Sad adoptive dads: paternal depression in the post-adoption period.
Depression, Mental (Surveys)
Mental health (Surveys)
Foli, Karen J.
Gibson, Gregory C.
|Publication:||Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Men's Studies Press ISSN: 1532-6306|
|Issue:||Date: Summer, 2011 Source Volume: 10 Source Issue: 2|
|Persons:||Named Person: Foli, Karen J.|
Despite understanding of the negative outcomes for children in a
household with a depressed parent, fathers who experience postadoption
depression have not been studied. This exploratory study describes
adoption professionals' perceptions of fathers' experiences
with postadoption depression. Twenty-five professionals who interact
with adoptive families returned completed web-based survey data.
Overall, respondents reported that fathers who experienced postadoption
depression, were perceived as more likely to become disengaged from the
family, and more likely to display anger and frustration rather than
sadness or melancholy. Respondents appear divided on whether the
adoptive father's depression was a reaction to the mother's
depression. Mental health professionals should consider gender
differences in depressive symptoms when assessing and treating adoptive
Keywords: depression, paternal, adoption, fathers
Ranked as the third highest cause of disability, depression is especially prominent in the 0 to 59 age group (The World Health Organization, 2008); this mood disorder affects an estimated 32.6 to 35.1 million adults or 16.2% of the adult population (Kessler, et al. 2003). By sex, it is estimated that 51.8% of the female and 48.2% of the male United States' population experience depression (Kessler, Berglund, Demler, Jin, Koretz, Merikangas, Rush, Waiters, & Wang, 2003).
Depression in parents, particularly mothers, following the birth of a child has been widely studied. Although rates vary, it is estimated that approximately 10%-15% of new mothers experience postpartum depression (O'Hara & Swain, 1996). The prevalence of paternal postpartum depression has also been investigated. In a meta-analyses across 43 studies and 28,004 participants, Paulson & Bazemore (2010) found a 10.4% meta-estimate (95% confidence interval [CI], 8.5%-12.7%) for paternal postpartum depression with higher rates of depression reported at 3- to 6-months in the postnatal period (25.6%; 95% CI, 17.3%-36.1%). A positive correlation was also found between maternal and paternal depression: (r = 0.384).
One of the most pernicious aspects of depression is the toll it can take on not just the affected individual, but also those connected to the individual, such as the children of parents who are experiencing depression. The effects of maternal depression in birthparents and adverse outcomes in children have been documented (for example, Hay, Pawlby, Sharp, Asten, Mills, & Kumar, 2001; Zajicek-Farber, 2009; Dietz, Donahue, Kelley, & Marshal, 2009; Weinberg, Olson, Beeghly, & Tronick, 2006). While the impact of paternal depression in birth fathers has been studied less frequently, evidence supports similar negative effects: adverse emotional and behavioral outcomes for children aged three to five years and an increased risk of conduct problems in boys in the presence of paternal depression in the postnatal period (Ramchandani, Stein, Evans, & O'Connor, 2005); and an association between postnatal paternal depression and later psychiatric disorders in their children, independent of maternal postnatal depression (Ramchandani, Stein, O'Connor, Heron, Murray, & Evans, 2008).
Less is known about parental postadoption depression (PAD) that may occur in the parents of the 1,782,000 children in the United States who are adopted (Vandivere, Malm, & Radel, 2009). In the research reported thus far, the rate of postadoption depression has a wide range, from 8%, 15.4% to 32%, with parents surveyed in varying contexts including intercountry and domestic (Dean, Dean, White, & Liu, 1995; Senecky, Hanoch, Inbar, Horesh, Diamond, Bergman, & Apter, 2009; Gait, 1999; McKay, Ross, & Goldberg, 2010). In a recent study of note, 86 adoptive mothers of infants under 12 months of age were followed during the first year post-placement. Using a modified Edinburg Postnatal Depression Scale (EPDS), significant depressive symptoms (EPDS [greater than or equal to] 12) were found in 27.9% of subjects, 0-4 weeks, 25.6% at 5-12 weeks, and 12.8% at 13-52 weeks postadoption. Interestingly, significant depressive symptoms were not associate with personal or family psychiatric history, but were associated with stress (p = 0.0011) and adjustment difficulties (p = 0.042) (Payne, Fields, Meuchel, Jaffe, & Jha, 2010).
