitive outcomes (Cooper et al., 2003; Murray et al., 2003).

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290 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Another study investigated the impact of interpersonal psychotherapy for maternal postpartum depression on child and parent outcomes. Al- though treatment improved maternal depression, it did not have a sig- nificant impact on parenting or child outcomes, even when mothers who responded successfully to treatment were analyzed separately (Forman et al., 2007; O’Hara et al., 2000). Based on the available data, treatment to remission seems promising for reduction of child psychopathology in older children. However, these studies have not measured possible changes in parenting behaviors as a function of mothers’ depression status, leaving unanswered at present the question of the role of possible improvements in parenting that are suffi- cient to improve child outcomes. In addition, treatment interventions have not shown sustained success in infant children of depressed mothers or in improving parenting skills, parent-child relationships, or child developmen- tal outcomes other than psychopathology. In addition, it remains unclear whether treatment that improves symptoms but does not lead to remission can have any benefits for child outcomes or whether any beneficial effects of parental treatment to remission are lost if the depression recurs. Gunlicks and Weissman (2008) call for more careful documentation of the relation between parental and child symptoms, the differential effect of parents’ treatment with psychological versus pharmacological treatment, and pos- sible mediators and moderators of the relation between parental improve- ment and child psychopathology. In addition to measures of children’s symptoms and diagnoses related to psychopathology, it is important to more fully understand the effects of parents’ treatment on other functional developmental outcomes for children, such as social, emotional, and aca- demic competence, as well as on quality of parenting. Interventions for Children of Depressed Parents in Early Childhood There is good evidence that intensive intervention early in life for high- risk children and their parents can have significant long-term effects on children’s outcomes (National Research Council and Institute of Medicine, 2009). These interventions target those at risk because of multiple factors, including in some cases parental depression; when reported, parental de- pression is found to be highly prevalent in some studies of early childhood interventions, such as Early Head Start (Administration for Children and Families, 2002). Early childhood interventions take place in a variety of settings, and many target multiple domains, such as health, mental health, social and emotional development, relationships, and parenting. The effectiveness of these interventions for children of parents with depression has not been specifically examined in most studies. In addition, there are few examples of programs that deliver interventions designed to

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29 PREVENTION OF ADVERSE EFFECTS target changes in both children’s outcomes and parents’ depression, either when parental depression is the primary concern or when depression serves as the identifier of a constellation of risk factors. Examples of approaches or programs with promise or informative evidence for future interventions are described below. Home Visitation A wide range of home visitation services exist that are intended to improve maternal well-being and to promote optimal child development, but only a few have been rigorously evaluated. A recent meta-analysis showed that home visiting programs do have significant cognitive and social-emotional development gains for children (Sweet and Appelbaum, 2004). Two national models, the Nurse-Family Partnership (NFP) and Healthy Families America (HFA), have each been subjected to at least three randomized controlled trials. Significant outcomes replicated across two or more trials include (1) improved prenatal health, (2) fewer child- hood injuries, (3) increased maternal employment, and (4) improved school readiness. Evidence for the prevention of child maltreatment—a major community justification for funding these programs—has proven harder to document, although several recent evaluations point to reductions in maternally reported maltreatment and harsh parenting. Home visiting programs offer an opportunity for access to depressed mothers and their children, and home visiting has been evaluated as a set- ting for treatment of postpartum depression (see Chapter 6). However, there have not been many rigorous, randomized evaluations of home visiting programs or program enhancements designed specifically for mothers with depression and their children, nor have there been many studies specifically assessing the links between child outcomes and maternal depression in home visiting programs. There have been some small trials of interventions delivered through home visiting that have evaluated both maternal and child outcomes. These include the treatment intervention described earlier, which showed some short-term benefit for maternal depression but had no effect on parenting or child outcomes (Cooper et al., 2003; Murray et al., 2003) as well two mother-child interventions described later in this chapter, which showed some promising effects on parent-child interaction and child development but no effect on maternal depressive symptoms (Horowitz et al., 2001; van Doesum et al., 2008). There is also some limited evidence on the effects of maternal depres- sion on the effectiveness of more broadly targeted home visiting programs. Program developers and researchers have identified three major impedi- ments to effectiveness that transcended the different home visiting ser- vice models: domestic violence, substance abuse, and maternal depression

