Mental health screening of fathers attending early parenting services in Australia

Abstract

Paternal perinatal depression and anxiety is a common, though under-recognized mental health condition experienced by men during their transition to fatherhood. An opportunity to screen for paternal mental health issues occurs when parents present for assistance with the care of their baby at early parenting services (EPSs). There are 10 EPSs located across Australia that provide specialist, multidisciplinary interventions to support parents experiencing complex parenting difficulties. Using structured telephone interviews, this qualitative study explored the views of 18 professional staff from nine EPSs regarding screening, referral processes and acceptability of screening fathers for mental health issues. A thematic analysis revealed that most EPSs screened fathers for depression. Participants agreed screening was important and that routine approaches to screening would help normalize the process for both men and services. Despite this, no uniform, comprehensive approach to identifying the mental health needs of fathers was found. EPSs provide a unique opportunity to address the mental health needs of fathers. Results from this study point to the need for a national approach to the development of father-specific screening guidelines for EPSs to improve family well-being, in parallel to those informing the Australian National Perinatal Mental Health Initiative for mothers.

Keywords

Assessment early parenting father mental health parenting support services

Introduction

It is now well established that men may experience psychological distress as they make the transition to becoming a father (Paulson and Bazemore, 2010). Studies of paternal perinatal depression (PPD) have identified symptoms identical to those of depressed mothers: self-blame, anxiety, lack of enjoyment as well as anger, irritability and feeling ‘burnt out’ (Madsen and Juhl, 2007). Predictors of PPD include previous depression, low-income and poor social support as well as decreased marital adjustment and perceived low parenting competence (deMontigny et al., 2013; Johansson et al., 2016; Koh et al., 2014). The effects of distressed fathers on family members are also well-documented. Infants whose fathers showed signs of depression were two to three times more likely to exhibit behaviour problems at three years of age (Fletcher et al., 2011) and twice as likely to have a psychiatric diagnosis at age seven (Ramchandani et al., 2008). Mothers too can be adversely affected by a father’s mental illness as their capacity to parent effectively may be reduced (Røsand et al., 2011). As a result, calls for fathers to be screened for depression occur frequently in the psychological, medical and nursing literature (e.g. Edward et al., 2015; Gutierrez-Galve et al., 2015; Musser et al., 2013).

A major barrier to fathers being assessed and receiving support has been their lack of contact with health services during the early years of parenting (Schmied et al., 2011). Fathers may attend some antenatal visits and most fathers are present at the birth; however, the focus of these interactions is the mother and baby (Rowe et al., 2013). For their part, fathers may perceive their role as secondary to the mother and be reluctant to express a need for support (Darwin et al., 2017).

In the post-birth period, services are geared towards infant care and well-being and while mothers remain central, fathers may be included. Consistent with family-centred care principles (Harrison, 2010; Shields et al., 2006, 2012), occasions where parents are presenting for assistance with their parenting offer opportunities for assessing the mental health needs of both parents. In Australia, early parenting services (EPSs) provide support to parents of children from birth to preschool age who are experiencing complex parenting difficulties requiring specialist and multidisciplinary intervention. Care is provided in partnership with the family for issues such as infant feeding, sleep and behavioural problems and maternal perinatal mental health concerns (Australasian Association of Parenting and Child Health (AAPCH), 2016; Fowler et al., 2016). These EPSs vary in size and funding sources and may offer residential and day stay services as part of the parenting services (Bennett and Cooke, 2012).

Parents may access the EPSs through various routes: home, community early parenting groups, centre-based consultations, telephone and online help, specialist intervention from multidisciplinary staff during extended home visits, day stay appointments or residential services. Recent studies have demonstrated that most mothers and fathers admitted to residential EPSs are satisfied that the intervention has equipped them with the necessary knowledge, skills and confidence to manage parenting challenges on their return to the community (Berry et al., 2015; Fowler et al., 2012). However, given that a high percentage of fathers accessing EPSs are distressed (Giallo et al., 2013), it is important to understand how EPSs address the mental health issues of fathers.

Therefore, this study aimed to identify and describe (a) the instruments and procedures for screening fathers attending residential and day stay services in EPSs, (b) the referral process and pathways for fathers with mental health problems attending residential and day stay services in EPSs and (c) the acceptability to staff of screening fathers’ mental health.

Method

The research team consisted of health and social science experts within disciplines of clinical midwifery and child and family health nursing, father-inclusive practice and extended experience with qualitative data collection and analytic approaches.

Sample

There are 10 EPSs in Australia; all managers were approached and one declined. Written consent was obtained from the managers responsible, who were asked to nominate one clinician and one supervisor to receive a research invitation. The nominated staff who subsequently volunteered gave informed consent. Thus, the collected data represents the complete population of EPS in Australia, minus one service.

