Parental depression affects as many as 1 in 5 US families. Pediatric professionals can play an important role in detecting parental depression, yet most studies on parental depression screening focus only on the postpartum period. The authors performed this scoping review to understand the existing literature on parental depression screening outside the postpartum period (child >12 months old) and to identify knowledge gaps.
Sources for this research include PubMed, CINAHL, SCOPUS, Web of Science, and APA Psych Info. We included English language papers concerning screening for maternal and/or paternal depression or mood disorders outside of the postpartum period by pediatric clinicians or in a pediatric health care setting. Extracted variables included publication year, title, author(s), country, geographic setting, clinical setting, child age range (in years), parental focus, sample size, study type, approach, screening instrument(s), and findings.
Forty-one papers were included. The proportion of positive parental depression screens was consistently high across the included studies. Relatively few structured screening programs outside of the postpartum period were identified, especially for fathers. The included studies suggest that screening can be accomplished in pediatric settings, but appropriate referral and follow-up of positive screens poses a major challenge. This review was limited to English language papers concerning parental depression outside of the postpartum period.
These findings suggest that screening for parental depressive symptoms outside the postpartum period could identify families in need of support. Research is required to identify best practices for referral and follow-up of parents who screen positive.
Parental depression impacts child and parent wellbeing. Pediatric professionals are well situated to play a role in detecting parental depression throughout childhood. However, most of the literature to date on parental depression has focused solely on the immediate postpartum period.
Screening for parental depression outside the postpartum period has the potential to identify families in need of support. Further research is required to identify best practices for referral and follow-up of parents who screen positive for depressive symptoms.
Parental depression affects as many as 1 in 5 families in the United States,1 with negative effects on parental and child wellbeing.2–4 The economic burden caused by lost work productivity and increased health care utilization among adults with depression in the United States is estimated at $210.5 billion per year,5 with maternal mood disorders costing approximately $31 800 per mother-child dyad across the first 6 years of a child’s life.6 The coronavirus disease 2019 (COVID-19) pandemic, with its far-reaching impact on physical, psychosocial, and economic wellbeing, has further increased the prevalence of maternal depression, with 1 study finding an increase in the rate of depression from 9% to 43% among mothers of children aged 18 months to 8 years during the pandemic.7
Most of the literature related to parental depression to date has focused on maternal depression. Mothers with depression, particularly those with chronic symptoms and those with additional psychiatric comorbidities, are at elevated risk for insecure attachments with their children8–11 and harsh parenting behaviors.12 Maternal depressive symptoms have negative effects on mothers’ caregiving behaviors13–15 and utilization of pediatric resources.16 Furthermore, disturbances in maternal-child interactions in the context of maternal depression alter children’s responses to stress at a neurobiological level, with measurable effects on regions of the brain involved in executive function skills.17–22 In the long term, maternal depression has been linked to negative cognitive and psychosocial outcomes in children.23–27
The consequences of maternal depression are not limited to mother-child relationships. Maternal depression is associated with increased paternal depressive symptoms as well as increased couple morbidity and parenting stress.28 Despite this connection, there are few studies examining the impact of paternal depression on children. Existing studies demonstrate that paternal depressive symptoms in the first year of life are associated with negative social, behavioral, and emotional outcomes in children, similar to the outcomes observed among children of depressed mothers.3,28,29
Early recognition and treatment of parental depression can mitigate negative effects on child health and development.30,31 However, multiple barriers exist to identifying and treating parents with depressive symptoms. To begin, many women with unmet behavioral health needs do not have a regular source of health care.32 Although obstetricians and gynecologists (OBs and GYNs) commonly serve as the sole primary care clinicians for women of reproductive age, 59% of OBs and GYNs believe that identification and treatment of depression is not their responsibility and 66% are not confident in their ability to manage depression.33 Given that most parents report that their infants receive health supervision visits34 and Bright Futures guidelines recommend at least annual well visits outside of the postpartum period, pediatric practices may be an ideal setting to identify parental depression and link families to support.35,36 Importantly, pediatric practices could also be a unique resource for men of childbearing age who often lack a clear source of health care, but attend pediatric visits with their children.37 However, screening for parental depression in the pediatric setting is limited both in current guidelines and in practice. Although maternal depression beyond the immediate postpartum period has the potential to impact child health and development, the current American Academy of Pediatrics (AAP) guidelines only recommend that pediatric clinicians screen for maternal depression in the first year of life.38,39 Further, whereas 85% of pediatric clinicians agree that recognizing maternal depression is their responsibility, only half are confident in their ability to do so.40 Among pediatric clinicians who screen for parental depression, the vast majority rely solely on observational cues to detect depressive symptoms.41 Only 9% report assessing for maternal depression using formal diagnostic criteria and only 3% report using a validated screening tool.40 Whereas the rate of maternal depression screening by pediatric clinicians has increased in recent years, those who do remain in the minority.42 As per current guidelines, screening for paternal depression is even more limited. The AAP recommends screening a mother’s partner for depression only at the child’s 6-month visit. Even if universally implemented, such limited screening of partners has the potential to under-identify paternal depression and its impact on children and families.43 Pediatric clinicians’ limited comfort with screening for parental depressive symptoms underscores the need for models that support clinicians and families. However, such models remain poorly defined.
This scoping review outlines the current research related to parental depression screening in the pediatric setting outside of the postpartum period (child >12 months old). Specifically, it describes the proportion of positive parental depression screens outside of the postpartum period, elucidates existing knowledge gaps in the field, and identifies potential barriers and opportunities for broader screening efforts.
Methods
Scoping reviews synthesize research evidence by mapping “key concepts underpinning a research area and the main sources and types of evidence available.”44 They are well suited to examine the extent of a body of literature and identify existing knowledge gaps.44–46 We use this approach to obtain a broad understanding of the literature on parental depression screening in pediatric health care settings outside of the postpartum period and to identify knowledge gaps. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines (Fig 1).
Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram. NA, not applicable.
Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram. NA, not applicable.
Eligibility Criteria
We included papers that met these inclusion criteria: (1) the study concerned screening for maternal and/or paternal depression or mood disorder, (2) the screening was conducted by a pediatric clinician or at a pediatric health care facility, (3) the screening was performed after the postpartum period (child >12 months old), and (4) the study was published in English. We excluded papers if they did not meet the above-specified inclusion criteria and studies based on secondary analysis of parental depression data collected for nonscreening related research. There was no exclusion based on publication year. We aimed to capture studies specific to screening for parental depression by pediatric health care clinicians outside of the immediate postpartum period, which we anticipated might reveal a gap in the current literature as of January 12, 2022.
Information Sources
A literature search was performed using PubMed, CINAHL, SCOPUS, Web of Science, and APA Psych Info. The most recent search was executed on January 12, 2022.