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2 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Population and Intervention Description Citation Demographics Setting Family Talk 7-session (average) Beardslee Parents with a history Most Intervention clinician-facilitated et al. of depression and their families family intervention (1997, children recruited for parents and 2003, from HMO their children 2007) Pilot families plus first trial or referred delivered by families plus additional from licensed social families combined for mental workers or clinical long-term follow-up: health psychologists n = 105 families providers compared to Age (parents): 43 (mean) 2-session lecture Age (children): 12 years group discussion (mean); 8–15 years (range) with parents Race/ethnicity: Predominantly White SES: Predominantly middle-class Single-parent: 19% Excluded: Parents acutely psychotic, acutely abusing substances, or in the midst of a divorce; or marital crisis. Children acutely depressed or with a history of depression; other psychiatric diagnoses not excluded Family Talk Adaptation of Podorefsky, Parents with a history Most Intervention Family Talk McDonald- of depression and their families Intervention for McDowdell, children recruited single, minority and from mothers Beardslee n = 16 families health and (2001) Age (parents): Not reported community Age (children): Not reported centers Race/ethnicity: 100% minority SES: Predominantly low-income Single-parent: 100% Excluded: Not reported

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 PREVENTION OF ADVERSE EFFECTS Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Changes in Increased family Increased understanding 4.5 years Randomized parents’ communication of parents’ depression trials behaviors and parental (interview ratings) and attitudes attention to toward their children’s depression experience (interview (interview ratings) ratings) Changes in Increased parental Post-inter- Randomized parents’ attention vention trial behaviors to children and report of (interview ratings) global benefit of intervention (interview ratings) continued

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Population and Intervention Description Citation Demographics Setting Parenting and Cognitive- Compas, Depressed parents (current Academic child coping behavioral Forehand, or history of during the research skills intervention; and Keller lifetime of their child) and setting parenting skills (presented their children training for at the parents and Society n = 111 families (155 teaching children for children) skills to cope with Research Age (parents): 42.8 (mean) their parents’ on Child Age (children): 11.4 years depression Develop- (mean); 9–15 years (range) ment in Race/ethnicity: 2009) 79% European American 7.7% African American 3.2% Asian American 1.3% Hispanic 7.7% Mixed ethnicity SES: Mixed with high levels of low-income families Single-parent: 36% Excluded: Parent with history of bipolar I, schizophrenia, or schizoaffective disorder; children with history of autism spectrum disorders, mental retardation, bipolar I disorder or schizophrenia or who met criteria for conduct disorder or substance/alcohol abuse or dependence NOTES: The committee did not seek to systematically identify every study on existing inter- ventions and program evaluations that target families with a depressed parent or that illustrate important conceptual principles for addressing these needs of these families; instead, whenever possible, the committee drew on existing meta-analyses and systematic reviews and whenever possible reviewed interventions that have been evaluated in at least one randomized trial. All outcomes reported in table are statistically significant. AQS = Attachment Q Sort Version 3; BSQ = Behavioral Screening Questionnaire; BSID = Bailey Scale of Infant Development; BDI = Beck Depression Inventory; CBCL = Child Be- havior Checklist; CBT = cognitive-behavioral therapy; CESD = Center for Epidemiologic Studies Depression Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth edition; EAS = Emotional Availability Scale, Infancy to Early Childhood Version; EEG = electroencephalogram; EPDS = Edinburgh Postnatal Depression Scale; HMO = health maintenance organization; HRSD = Hamilton Rating Scale for Depression; ITSEA = Infant Toddler Social and Emotional Assessment; KSADS = Kiddie-Schedule for Affective Disorders and Schizophrenia; KSADS-E = K-SADS, Epidemiological Version; MADRS = Montgomery Asberg Depression Rating Scale; PDR = Parent Daily Report; PSI = Parenting Stress Index; SCI-D = Structured Clinical Interview for DSM-IV; SES = socioeconomic status.

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 PREVENTION OF ADVERSE EFFECTS Follow-up Research Parent Outcomes Parenting Outcomes Child Outcomes Time Method Reduced Not assessed At 12 months: improved 12 months Randomized depressive children’s self-reports trial symptoms of depressive symptoms at 2 months and other internalizing (BDI-II); not and externalizing sustained at 6 problems (CESD and or 12 months Youth Self-Report); improved parents’ reports of adolescents’ externalizing symptoms (CBCL)

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