Data collection

Structured telephone interviews included demographic questions (including qualifications and experience) and questions about PPD screening and referral prevalence, processes, referral pathways and barriers to paternal screening within the services. The interviewer used prompts to elicit depth or elaboration from participants. Interviews ranged from 15 to 40 minutes and each was recorded, de-identified and transcribed.

Data analysis

A thematic survey analysis approach was used (Sandelowski and Barroso, 2003). In a thematic survey analysis, text is coded into a priori categories, as well as categories representing nuance in the transcribed text; however, data are not transformed at an interpretive or theoretical level (Sandelowski and Barroso, 2003). We first analysed the texts to describe what participants discussed, creating categories based on the interview questions as described above. We then ‘on-coded’ these categories for underlying ideas, thoughts or attitudes towards screening and fathers’ presence in the EPSs. Data analysis was conducted by the second, third and fourth authors; regular meetings were held to discuss coding issues and determine agreement between authors on code labels and coded text. Organization and coding of the qualitative data was completed with NVivo 11 (QSR International). Ethical approval for this study was granted by the University Human Research Ethics Committee.

Results

In this study, 18 (17 female, 1 male) professional staff from 9 EPSs were interviewed about their organizations’ policies and procedures for screening fathers for depression – see Table 1 Participant characteristics. Eight participants identified as clinicians and 10 as supervisors or managers. All of the interviewees had significant professional experience (10 years or more) in the area of child and family health services and reported their formal qualifications as nursing 11 (31.4%), child and family health nursing 11 (31.4%), psychology 3 (8.6%), social work 3 (8.6%), counselling 2 (5.7%), midwifery 2 (5.7%) and other 3 (8.6%) (the total number of qualifications reported, not the number of participants). The participant codes used in presenting the results include an organization code (S1, S2, etc.) and a unique individual identifier (P1, P2…P18).

Table 1.

Participant characteristics (n = 18).

Variable	n (%)
Position
Clinician	8 (44.4)
Supervisor or manager	10 (55.5)
Gender
Male	1 (5.6)
Female	17 (94.4)
Experience (M, SD)	24.4 years (9.62) Range 10–40 years
Time in current role (M, SD)	7.3 years (5.62) Range 0.25–21 years
Qualifications*
Nursing	11 (31.4)
Midwifery	2 (5.7)
Psychology	3 (8.6)
Counselling	2 (5.7)
Social work	3 (8.6)
Child and family health nursing	11 (31.4)
Other	3 (8.6)

Note: M: mean; SD: standard deviation.

*Percentages are based on the total number of qualifications reported, not on the number of participants.

Analysis of the interview data revealed five broad categories: (a) identifying fathers’ mental health needs, (b) the process for explaining the screening to fathers, (c) screening for paternal depression when fathers are not present, (d) addressing fathers’ mental health needs and (e) barriers to screening.

Identifying fathers’ mental health needs

Almost all of the services (7/9) indicated they screened fathers for depression. Which fathers were screened depended on the service’s function as well as on the level of fathers’ involvement in the care.

Fathers were screened if they were primary caregivers, admitted to the service, or actively participating in the program.

…If they’re admitted then all fathers get a DASS depression and anxiety done. If fathers visit, and some fathers stay overnight and not participate in the care, they don’t get admitted. Fathers that participate in the care, [even] if they go off to work but are otherwise most of the time in residential stay, then they will get a depression score done…(S5P10)

Screening also occurred at the universal contact visit (a home visit when the baby is less than four weeks of age) by EPSs that were part of the state health department’s universal system offering a child and family health nursing service.

If fathers were not part of the routine screening processes as described above, they were nevertheless encouraged to be screened if their history or family referral information flagged possible depression. Fathers would also be screened if mothers identified his possible depression during the admission interview or if the nurse had concerns about the father’s presentation.

The majority of services used The Edinburgh Postnatal Depression Scale (EPDS, Cox et al., 1987) as the screening tool for fathers. Some services used the Depression Anxiety Stress Scales (DASS)] (Lovibond and Lovibond, 1995), and other assessments were also used: the Family Assessment Form, a Post-Natal Risk Questionnaire, the Psychological Risk Assessment and the K10 (Kessler et al., 2002). The DASS was considered by one service to be more useful for both mothers and fathers, because the EPDS was considered to not effectively screen for anxiety. Another service used an adapted form of the EPDS for fathers. Some services indicated using supplementary assessment tools such as the Karitane Parenting Confidence Scale, and in some services, assessment processes for fathers were not clear.