Search
There was no registered review protocol for this study. We developed a search strategy for PubMed with the guidance of a medical research librarian. The search terms were subsequently adapted for the other databases specified above. The search terms used for the PubMed search were as follows: (“depression” OR “mental health” OR “mood disorders” OR “behavioral medicine” OR “behavioral health”) AND (“parents” OR “mothers” OR “fathers” OR “caregivers” OR “maternal” OR “paternal” OR “parental” OR “caregiver”) AND (“screening” OR “mass screening” OR “systematic screening”) AND (“pediatrics” OR “pediatricians” OR “pediatric setting” OR “pediatric clinic”). Search strategies for the other databases used are specified in Supplemental Table 3. In total, 1566 studies were identified and compiled in an EndNote library. Following removal of duplicates, first automatically using EndNote and then manually, 1030 papers remained.
Selection of Sources of Evidence
During the first round of screening, 2 independent reviewers assessed the titles and abstracts of each of the 1030 papers identified. Disagreements between the reviewers were decided by a third independent reviewer. At the end of this first round, 82 papers remained. Two independent reviewers then reviewed the full texts of these 82 papers to assess their eligibility. Papers were included if they met the inclusion criteria described above. After this second round of screening, 41 papers remained for inclusion.
Data Charting Process
Authors A.H. and N.U. charted the data obtained from the included papers utilizing a table, which was reviewed for accuracy by authors M.J. and S.P. No additional data were sought from the investigators of the included studies.
Data Items
Data were collected from the source papers on the following variables: publication year, title, author(s), country, geographic setting (urban, suburban, rural, or other), clinical setting (outpatient primary care, outpatient subspecialty, emergency department, general outpatient, outpatient tertiary care center, general inpatient, inpatient intensive care, or other), child age range (in years), parental focus, sample size, study type (experimental or observational),47 approach (screening protocol as well as referral and/or follow-up protocol when applicable), screening instrument(s) used, and findings (including but not limited to proportion of positive screens, correlation of depressive symptoms with outcomes, and rate of follow-through with recommended referrals).
Synthesis of Results
We summarized data from the included papers in Table 1 and in narrative form below.
Studies Screening for Parental Depression Outside of the 12-mo Postpartum Period
| Year | Title | Author (s) | Country | Geographic Setting | Clinical Setting | Child Age Range, y | Parental Focus | Sample Size (n Approximated Based on Reported Percentages) | Study Type | Approach | Screening Instrument (s) | Findings |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1985 | Behavioral deviance and maternal depressive symptoms in pediatric outpatients | Fitzgerald59 | UK | Urban | Outpatient (subspecialty) | 3–4, 7–11 | Maternal | 103 mothers | Observational | • Recruited mothers of 3–4 and 7–11 y-old medical and surgical outpatients,• Compared rates of depressive symptoms of mothers 3–4 y-old medical versus surgical outpatients and mothers of 7–11 y-old medical versus surgical outpatients | Wakefield self-assessment depression inventory | • 32% mothers of 7–11 y-old medical outpatients, 31% of 3–4 y-old medical outpatients, 17% of 7–11 y-old surgical outpatients, and 9% of 3–4 y-old surgical outpatients screened positive |
| 1992 | Screening for maternal depression in pediatric clinics | Kemper and Babonis65 | USA | Not specified | Outpatient (primary care) | 0–6 | Maternal | 667 mothers | Observational | • Recruited mothers of children attending routine health care visits at 5 pediatric practices (private, university, and military)• Two versions of a screening instrument for depressive symptoms were administered by medical students | 3-item and 8-item versions of the Rand screening instrument for depressive disorders | • 19% of mothers screened positive for depression, • mothers who screened positive were younger and had less education and lower monthly incomes,• Positive screens were more common in teaching clinics (20%) and military clinics (24%) than in private practices (12%), among single versus married mothers (32% vs 15%), among mothers of color versus White mothers (29% vs 16%), and among those with positive screening test results for drugs compared with those with negative results (45% vs 17%) (P <.01 for all comparisons) |
| 1992 | Self-administered questionnaire for structured psychosocial screening in pediatrics | Kemper82 | USA | Urban | Outpatient (primary care) | Not specified | Maternal | 114 mothers | Observational | • Parents completed questionnaires in waiting room containing screening instruments for substance abuse, depression, self-esteem, and social support, and questions about domestic violence, homelessness, and parental history of abuse, | 8-item Screening Instrument for Depression | • Maternal depression was identified in 16% of mothers who completed the questionnaire vs 4% identified by medical record, this difference between questionnaire and chart was statistically significant (P <.01) |
| • Compared medical records of children whose mothers completed questionnaires to sample of children whose mothers did not | ||||||||||||
| 1994 | Family psychosocial screening: should we focus on high-risk settings? | Kemper et al 66 | USA | Not specified | Outpatient (primary care) | 0–6 | Maternal | 1404 mothers | Observational | • Recruited mothers of children attending well child visits (758 in teaching clinic, 444 in private practice, and 202 at military clinic), | Rand corporation's screening instrument for depressive disorders | • Positive screens for maternal depression ranged from 12% to 35%, • psychosocial problems were common even at “low risk” clinics |
| • Clinic sites deemed “low,” “medium,” or “high” risk | ||||||||||||
| • Mothers at all sites completed a questionnaire that included information on mother's history of abuse or neglect, depressive symptoms, and history of drinking and drug use | ||||||||||||
| 1994 | Depressive symptoms and work role satisfaction in mothers of toddlers | Olson and DiBrigida67 | USA | Urban | Outpatient (primary care) | 1–2 | Maternal | 233 mothers | Observational | • Depression screening measures were completed by mothers attending health supervision visits at 2 community pediatric practices | 20-item depression screening instrument developed by Barrett, Oxman, and Gerber (modified hopkins symptom checklist) | • Depressive symptoms present in 42% of mothers (95% CI 39% to 45%) |
| • Rates of symptoms were similar across employment groups (P = NS) but 67% of mothers who were dissatisfied with their current work role had depressive symptoms compared with 35% of those who were satisfied (P <.001) | ||||||||||||
| • Mothers who were dissatisfied with employment status were 3.7×more likely to be depressed (95% CI interval 1.8 to 77, P = .0003) | ||||||||||||
| 1998 | Depressive symptoms in inner-city mothers of young children: who is at risk? | Heneghan et al60 | USA | Urban | Outpatient (primary care) | 0.5–3 | Maternal | 279 mothers | Observational | • English-speaking mothers of children presenting for well-child visits completed an interview and self-report checklist of mental health symptoms | Psychiatric symptom index (PSI) | • Mean PSI total score was 19, 39% scored ≥20, 18% scored ≥30 |