Regardless of the precise rate of incidence of parental postadoption depression, the effects of parental depression on children, either adopted or not adopted, seem to be similar. Tully, Iacono &, McGue (2008) compared the effect of parental depression on 568 adopted adolescents and 416 nonadopted adolescents. Overall findings included an association between "either parent having major depression and a mother having major depression with a significantly greater risk for major depression and disruptive behavior disorders in both nonadopted and adopted adolescents" (p. 1148).
CONCEPTUAL FRAMEWORK: PARENTAL EXPECTATIONS
Expectations of the parenting experience have been found to influence stress and depression in both birth and adoptive parents. Levy-Shift, Goldshmidt, & Har-Even (1991) found predictors of the transition to parenthood for both adoptive and biological parents were parental expectations and depressed mood. For birth fathers, the strongest correlations of depressed mood in fathers were found to be: the level of the mother's depression; the high discrepancy between expectations and the reality of family and social life after the birth of the child; and low satisfaction with the marital relationship (Bielawska-Batorowicz & Kossakowska-Petrycka, 2006). Researchers have also noted the positive expectations held by most adoptive parents in the pre-adoption time period (Welsh, Viana, Petrill, & Mathias, 2008), which may account for the discrepancies between expected family life and the reality of family life in the postadoption time period.
Expectations of parents who adopted children from institutionalized care and the relationship to stress was studied by Chesney (2008) who found: "In particular, gaps between expectations and experiences that are related to children's behavior and parents' responses to behavior seem to be the strongest predictor of parenting stress, followed by unmet expectations regarding child activity/attention demands versus parents needs for time and rest" (p. 257).
In an inductive approach to parental experiences, Foli (2010a) derived expectations as a constant theme in narrative data. During semi-structured interviews with both parents and adoption experts, and parental support group data, the themes of unfulfilled/unrealistic expectations in the domains of self, child, family/friends, and society/others were revealed (Foli, 2010a). These expectations, or clusters of expectations, represented different dimensions to postadoption depression. Foli (2010a) also noted gender differences. Fathers reported that, if they had to begin the adoption process again, they would have asked specific questions about their child's history. They expressed anger, perceiving that they had not been fully informed of their child's needs, or relating how their lives had been affected by their families. Fathers also related feeling overwhelmed and wanted to problem solve, take an active approach to their situations, and expressed how the system had not provided the necessary supports or information that had been needed.
PURPOSE OF THE STUDY
The purpose of this exploratory study is to describe adoption professionals' observations of contributors and paternal depressive symptoms related to PAD. No data have been collected that assesses professionals' perceptions of this mood disorder, despite the evidence that postadoption depression is experienced by parents. The decision to assess professionals' perceptions was based upon adoption professionals' ability to interface with the different contexts of adoption (domestic/inter-country; private/public, etc.). Further, professionals play critical roles in the adoption process and are able to observe processes that may not be noted or disclosed by parents. Shame, fear, and guilt are predominant barriers to parents' disclosure of depressive symptoms (Foli, 2010).
Three large web-based adoption organizations' distribution lists or listservs, as well as individual adoption agencies, organizations, and adoption clinics were approached by the investigator and sent the link to the Internet survey for distribution to staff members. Follow-up reminders were sent at approximately 2 and 3 weeks after the initial contact to encourage those that had not completed the survey. Adoption professionals or advocates who could read English, had access to the Internet, and interact or who have interacted with parents were included in the study.
An investigator-generated survey was composed based on a literature review of men's experiences with major depression and risk factors/contributors associated with depression in the postpartum time period (Beck, 2002, 2006). The tool was peer-reviewed by faculty and sent to adoption professionals to assure content validity. The Institutional Review Board granted exempt status to this study. As participants completed the survey, data were immediately saved and stored by a university-based data capture and storage system. Since the number of participants varied with each section of the survey, percentages will not be reported; the findings reported here are a part of a larger data set. Two questions were asked of the participants in this study:
1. What are the participant-observed contributors of PAD?
2. Do participants believe that PAD is experienced by adoptive fathers and if so, what are the observed characteristics of paternal PAD?
Professionals were initially asked to self-screen themselves by answering whether they currently interact or have interacted with adoptive parents. If they had not, they were instructed to exit the survey. As Table 1 reports, the majority of participants were Caucasian (n = 24) women (n = 30) who, on average, were 48 years old (range 27 years to 66 years). The sample was comprised of social workers (n = 20), nurses (n = 3) and adoption educators, physicians, psychologists, and adoption advocates (n = 7). The majority of the participants had between 3 and 20 years of experience (n = 27) and spend (or did spend) between 10 and 30 hours per week interacting with adoptive families (n = 24). Most participants currently interact with 4 to 15 clients per week (n = 21). The majority of participants (n = 15) described themselves as very or somewhat religious. Interestingly, 18 out of 32 participants were adoptive parents.