Participants generally agreed that it was important to screen fathers for depression. They discussed the growing awareness of men’s role in family well-being and the need for a holistic approach to child and family care. They were aware of the increased prevalence of men’s depression:

[There are] a lot of men, basically, either suffering in silence, or, of course, self-medicating with alcohol…(S5P9)

Participants felt that screening and involvement of fathers in family services could make a difference. Several participants outlined their service’s commitment to screening, having created a ‘good platform on which to build’ (S2P3). One noted that they were:

…[i]dentifying more Dads that do have depression…(S5P10)

This was perhaps because they included screening of fathers at intake. An overall view was that more frequent screening would normalize the process for both men and services and that further research is required to create specific tools for men that are more appropriate and facilitates men’s participation in family care.

Process for explaining the screening to fathers

When screening of fathers was usual practice within an EPS, the general approach was to normalize the screening request as something that is done with all family members attending the service. This request usually occurs during the intake phase, by telephone or as a pre-admission interview. EPSs emphasize to parents that fathers are not being singled out for special attention because:

…[w]e ask everybody these questions…(S6P12)

Nevertheless, clinicians explain to parents that there is an increased recognition of depression and anxiety in men around the time of the birth. Most services stated that they also discuss the signs and symptoms of depression. The screening was generally explained to fathers as a tool, not a diagnostic test.

…We make it quite clear [to fathers] this is just a screening tool, it just provides us with some information about what sort of risk group that the caregiver fits in…(S8P16)

Several services emphasize to fathers that the results of the screening help determine whether there are any mental health issues and assist the EPS to provide tailored support for parenting concerns. Services also explain the voluntary nature of screening and respect fathers’ decisions to decline screening.

Screening for depression among fathers when they are not present

Due to contextual factors such as time of day and service type, fathers are not always present at the initial assessments, conversations or interviews undertaken with the family. An important issue then is whether fathers’ mental health is discussed at these times, and if so, what information is exchanged.

In some services, when fathers are not present during formal or informal family functioning assessments (as opposed to depression screening), mothers are invited to discuss family issues, including mental health, family violence, drug and alcohol use, for herself and for her partner. In some cases, these conversations extend to family ‘dynamics’, team work and the co-parenting partnership.

Other services indicated that if the father is not present, his health is not discussed or only discussed if mothers seek support for him, or only in relation to how he is supporting the mother. In several services, this discussion essentially centres on mother and child safety from fathers’ violence or drug and/or alcohol. Whichever format is used, services recognize that it is:

…[u]p to them [the mothers] to tell us…(S6P12)

However, there was also an awareness of the tension between mothers’ sharing of information, and confidentiality for fathers; additionally, some services did not accept the veracity of mothers’ descriptions of the father.

Another view of fathers’ mental health was that unless it was clear to clinicians that the father–child relationship was suffering the father was referred out to other services.

Addressing fathers’ mental health needs

Services’ responses to fathers’ mental health problems varied according to whether the father is admitted to the service, if he attends as a partner, or if he does not attend yet the service is aware of his mental health. Services may either engage with the father or offer referrals.

If the father is admitted as a client to the service (residential or not), and there is a positive screen or indication of mental health issues, the care is the same as is offered to the mother:

…[i]t would be no different to the process which we actually provide a service for our mothers…(S4P8)

When men attend the service as a partner (as opposed to being admitted), and his mental health is poor, engagement varies. If a father visits the mother frequently, clinicians have an opportunity to connect with him, whether informally, ‘in the corridor’, or, for example, through fathers’ nights. Clinicians may talk with fathers, acknowledge the issue, and give direction, information and guidance or, if a father was very distressed, refer to admission. If required, most centres provided referrals for men who were admitted to the unit and if he was attending as a partner. A referral could be a formal letter or an informal recommendation. Most services stated that they recommend the father’s first call to be to a General Practitioner. Other recommendations were made to employee assistance programmes, psychologists, counselling or social workers. Clinicians could not insist that fathers seek professional assistance. If fathers did not attend the EPS in any way, services were unlikely to provide a referral.

EPSs had a wide range of resources that they offered fathers including helpline numbers, informative literature and websites to other services, programmes or groups. Follow-up of the father’s health appeared to depend on the usual practice implemented for mothers; if he had been admitted, then periodic phone calls were made. However, if he had been a visitor or unseen, there were few formal strategies to follow for the father’s health. Some services stated that they would ask the mother how the father was ‘travelling’; however, there was little tracking of the outcomes of referrals, recommendations or information sharing.

Barriers to screening

There was general agreement that fathers were a ‘difficult cohort to capture’ (S5P9) and even more difficult in rural areas. Barriers to routine screening of fathers included work–family balance, service-level focus and characteristics of men themselves. The problematic balance of work and family was acknowledged as a barrier.