| • Anxiety and depression subscales were correlated with PSI total scores | ||||||||||||
| • PSI scores did not vary by age, race, birthplace, education, employment, marital status, or family composition | ||||||||||||
| • PSI scores were higher for mothers receiving public assistance (P <.05) and those with self-reported poor or fair financial status (P <.005) | ||||||||||||
| • Scores were higher among mothers who reported poor health status (P <.005), mothers with activity limitations due to illness had higher scores than those without (P <.005) | ||||||||||||
| 1998 | The scope of unmet maternal health needs in pediatric settings | Kahn et al64 | USA | Not specified | Outpatient (primary care) | 0–1.5 | Maternal | 559 mothers | Observational | • Women were screened by a research assistant in waiting room before child's appointment• 10–15 min survey was self-administered and completed in either waiting area or exam room | 3 questions from Rand screening instrument for depressive disorders | • 39.6% of women reported depressive symptoms (P < .001)• More than 90% of participants said they would welcome or not mind an offer to assist with appointment-making with an adult care provider if affected by 1 of the issues examined |
| 1999 | Impact of screening for maternal depression in a pediatric clinic: an exploratory study | Needleman et al61 | USA | Urban | Outpatient (primary care) | Not specified | Maternal | 73 mothers | Observational | • Mothers were referred to pediatric social workers who rated degree of depression clinically and administered a depression measure• Mothers were referred for mental health and assessment and treatment based on the social worker's clinical judgement and CES-D scores• Follow-up calls were made 1–6 mo later | Center for epidemiologic studies depression questionnaire (CES-D) | • 67% of mothers had significant depressive symptoms (CES-D ≥16) but only 29% of total sample were identified by social workers based on clinical assessment• 58% of high-scoring mothers showed at least minimal clinical depressive symptoms, 14% showed no symptoms• 59% (26 of 44) of referred mothers agreed to seek mental health assessment and treatment but only 11% (3 of 26) had attended recommended visit at follow up |
| 2000 | Do pediatricians recognize mothers with depressive symptoms? | Heneghan et al78 | USA | Urban | Outpatient (primary care) | 0.5–3 | Maternal | 214 mothers | Observational | • Mothers completed a depression screening tool and pediatric health care providers completed a questionnaire assessing mothers’ symptoms, each unaware of other’s responses | PSI | • Out of 214 mothers 86 (40%) scored ≥20 (high symptom level)• Of mothers who scored ≥20, 25 were identified by providers as being at risk (29%) |
| • Sensitivity, specificity, PPV, and NPV of provider identification of maternal symptoms was evaluated against depression measure | ||||||||||||
| 2004 | Rates of maternal depression in pediatric emergency department and relationship to child service utilization | Flynn et al 68 | USA | Not specified | Pediatric emergency department | 0–7 | Maternal | 176 mothers | Observational | • Approached women who brought a child to the pediatric emergency department for a visit that was not severe trauma or the highest level of acuity• Administered survey that included screening tools for alcohol use and depression and questions on child health and maternal depression treatment | CES-D, 3-item Rand screening instrument for depression | • 31% of mothers screened positive for depression risk, of whom 78% were not being treated• Elevated depression was correlated with missed pediatric outpatient visits (OR = 2.9, P <.05) and greater use of emergency services (OR = 3.2, P <.05)• Mothers with depressive symptoms were younger, had fewer years of education, and were more likely to be Medicaid recipients or uninsured• Mothers who screened positive were more likely to rate own health as worse and had higher risk for alcohol use |
| 2004 | Maternal distress, child behavior, and disclosure of psychosocial concerns to a pediatrician | Wildman et al 58 | USA | Urban | Outpatient (primary care) | 4–12 | Maternal | 138 female caregivers (biological mothers, foster mothers, and grandmothers) | Observational | • Research assistants approached mothers in the waiting room of a primary care clinic and mothers completed measures while waiting• After child’s visit with the pediatrician, mothers completed exit questionnaire | Beck Depression Inventory (BDI) | • Among 36 mothers (24.1%) with elevated scores (BDI ≥10), 58.3% were concerned about child’s behavior compared with 25.7% of mothers without elevated BDI scores• 10.6% of mothers without elevated BDI scores had children with elevated PSC scores vs 27.8% of mothers with elevated BDI scores |
| 2005 | Two approaches to maternal depression screening during well child visits | Olson et al77 | USA | Rural | Outpatient (primary care) | 0–16 | Maternal | 473 mothers | Experimental | • Clinicians screened mothers of children of all ages who were scheduled for the first 3 well child visits of the morning and the afternoon on randomly selected days over a 1-mo period• In first condition, pediatricians screened mothers via a scripted interview, in second condition, 223 mothers completed paper-based depression screening | Patient Health Questionnaire-2 (PHQ-2) | • Yield from paper-based screen was 22.9% vs 5.7% for interview• 7.6% of women screened with paper tool were referred to mental health vs 1.6% of those screened via interview• General pediatricians commented that mothers indicated that they appreciated the attention to their family |
| 2006 | Brief maternal depression screening at well-child visits | Olson et al76 | USA | Rural | Outpatient (primary care) | Not specified | Maternal | 1398 mothers | Observational | • 3 pediatric practices implemented screening for parental depression at every well-child visit for a 1-mo period,• After pilot phase, practices took part in a program to determine the feasibility of implementing screening and referral at all well-child visits for a longer 6-mo period | PHQ-2 | • 17% of mothers reported ≥1 depressive symptom and 6% scored as being at risk for depression• Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms• For most visits discussion time responding to screening was minimal |
| 2006 | Improving women's health during internatal periods: developing an evidenced-based approach to addressing maternal depression in pediatric settings | Feinberg et al62 | USA | Urban | Outpatient (primary care) | Not specified | Not specified | Not specified | Observational | • Screening program was developed that included (1) screening of all mothers at well-child visits, (2) assessment of additional symptoms, level of impairment, suicidality risk, and preference for follow-up, (3) education on depressive symptoms, their impact on parenting, and management strategies, and (4) referrals for follow-up care• Conducted 9 focus groups and 36 interviews of mothers, site-based health care providers, and community-based professionals to assess acceptability of program | PHQ-2, PRIME-MD, PHQ-9 | • Providers found PHQ-2 nonburdensome |
| • Women with low levels of symptoms often declined further intervention beyond routine follow up in the pediatric setting, | ||||||||||||
| • For more symptomatic women, follow up with the woman’s own primary care provider was often preferred• Reticence to access behavioral health services was related to stigma associated with a mental health condition• Mothers and professionals both expressed a need for education about symptoms of depression, self-management strategies, and community-based services | ||||||||||||