Research Question 1
In response to questions related to observed contributors to PAD, the five most agreed upon contributing factors were: life stress; lingering grief issues over infertility or loss of birth child; maternal/paternal delayed or lack of bonding; depression during the adoption process; and difficult infant/child temperament. As shown in Table 2, adoption professionals also responded "strongly agreed" or "agreed" to the following items: history of depression, childcare stress and lack of social support.
In addition to the close-ended questions, open text boxes were provided. The following were offered by the participants as additional contributors:
* "Parents expectations of the process, experience and reality. Personality of the child (especially based on expectations)."
* "Age of adoptive parents, previous parenting experience, lack of full disclosure of child/ren's background information."
* "Death in the family shortly before or after a placement; unresolved issues of how the parent was parented."
* "Child's history of trauma; unresolved issues with parent's family of origin/self-esteem/developmental issues such that not feel (sic) like a competent parent so not a competent adult."
Research Question 2
In response to the global question: Do you believe fathers experience postadoption depression, 20 of the 25 respondents responded "yes"; five individuals declined to answer this question. Table 3 presents the findings from the 20 individuals who replied "yes" to the global question.
In answer to the question, "Please indicate the other ways that fathers experience postadoption depression," the following responses were offered:
* "Withdraw from marital interactions, not pay attention to the child, work long hours, put all of the parenting and household duties on to the mother and zone out in front of the television, easily frustrated, etc."
* "Increased burden or supporter and loss of marital relationship as it was previously."
* "Workaholic behavior, alcohol or drug use (in extreme cases)."
* "Critical, over-demanding."
* "Spend more time out of the house."
* "Express feeling depressed."
* "I have found less adoptive fathers experience PAD, however, I have seen it happen. Mother's PAD seem (sic) to last longer, and have an impact for a greater amount of time. I have found that mothers seem to be impacted more on a personal level, as though there is something innately wrong with them because as a mother, they should be more loving and nurturing ..."
* "None" (2 respondents)
* "Don't know" (9 respondents)
Professionals responding to the survey indicated a number of contributing factors to postadoption depression. Six of the postpartum depression predictors (Beck, 2002; 2006) were also noted as contributors of PAD: life stress, depression during the adoption process (pregnancy), difficulty infant/child temperament, history of depression, childcare stress, and lack of social support. Two contributors, which also had higher frequency counts (lingering issues of infertility and maternal/paternal delayed or lack of bonding with the child), may be unique to adoptive parents.
The majority of respondents believed that adoptive fathers experience postadoption depression and that this experience is different than that of adoptive mothers. They also reported that fathers are more likely to become disengaged from family, and fathers are more likely to display anger and frustration rather than sadness or melancholy. Respondent answers were less clear as to whether paternal PAD was a reaction to the adoptive mothers' depression and whether fathers were less likely to talk about their feelings.
Although the sample size was modest, findings can be used to influence how adoptive fathers are screened and assessed for depression. The use of standard depression scales and postpartum depression tools (EDPS) to detect depression in adoptive fathers should be further assessed for sensitivity and specificity in this population. The Gotland Male Depression Scale (GS), a 13-item scale that assesses for male depression, contains questions about anger attacks and alcohol use that other scales do not contain and may prove to be more valid in paternal postadoption depression. The GS scale was found to be superior to the Major Depression Inventory in detecting depression in males treated for alcohol dependency (17% versus 39%) (Zierau, Bille, Rutz, & Bech, 2002); and an .80 correlation between the GS and the Beck Depression Inventory in the assessment of depression (in men) was found in a drop-in primary care clinic (Stromberg, Backlund, & Lofvander, 2010).
IMPLICATIONS FOR PRACTICE
Several important implications for practice are generated by this study. Post-placement visits are conducted after the child is placed in the home with professional services usually ending after the necessary forms have been filed. Subsequently, if the parent (or parents) is struggling, he/she is left to cope with their depression without support being readily available. Strengthening postadoption programs and services to include parent support groups, education on parental transitions, recognition of depressive symptoms, gender differences in how depression is expressed, and the unique needs of children who are adopted are necessary.