…We push this idea that it’s both your baby, but on the other hand, the workplace imperatives mean that he is out bringing the bacon in…(S9P18)

Additionally, some participants accepted that services had an incomplete understanding of men’s transition to fatherhood, which inhibited an informed approach to working with fathers. This could manifest as a:

…[p]atronising, adjunct kind of attitude that you can have, so they’re kind of an add-on to the mother, rather than a very significant part, as much as the mother in the child’s life…(S3P5)

Practical factors were also implicated, such as service hours limiting time available to build a trusting relationship with the father, the prevalence of female staff and the lack of male-specific screening tools.

Participants also recognized that fathers’ perspectives on help-seeking, mental health and services obstruct their involvement in depression screening. There was a sense that the norm was still ‘men don’t want to talk about things…’ (S6P12). Men’s limited involvement was also felt to be influenced by men’s expectations that the service was for their partner’s mental health, and father was there as a support person ‘…This is not about me…’ (S1P1). Men were often ‘…surprised…’ (S1P1) when they were offered a depression screening.

Discussion

This study drawing on data from 9 of the 10 EPSs in Australia points to the lack of an effective, uniform approach to identifying and addressing the mental health needs of fathers. This represented almost the complete population of EPS in Australia; therefore, the data are representative of this particular domain of practice. Consistent with earlier research on the assessment of the mental health needs of fathers conducted in Australian EPSs (Giallo et al., 2013), clinicians agreed that screening fathers for depression and anxiety was important and should occur within their services. However, clinicians’ involvement with and access to fathers differed across these programmes and protocols and clinicians’ approaches to screening fathers’ mental health varied.

While some services had protocols to guide the identification of fathers who may be experiencing anxiety or depression, it was clear that, overall, the approach to screening fathers in EPSs was not consistent with family-centred care (Harrison, 2010; Shields et al., 2006, 2012). Screening of non-admitted fathers, for example, was serendipitously contingent on fathers’ attendance with their partner. In several services when fathers were absent, father’s mental health was raised only in relation to concerns for mother and child safety from fathers’ violence or drug and/or alcohol. These are unreliable indicators of men’s mental health issues (Martin et al., 2013; Wilhelm, 2009) and do not provide a universal platform to ensure fathers’ mental health status is addressed (Fletcher et al., 2014). As fathers are a legitimate part of the family, consistency in the mental health screening of fathers similar to mothers is something that EPSs could use to guide consistency in the application of family-centred care.

There also appeared a lack of recognition that fathers may require different screening measures or treatment for depression and anxiety than those for mothers (Leach et al., 2016). The available evidence identifying that men’s experience and manifestation of depression and anxiety differs from women’s (Brownhill et al., 2005; Martin et al. 2013) and thus the screening process and treatment is likely to differ too (Brownhill et al., 2005), appears not to be incorporated into EPS practice.

Implications

Despite general agreement on the need to assess and address fathers’ mental health, there is wide variability among EPS sites. Within sites, the different approaches taken to inpatient, outpatient and visiting fathers suggest that opportunities to improve family functioning are being overlooked. An opportunity exists to apply the approach of those sites where fathers are more comprehensively assessed to services with less well-developed protocols and practices. While there may be resource implications or structural barriers to improved practice, disseminating knowledge of effective screening practices in similar services would provide a logical first step. The experience in attempting to improve screening for maternal depression has shown that changes to procedures will need to be supported by specific training and improved referral systems across services (Hickie, 2004). EPS services can learn from other perinatal services grappling with the complexities of fathers’ inclusion in women-centred practice (Rollans et al., 2016). There is a role for professional bodies such as the AAPCH in supporting the development of common clinical approaches to paternal mental healthcare.

Limitations

This study captured the views and experiences of clinicians and supervisors working in EPSs but not that of the fathers or of their partners regarding screening fathers for depression and anxiety. Individuals were invited to describe their professional and service practices, and this is different to a more objective audit or survey of specific policies and procedures. There was also no specific commentary on the screening process for minority groups of fathers such as Aboriginal fathers or those from culturally and linguistically diverse communities attending EPSs.

Conclusion

This study provides an insight into the views and practices of health professionals in Australian EPSs regarding the screening of fathers for depression and anxiety. While the importance of screening fathers for depression was acknowledged, and clinicians do inquire about fathers’ well-being, there appeared to be a lack of consistency in how to approach fathers’ possible mental health needs. If fathers were not admitted to a residential programme, they risked falling through the cracks, particularly if clinicians did not realize the implications of a father’s mental health status on infant and family relationships. As the EPSs provide a unique entry point for families with complex health needs, they are suitably placed to identify the specific mental health needs of fathers. Evidence-based screening guidelines for clinicians who must manage competing demands on their time would assist these services to meet their goals in support of families. The knowledge and experience gained in formulating father-specific screening guidelines for EPSs could inform the development of a national approach to improve family well-being through addressing paternal mental health in parallel with the existing National Perinatal Mental Health Initiative for mothers.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Australasian Association of Parenting and Child Health.

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