| 2007 | Screening for maternal depression in a low education population using a 2-item questionnaire | Cutler et al74 | USA | Urban | Outpatient (primary care) | 0.011–4.5 | Maternal | 94 mothers | Observational | • Recruited English and Spanish speaking mothers who brought children for a well-visit | PHQ-2, Edinburgh Postnatal Depression Scale (EPDS) | • Sensitivity of PHQ-2 for identifying a positive EPDS score was 43.5%, specificity 97.2% |
| • Mothers screening positive on either of 2 depression screens were referred to social worker for further assessment• Followed up with mothers who screened positive at 3 mo to see if further assessment had taken place | • 12.8% screened positive on PHQ-2 (95% CI 7.1% to 21.6%) compared with 24.5% on EPDS (95% CI 16.4% to 34.6%), 26.6% screened positive on ≥1 instrument (95% CI 18.3% to 36.9%)• Sensitivity of PHQ-2 was higher for mothers with education beyond high school (P = .02)• 22 of 25 women who screened positive accepted a referral for additional services• Among 22 who accepted a referral follow up was obtained for 15; 4 of whom reported that they had received services | |||||||||||
| 2007 | Screening for depression in an urban pediatric primary care clinic | Dubowitz et al69 | USA | Urban | Outpatient (primary care) | <6 | Maternal, Paternal | 216 caregivers (203 mothers, 9 fathers) | Observational | • Mothers bringing in children for child health supervision at a primary care clinic completed a screening questionnaire | Parent screening questionnaire (adapted from existing screen), BDI-II | • 12% of mothers met BDI-II cutoff value for clinically moderately depressed. |
| • Mothers then completed the computerized study protocol within 2 mo including parent screening questionnaire and depression measure | ||||||||||||
| • Different combinations of depression questions were evaluated against standard clinical cutoffs | ||||||||||||
| 2011 | Predictors of depressive symptoms in parents of chronically ill children admitted to the pediatric ICU | Fauman et al71 | USA | Not specified | Inpatient (intensive care) | 1.5–18 | Maternal, paternal | 61 parents (37 mothers, 24 fathers) | Observational | • Parents of chronically ill children admitted to a tertiary level PICU completed a background questionnaire and depression measure | BDI-II | • 45.9% of mothers and 16.7% of fathers met cutoff for mild depressive symptoms |
| • Parents with elevated symptoms and/or who requested referral for counseling were referred to a psychiatry intake line or supplied with information on community mental health programs | ||||||||||||
| 2012 | Maternal psychiatric morbidity and childhood malnutrition | Ejaz et al49 | Pakistan | Urban | Inpatient (general) | 0.25–3 | Maternal | 100 mothers | Observational | • 50 mothers of children with moderate and severe malnutrition and 50 mothers of control children of normal wt were screened using HADS | Hospital Anxiety and Depression Scale (HADS) | • HADS scores were significantly elevated (>21) in 50% of mothers of malnourished children vs 46% of controls (OR = 0.85 (95% CI −0.38 to −1.86) |
| 2012 | A randomized controlled trial of screening for maternal depression with a clinical decision support system | Carroll et al63 | USA | Urban | Outpatient (primary care) | 0–1.25 | Maternal | 3520 mothers | Experimental | • Mothers were randomized to 3 groups: (1) PSF completed by mother in the waiting room with physician alert for positive screen, (2) PSF with physician alert screens plus “just in time” (JIT) printed materials to aid physicians, and (3) control group where physicians were reminded to screen on printed worksheet | PHQ-2 | • More mothers were noted to have depressed mood in the PSF (OR 7.93, 95% CI 4.51 to 13.96) and JIT groups (OR 8.1, 95% CI 4.61 to 14.25) compared with control group |
| • More mothers had signs of anhedonia in the PSF (OR 12.58, 95% CI 5.03 to 31.46) and JIT groups (OR 13.03, 95% CI 5.21 to 32.54) compared with control group | ||||||||||||
| • Physicians referred mothers for assistance significantly more often in the PSF (2.4%) and JIT groups (2.4%) compared with the control group (1.2%) (OR 2.06, 95% CI 1.08 to 3.93) | ||||||||||||
| 2013 | Markers of maternal depressive symptoms in an urban pediatric clinic | Sia et al57 | USA | Urban | Outpatient (primary care) | 1–6 | Maternal | 917 mothers | Observational | • Case-control study of mothers screened for depressive symptoms at well child visits at an inner-city pediatric clinic• Mothers with depressive symptoms were compared with controls with no symptoms• Potential markers for maternal depressive symptoms were collected from child’s medical record and grouped by child health and development, child health care utilization, and maternal psychosocial factors• Patients of 3 primary care practices were screened for eligibility | Quick Inventory of Depressive Symptomatology Self-Rated Questionnaire (QIDS-SR) | • Among 917 screened, 23.3% scored in depressive range• Maternal depressive symptoms were significantly associated with reports of concerns or negative attributions about child’s behavior (AOR 2.35, P = .01) as well as concerns about speech (AOR 2.4, P = .04) and sleep (AOR: 7.75, P <.001)• Maternal depressive symptoms were associated with child emergency department visits• Maternal depressive symptoms were associated with a history of maternal depression (AOR 4.94, P = .001), prior social work referral (AOR 1.98, P = .01), and pediatric provider concerns for child abuse or neglect at previous visit |
| 2013 | Building healthy children: evidence-based home visitation integrated with pediatric medical homes | Paradis et al84 | USA | Not specified | Outpatient (primary care) | ≤2 | Maternal | 497 mothers | Experimental | • Families were randomized to treatment versus control groups | Not specified | • At baseline, 22% had significant depressive symptoms |
| • Treatment families received parents as teachers, child-parent psychotherapy, and interpersonal psychotherapy as needed | ||||||||||||
| • Control families received referral to community services only | ||||||||||||
| • All families were evaluated at baseline and at 12, 24, 36, and 48 mo | ||||||||||||
| 2014 | Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiologic Study across 9 countries | Quittner, et al53 | Belgium, Germany, Italy, Spain, Sweden, Netherlands, Turkey, UK, USA | Not specified | Outpatient (subspecialty) | 0–18 | Maternal, paternal | 4102 parents (3127 mothers, 975 fathers) | Observational | • Patients with CF aged >12 and caregivers of children with CF aged 0–18 at 154 centers in 9 countries completed depression and anxiety screens, | HADS, CES-D | • Symptoms of depression were found in 37% of mothers and 31% of fathers |
| • Psychological symptoms were compared across countries | • Elevated anxiety was found in 48% of mothers and 36% of fathers | |||||||||||
| 2015 | Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial | Fernandez y Garcia, et al72 | USA | Urban, suburban, and rural | Outpatient (primary care) | 0–12 | Maternal | 104 mothers | Experimental | • Mothers with positive depression screens presenting for well-child checks received interventions from research assistant | 2-item depression screen (see Dubowitz et al 2007) | • More mothers in intervention group tried to contact a resource (73.8% vs 53.5%) (95% CI, 0.1% to 38.5%, P = .052) |