Universal screening for depression in adoptive parents post-placement could facilitate prevention and early (depressive) onset treatment. Empirical evidence supports interventions by health care providers designed to prevent postpartum depression in birth mothers. Universal screening, using the Edinburgh Postnatal Depression Scale in birth mothers, was used to implement prevention services in the postnatal period; these services were found to be effective in reducing the likelihood of the mother experiencing postpartum depression (Brugha, Morrell, Slade, & Walters, 2010). Such screenings and services need to be made available to both mother and father (Foli, 2010b), as the father's role may be considered secondary to those of the mother or overlooked by healthcare providers. Interventions directed toward fathers should include strategies to re-engage them with the family, awareness that paternal depression may be outwardly expressed by anger and disengagement from the family, and facilitate nonjudgmental and therapeutic interactions with fathers to lessen paternal frustrations.
Adoptive fathers may struggle with depression after their child is home and universal screenings should be undertaken for both the adoptive mother and father in the post-placement time period. Comparison of pre-adoptive expectations and the actual experiences of parenting may be helpful as interventions are planned. Often, fathers are not screened for mental health services or support. Professionals should consider gender differences in depressive symptoms when assessing and treating adoptive fathers.
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KAREN J. FOLI (a) and GREGORY C. GIBSON (b)
(a) Purdue University School of Nursing, Indiana, USA.
(b) National Registry of Emergency Medical Technicians, Columbus, OH, USA.
Correspondence concerning this article should be sent to Karen J. Foli, Purdue University School of Nursing, Johnson Hall of Nursing, Room 234, 502 N. University Street, West Lafayette, Indiana 47907-2069, USA. Email: firstname.lastname@example.org
Table 1 Respondent Demographic and Professional Characteristics * Gender Women n = 30 Men n = 1 Age Mean 48 years Range 27 to 66 years old Race Caucasian/White n = 24 Asian American/Pacific Islander n = 1 Highest level of education four-year college n = 8 post-graduate degree n = 22 Post-graduate degree earned MSW n = 5 PhD n = 13 Psych D n = 1 JD n = 1 Employment full-time n = 19 part-time n = 7 self-employed n = 3 Principle area of adoption Public (Domestic) n = 5 Private (Domestic) n = 9 Private (International) n = 14 Kinship n = 1 * As the data collection was performed via a web based survey, respondents could choose to skip or refuse to answer an item; thus n values vary by question. For clarity, the n values for each item are presented. Table 2 Observed Postadoption Depression Contributing/Risk Factors "How strongly you think each of the following contributes to or places parents at risk for postadoption depression....." Strongly Agree/Agree n Life stress 27 Lingering grief issues over infertility or loss of birth child 26 Maternal/paternal delayed or lack of bonding with the child 26 Depression during the adoption process 26 Difficult infant/child temperament 26 History of depression 25 Childcare stress 25 Lack of social support (instrumental and emotional) 25 Personality traits or temperaments of the parent 23 Unanticipated/unknown special needs of the child 23 Perceived parental rejection from the child 22 Lack of feeling legitimacy or adequacy as a parent 21 Low self-esteem 21 Lack of preparedness, including lack for formal adoption 20 education Pre-adoption anxiety 20 Marital/relationship dissatisfaction 20 Post-adoption blues 19 Changes in lifestyle/freedom/ loss of life rewarding 17 experiences The child's sense of loss and grief associated with adoption 16 Adopting more than one child at a time 15 Unplanned/unwanted adoption 14 Known special needs of the child 13 Strained interactions with birthparents 13 Intrusive questions from acquaintances, family and friends 10 Guilt over birthparents' loss 9 Feeling excluded from society because of being an adoptive 9 parent Feeling excluded from society because of transracial 9 adoption Marital/partnership status 9 Age of the child (older than 24 months) 8 Low socioeconomic status 7 Table 3 Perceptions of Paternal Postadoption Depression Item Strongly Neither Strongly Decline Agree/ Agree/ Disagree/ to Answer Agree Disagree Disagree Fathers experience postadoption depression in the 5 3 11 1 same manner as mothers. Fathers are less likely to talk about their feelings and 4 16 0 0 therefore, internalize their emotions. Fathers are more likely to become 16 3 1 0 disengaged from family. The father's depression is a 4 5 9 2 reaction to the adoptive mother's depression. Fathers are more likely to display anger and 16 1 2 1 frustration than sadness or melancholy.
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