| • Intervention included office-based written and verbal depression education, motivational messages encouraging further assessment, and a telephone booster 2 d later | ||||||||||||
| • Measured proportion of mothers in each group who reported trying to contact any resources to discuss the positive screen by 2 wk postintervention | ||||||||||||
| 2015 | Depression and burden among caregivers of children with autism spectrum disorder | Lerthattasilp et al55 | Thailand | Not specified | Outpatient (primary care) | 0–15 | Maternal, paternal relatives | 51 caregivers (35 mother, 10 father, 5 relative) | Observational | • Questionnaire administered to caregivers to assess caregiver depression and burden | CES-D, Thai version | • The prevalence of depression among caregivers was 5.9%, |
| • Assessment of patient's diagnosis obtained from psychiatrists and pediatricians | • 45.1% reported little or no caregiver burden, 45.1% reported mild to moderate burden, 7.8% moderate to severe burden, 2.0% severe burden, • significant positive correlation between caregiver depression and caregiver burden (P = .012) | |||||||||||
| 2016 | Quality of life and psychological screening in children with type 1 diabetes and their mothers | Duru et al50 | Turkey | Not specified | Outpatient (subspecialty) | 8–7 | Maternal | 60 mothers | Observational | • 30 children with type 1 diabetes and 30 controls completed measures of depressive symptoms | State-trait anxiety inventory (STAI), BDI | • Mean BDI score was higher among mothers of children with diabetes compared with controls (P = .004) |
| • 30 mothers of children with diabetes and 30 controls completed measures of depression, anxiety, and health-related quality of life | • Child depression scores of children with type 1 diabetes were positively correlated with the BDI scores of their mothers (P < .001) | |||||||||||
| 2017 | Maternal diabetes distress is linked to maternal depressive symptoms and adolescents' glycemic control | Rumburg et al51 | USA | Not specified | Outpatient (subspecialty) | 10–16 | Maternal | 81 mothers | Observational | • Mothers of youth diagnosed with type 1 diabetes were recruited from a diabetes clinic, • research staff administered screening questionnaire before child’s clinic visit | Patient Health Questionnaire-9 (PHQ-9) | • 49% were above clinical cutoff for mild depressive symptoms, • 25% were above cutoff for moderate depressive symptoms, • diabetes distress strongly related to depressive symptoms (P < .001) |
| 2017 | Psychosocial functioning in pediatric heart transplant recipients and their families | Cousino et al87 | USA | Not specified | Outpatient (subspecialty) | 0–22 | Maternal, paternal, other | 56 parents and guardians (41 mothers, 10 fathers, 1 other, 4 did not respond) | Observational | • Medical assistants administered paper screening tool to parents or guardian of pediatric heart transplants at clinic visit | Psychosocial assessment tool (PAT) | • Few parents or guardians (2%) endorsed clinically significant family problems such as parental depression, anxiety, substance use, or relational problems, but 9% of respondents reported high levels of caregiver stress, |
| • Tool was provided to pediatric transplant behavioral health clinician who used them to guide conversation with family | • PAT score was not associated with demographic or health-related factors | |||||||||||
| • The screening tool was scored to determine psychosocial risk and the associations between risk and demographic, and health-related variables | ||||||||||||
| 2018 | Prevalence of depression among fathers at the pediatric well-child care visit | Cheng et al73 | USA | Not specified | Outpatient (primary care) | <1.25 | Paternal | 806 fathers | Observational | • A computer-based decision support system, was used to administer a patient-tailored, 20-item prescreening form on a tablet to parents in clinic waiting room | Modified 3-item version of the EPDS | • Among fathers who answered the prescreening form, 4.4% screened positive |
| • Data were merged with child’s medical record data to create physician worksheet with 6 prompts designed to call pediatrician’s attention to the child’s specific health risks | ||||||||||||
| 2018 | Health-related quality of life, anxiety, depression and distress of mothers and fathers of children on home parenteral nutrition | van Oers et al88 | Netherlands | Not specified | Outpatient (subspecialty) | 0–18 | Maternal, paternal | 62 parents (37 mothers, 25 fathers) | Observational | • Parents with children receiving HPN for ≥3 mo were invited by letter to register on web site | HADS | • 14.7% of mothers and 16.7% of fathers scored in the clinical range for depression |
| • Parents and children completed surveys 1 wk before outpatient consult with clinician | ||||||||||||
| • Answers were discussed during the consultation | ||||||||||||
| 2020 | Evaluation of the psychological status of mothers of children with cystic fibrosis and the relationship between children's clinical status | Unal Yuksekgonu, et al48 | Turkey | Not specified | Outpatient (subspecialty) | 5–23 | Maternal | 36 mothers | Observational | • Patients with cystic fibrosis and primary care givers were recruited from pulmonary clinic to assess psychosocial status of care givers and its relationship with child clinical scores | BDI | • Depression was present in 69.4% of mothers, severity was correlated with poor child clinical status, • increased depression was associated with negative attitudes toward child-rearing (P <.05) |
| 2020 | Long-term trajectories of depression symptoms in mothers of children with cancer | Howard Sharp et al 89 | USA | Not specified | Outpatient (subspecialty) and in-patient | 5–17 | Maternal | 327 mothers | Observational | • Families were approached at either outpatient oncology clinic or inpatient hospital units | BDI-II | • Three trajectories were identified across 5-y study period: “low depression symptoms” (63.3%), “moderate depression symptoms” (31.5%), and “high depression symptoms” (5.2%) |
| • Mothers completed questionnaires in the hospital or at home after diagnosis or relapse and at 1 y, 3 y, and 5 y after enrollment | ||||||||||||
| 2020 | Health-related quality of life and emotional distress among mothers of sons with muscular dystrophy as compared with sex- and age group-matched controls | Jackson et al 90 | USA | Not specified | Outpatient (subspecialty) | Not specified | Maternal | 108 mothers | Observational | • 82 mothers of sons with Duchenne or Becker muscular dystrophies and 26 sex- and age group–matched controls completed self-report measures | HADS | • Elevated symptoms of anxiety were reported by 39% of mothers who had sons with Duchenne or Becker muscular dystrophies compared with 19% among controls |
| • Elevated depressive symptoms were reported by 7% of mothers who had sons with Duchenne or Becker muscular dystrophies compared with none among controls | ||||||||||||
| 2020 | Depression as a predictor of hypoglycemia worry in parents of youth with recent-onset type 1 diabetes | McConville et al56 | USA | Not specified | Outpatient (subspecialty) | 5–9 | Maternal, others not specified | 107 parents (94 mothers) | Observational | • Families of children with recent onset type 1 diabetes were enrolled and completed assessments at baseline, 6 mo, 12 mo, and 18 mo | CES-D | • 25.6% parents met cutoff for depressive symptoms |
| • Multilevel modeling was used to examine 18-mo trajectories of hypoglycemia worry and examine if parental depression modified trajectory | • Parents with elevated depressive symptoms reported higher levels of worry compared with those without (P < .05) | |||||||||||
| 2020 | Psychosocial screening and mental health in pediatric cancer: A randomized controlled trial | Barrera et al 91 | Canada | Urban and Rural | Outpatient (subspecialty) | 8–16 | Maternal, paternal | 122 caregivers (98 female, 24 male) | Experimental | • Caregivers completed the Psychosocial Assessment Tool (PAT) and Hospital Anxiety and Depression Scale (HADS) 2–4 wk after child's cancer diagnosis and were randomized into either intervention (clinical care team received PAT results) or control group | HADS | • No significant difference was found in caregiver depression symptoms between the intervention and control groups at 6 mo overall, |
| • Caregivers completed HADS and PAT 6 mo later | • At 6 mo, caregivers in the intervention group showed improvement in depression scores compared with the control group when their psychosocial risk was high near diagnosis | |||||||||||
| 2020 | Rates of depression and anxiety in Italian patients with cystic fibrosis and parent caregivers: implementation of the mental health guidelines | Graziano et al92 | Italy | Not specified | Outpatient (subspecialty) | 0–17 | Maternal, paternal | 186 caregivers (117 mothers, 69 fathers) | Observational | • Caregivers of children diagnosed with CF were approached, consecutively, during routine clinic visits | PHQ-9, GAD-7 questionnaire | • Elevated symptoms of depression were found in 61% of mothers (N = 72), and 49% of fathers (N = 34) |
| • Participants completed the screening tools by paper and pencil via self-report | • 7% of mothers and no fathers endorsed suicidal ideation | |||||||||||
| • Psychologist scored and interpreted the results | ||||||||||||
| • Elevated scores were addressed systematically, and supportive interventions and referrals were provided, if necessary, according to the guidelines | ||||||||||||
| 2021 | From planning to implementation: creating and adapting universal screening protocols to address caregiver mental health and psychosocial complexity | Buchholz et al 93 | USA | Not specified | Outpatient (primary care) | Not specified | Maternal | 14660 mothers | Observational | • A screening process was developed for 3 primary care clinics within 1 hospital system | Internally developed 14-question screen | • Child health clinic: 6.1% screened positive in the psychosocial adversity section of screener (includes caregiver mental health concerns) |
| • Screening workflows were developed and included processes for medical providers to review and discuss screening results with families, determine how and when to access the IBH) team during a family’s visit, and documentation of screening results and recommendations | • Young mother’s clinic: 8.7% screened positive in the psychosocial adversity section | |||||||||||
| • 4 main intervention strategies were implemented across all 3 clinics to address caregiver needs identified through screening | • Special care clinic:13.1% endorsed items in the psychosocial adversity section | |||||||||||
| • Early childhood behavioral health via healthy steps; behavioral health consultation in addition to connecting the family with community mental health resources, short term behavioral health therapy sessions, and care coordination | • Child health and special care clinics: elevated or positive caregiver screenings yielded increased IBH intervention when compared with screenings that were not elevated or positive | |||||||||||
| • Caregivers were referred to community mental health 245 times in the child health clinic and 44 times in the special care clinic) | ||||||||||||
| 2021 | Developmental and behavioral problems of preschool-age children with chronic rheumatic diseases | Yoldas et al94 | Turkey | Not specified | Outpatient (subspecialty and primary care) | 1.5–5.9 | Maternal | 91 mothers | Observational | • 46 children with a diagnosis of FMF or JIA were included in the case group | State-trait anxiety inventory (STAI), BDI | • Maternal anxiety scores were associated with internalizing (P = .002) and total problems (P = .003) in children with FMF |
| • Comparison group included 45 participants recruited from general pediatric outpatient clinics for well-child visits | ||||||||||||
| 2021 | Communicative environmental factors including maternal depression and media usage patterns on early language development | Yoldas and Ozmert et al95 | Turkey | Not specified | Outpatient (subspecialty and primary care) | 1–3.5 | Maternal | 101 mothers | Observational | • 51 children with a diagnosis of language delay were included in the case group | BDI | • Maternal depression scores, duration of TV viewing, background TV were higher in the children with language delay compared with control group (P < .05) |
| • Comparison group included 59 children with typical development | • The total amount of screen viewing (mean 4.1 h) and duration of TV viewing (mean 2.9 h) were higher among children with mothers whose depressive symptoms were above the cut-off (P = .015 and P = .018, respectively) | |||||||||||
| • Developmental pediatrician evaluated general and language development of all children • Maternal depressive symptoms, media usage, and other risk factors were assessed | • Mothers with depressive symptoms under the cut-off also preferred screen for educational purposes and entertainment, mothers with depressive symptoms above the cut-off mostly aimed to keep their child occupied (57.1% vs 21.2%) (P = .011) | |||||||||||
| • Maternal depressive symptoms, media usage, and other risk factors were assessed | ||||||||||||
| 2021 | Prevalence of depression and anxiety among mothers of children with neuro-developmental disorders at a tertiary care center, Puducherry | Fatima et al96 | India | Not specified | Outpatient (tertiary-care center) | Range not specified, mean 6.9 | Maternal | 120 mothers | Observational | • Mothers of children with selected neuro-developmental disorder (epilepsy, cerebral palsy, intellectual disability, attention deficit hyperactivity disorder, and autism spectrum disorder) attending follow-up clinics for their children were evaluated for depression and anxiety through 2 questionnaires | PHQ-9, Generalized Anxiety Disorder-7 (GAD-7) questionnaire, MINI International Neuropsychiatric Inventory | • 52 mothers were screened positive for depression and 46 (37.5%, 95% CI 29.2–46.4) met diagnostic criteria on the MINI International neuropsychiatric inventory |
| • Those with screens above the cut off were then evaluated with the MINI International Neuropsychiatric Inventory to confirm diagnosis of depression and anxiety | • 91 mothers were screened positive for anxiety and 52 (43.3%, 95% CI 34.7–52.3) met diagnostic criteria on the MINI International Neuropsychiatric Inventory | |||||||||||
| 2021 | Social needs screening during the COVID-19 pandemic | Mayo et al97 | USA | Not specified | Outpatient (general) | 0–21 | Not specified | 328 caregivers | Observational | • Callers collected data from their telephone conversations with families while using the screening tool | Adapted from the Safe Environment for Every Kid (SEEK) Parent Questionnaire-R (PQ-R) | • 53% of the patients' guardians answered the screener's phone calls |
| • Resident physician and medical student volunteers performing phone screening completed a 1-h training session | • Depression symptoms were identified in 18% of those screened | |||||||||||
| • At the time of phone screening, applicable resources were provided to families over the phone | • 81% of caregivers identified with depression symptoms, identified this as a new need during COVID | |||||||||||
| 2021 | Systematic depression and anxiety screening for patients and caregivers: implementation and process improvement in a cystic fibrosis clinic | Goetz et al81 | USA | Not specified | Outpatient (subspecialty) | Not specified | Not specified | Not specified | Experimental | • Year 2 of project: all caregivers of children with CF <18 were screened at the same time as patient screening, | PHQ-2, PHQ-9, GAD-7 | • Year 2: 2% of caregivers screening positive for symptoms of depression, |
| • The review of the caregiver screening was completed and referral for further evaluation outside of the CF clinic was recommended if PHQ-2 was positive, with a handout of resources provided to all caregivers with elevated screens on the back of the screening form | • Year 3: the PHQ-9 was more frequently positive (18.6%) vs PHQ-2 (12%), suggesting the PHQ-9 was more sensitive | |||||||||||
| • Year 3: caregivers were randomized to receive either the PHQ-2 or PHQ-9 and were screened for anxiety | • Annual caregiver screening rates were >95%, screening caregivers for depression and anxiety was generally well accepted | |||||||||||
| • Year 4: all caregivers were screened with the PHQ-9 | • 56% agreed and 6% disagreed that the CF center should be responsible for caregiver depression assessment and treatment |
| Year | Title | Author (s) | Country | Geographic Setting | Clinical Setting | Child Age Range, y | Parental Focus | Sample Size (n Approximated Based on Reported Percentages) | Study Type | Approach | Screening Instrument (s) | Findings |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1985 | Behavioral deviance and maternal depressive symptoms in pediatric outpatients | Fitzgerald59 | UK | Urban | Outpatient (subspecialty) | 3–4, 7–11 | Maternal | 103 mothers | Observational | • Recruited mothers of 3–4 and 7–11 y-old medical and surgical outpatients,• Compared rates of depressive symptoms of mothers 3–4 y-old medical versus surgical outpatients and mothers of 7–11 y-old medical versus surgical outpatients | Wakefield self-assessment depression inventory | • 32% mothers of 7–11 y-old medical outpatients, 31% of 3–4 y-old medical outpatients, 17% of 7–11 y-old surgical outpatients, and 9% of 3–4 y-old surgical outpatients screened positive |
| 1992 | Screening for maternal depression in pediatric clinics | Kemper and Babonis65 | USA | Not specified | Outpatient (primary care) | 0–6 | Maternal | 667 mothers | Observational | • Recruited mothers of children attending routine health care visits at 5 pediatric practices (private, university, and military)• Two versions of a screening instrument for depressive symptoms were administered by medical students | 3-item and 8-item versions of the Rand screening instrument for depressive disorders | • 19% of mothers screened positive for depression, • mothers who screened positive were younger and had less education and lower monthly incomes,• Positive screens were more common in teaching clinics (20%) and military clinics (24%) than in private practices (12%), among single versus married mothers (32% vs 15%), among mothers of color versus White mothers (29% vs 16%), and among those with positive screening test results for drugs compared with those with negative results (45% vs 17%) (P <.01 for all comparisons) |
| 1992 | Self-administered questionnaire for structured psychosocial screening in pediatrics | Kemper82 | USA | Urban | Outpatient (primary care) | Not specified | Maternal | 114 mothers | Observational | • Parents completed questionnaires in waiting room containing screening instruments for substance abuse, depression, self-esteem, and social support, and questions about domestic violence, homelessness, and parental history of abuse, | 8-item Screening Instrument for Depression | • Maternal depression was identified in 16% of mothers who completed the questionnaire vs 4% identified by medical record, this difference between questionnaire and chart was statistically significant (P <.01) |
| • Compared medical records of children whose mothers completed questionnaires to sample of children whose mothers did not | ||||||||||||
| 1994 | Family psychosocial screening: should we focus on high-risk settings? | Kemper et al 66 | USA | Not specified | Outpatient (primary care) | 0–6 | Maternal | 1404 mothers | Observational | • Recruited mothers of children attending well child visits (758 in teaching clinic, 444 in private practice, and 202 at military clinic), | Rand corporation's screening instrument for depressive disorders | • Positive screens for maternal depression ranged from 12% to 35%, • psychosocial problems were common even at “low risk” clinics |
| • Clinic sites deemed “low,” “medium,” or “high” risk | ||||||||||||
| • Mothers at all sites completed a questionnaire that included information on mother's history of abuse or neglect, depressive symptoms, and history of drinking and drug use | ||||||||||||
| 1994 | Depressive symptoms and work role satisfaction in mothers of toddlers | Olson and DiBrigida67 | USA | Urban | Outpatient (primary care) | 1–2 | Maternal | 233 mothers | Observational | • Depression screening measures were completed by mothers attending health supervision visits at 2 community pediatric practices | 20-item depression screening instrument developed by Barrett, Oxman, and Gerber (modified hopkins symptom checklist) | • Depressive symptoms present in 42% of mothers (95% CI 39% to 45%) |
| • Rates of symptoms were similar across employment groups (P = NS) but 67% of mothers who were dissatisfied with their current work role had depressive symptoms compared with 35% of those who were satisfied (P <.001) | ||||||||||||
| • Mothers who were dissatisfied with employment status were 3.7×more likely to be depressed (95% CI interval 1.8 to 77, P = .0003) | ||||||||||||
| 1998 | Depressive symptoms in inner-city mothers of young children: who is at risk? | Heneghan et al60 | USA | Urban | Outpatient (primary care) | 0.5–3 | Maternal | 279 mothers | Observational | • English-speaking mothers of children presenting for well-child visits completed an interview and self-report checklist of mental health symptoms | Psychiatric symptom index (PSI) | • Mean PSI total score was 19, 39% scored ≥20, 18% scored ≥30 |
| • Anxiety and depression subscales were correlated with PSI total scores | ||||||||||||
| • PSI scores did not vary by age, race, birthplace, education, employment, marital status, or family composition | ||||||||||||
| • PSI scores were higher for mothers receiving public assistance (P <.05) and those with self-reported poor or fair financial status (P <.005) | ||||||||||||
| • Scores were higher among mothers who reported poor health status (P <.005), mothers with activity limitations due to illness had higher scores than those without (P <.005) | ||||||||||||
| 1998 | The scope of unmet maternal health needs in pediatric settings | Kahn et al64 | USA | Not specified | Outpatient (primary care) | 0–1.5 | Maternal | 559 mothers | Observational | • Women were screened by a research assistant in waiting room before child's appointment• 10–15 min survey was self-administered and completed in either waiting area or exam room | 3 questions from Rand screening instrument for depressive disorders | • 39.6% of women reported depressive symptoms (P < .001)• More than 90% of participants said they would welcome or not mind an offer to assist with appointment-making with an adult care provider if affected by 1 of the issues examined |
| 1999 | Impact of screening for maternal depression in a pediatric clinic: an exploratory study | Needleman et al61 | USA | Urban | Outpatient (primary care) | Not specified | Maternal | 73 mothers | Observational | • Mothers were referred to pediatric social workers who rated degree of depression clinically and administered a depression measure• Mothers were referred for mental health and assessment and treatment based on the social worker's clinical judgement and CES-D scores• Follow-up calls were made 1–6 mo later | Center for epidemiologic studies depression questionnaire (CES-D) | • 67% of mothers had significant depressive symptoms (CES-D ≥16) but only 29% of total sample were identified by social workers based on clinical assessment• 58% of high-scoring mothers showed at least minimal clinical depressive symptoms, 14% showed no symptoms• 59% (26 of 44) of referred mothers agreed to seek mental health assessment and treatment but only 11% (3 of 26) had attended recommended visit at follow up |
| 2000 | Do pediatricians recognize mothers with depressive symptoms? | Heneghan et al78 | USA | Urban | Outpatient (primary care) | 0.5–3 | Maternal | 214 mothers | Observational | • Mothers completed a depression screening tool and pediatric health care providers completed a questionnaire assessing mothers’ symptoms, each unaware of other’s responses | PSI | • Out of 214 mothers 86 (40%) scored ≥20 (high symptom level)• Of mothers who scored ≥20, 25 were identified by providers as being at risk (29%) |
| • Sensitivity, specificity, PPV, and NPV of provider identification of maternal symptoms was evaluated against depression measure | ||||||||||||
| 2004 | Rates of maternal depression in pediatric emergency department and relationship to child service utilization | Flynn et al 68 | USA | Not specified | Pediatric emergency department | 0–7 | Maternal | 176 mothers | Observational | • Approached women who brought a child to the pediatric emergency department for a visit that was not severe trauma or the highest level of acuity• Administered survey that included screening tools for alcohol use and depression and questions on child health and maternal depression treatment | CES-D, 3-item Rand screening instrument for depression | • 31% of mothers screened positive for depression risk, of whom 78% were not being treated• Elevated depression was correlated with missed pediatric outpatient visits (OR = 2.9, P <.05) and greater use of emergency services (OR = 3.2, P <.05)• Mothers with depressive symptoms were younger, had fewer years of education, and were more likely to be Medicaid recipients or uninsured• Mothers who screened positive were more likely to rate own health as worse and had higher risk for alcohol use |
| 2004 | Maternal distress, child behavior, and disclosure of psychosocial concerns to a pediatrician | Wildman et al 58 | USA | Urban | Outpatient (primary care) | 4–12 | Maternal | 138 female caregivers (biological mothers, foster mothers, and grandmothers) | Observational | • Research assistants approached mothers in the waiting room of a primary care clinic and mothers completed measures while waiting• After child’s visit with the pediatrician, mothers completed exit questionnaire | Beck Depression Inventory (BDI) | • Among 36 mothers (24.1%) with elevated scores (BDI ≥10), 58.3% were concerned about child’s behavior compared with 25.7% of mothers without elevated BDI scores• 10.6% of mothers without elevated BDI scores had children with elevated PSC scores vs 27.8% of mothers with elevated BDI scores |
| 2005 | Two approaches to maternal depression screening during well child visits | Olson et al77 | USA | Rural | Outpatient (primary care) | 0–16 | Maternal | 473 mothers | Experimental | • Clinicians screened mothers of children of all ages who were scheduled for the first 3 well child visits of the morning and the afternoon on randomly selected days over a 1-mo period• In first condition, pediatricians screened mothers via a scripted interview, in second condition, 223 mothers completed paper-based depression screening | Patient Health Questionnaire-2 (PHQ-2) | • Yield from paper-based screen was 22.9% vs 5.7% for interview• 7.6% of women screened with paper tool were referred to mental health vs 1.6% of those screened via interview• General pediatricians commented that mothers indicated that they appreciated the attention to their family |
| 2006 | Brief maternal depression screening at well-child visits | Olson et al76 | USA | Rural | Outpatient (primary care) | Not specified | Maternal | 1398 mothers | Observational | • 3 pediatric practices implemented screening for parental depression at every well-child visit for a 1-mo period,• After pilot phase, practices took part in a program to determine the feasibility of implementing screening and referral at all well-child visits for a longer 6-mo period | PHQ-2 | • 17% of mothers reported ≥1 depressive symptom and 6% scored as being at risk for depression• Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms• For most visits discussion time responding to screening was minimal |
| 2006 | Improving women's health during internatal periods: developing an evidenced-based approach to addressing maternal depression in pediatric settings | Feinberg et al62 | USA | Urban | Outpatient (primary care) | Not specified | Not specified | Not specified | Observational | • Screening program was developed that included (1) screening of all mothers at well-child visits, (2) assessment of additional symptoms, level of impairment, suicidality risk, and preference for follow-up, (3) education on depressive symptoms, their impact on parenting, and management strategies, and (4) referrals for follow-up care• Conducted 9 focus groups and 36 interviews of mothers, site-based health care providers, and community-based professionals to assess acceptability of program | PHQ-2, PRIME-MD, PHQ-9 | • Providers found PHQ-2 nonburdensome |
| • Women with low levels of symptoms often declined further intervention beyond routine follow up in the pediatric setting, | ||||||||||||
| • For more symptomatic women, follow up with the woman’s own primary care provider was often preferred• Reticence to access behavioral health services was related to stigma associated with a mental health condition• Mothers and professionals both expressed a need for education about symptoms of depression, self-management strategies, and community-based services | ||||||||||||
| 2007 | Screening for maternal depression in a low education population using a 2-item questionnaire | Cutler et al74 | USA | Urban | Outpatient (primary care) | 0.011–4.5 | Maternal | 94 mothers | Observational | • Recruited English and Spanish speaking mothers who brought children for a well-visit | PHQ-2, Edinburgh Postnatal Depression Scale (EPDS) | • Sensitivity of PHQ-2 for identifying a positive EPDS score was 43.5%, specificity 97.2% |
| • Mothers screening positive on either of 2 depression screens were referred to social worker for further assessment• Followed up with mothers who screened positive at 3 mo to see if further assessment had taken place | • 12.8% screened positive on PHQ-2 (95% CI 7.1% to 21.6%) compared with 24.5% on EPDS (95% CI 16.4% to 34.6%), 26.6% screened positive on ≥1 instrument (95% CI 18.3% to 36.9%)• Sensitivity of PHQ-2 was higher for mothers with education beyond high school (P = .02)• 22 of 25 women who screened positive accepted a referral for additional services• Among 22 who accepted a referral follow up was obtained for 15; 4 of whom reported that they had received services | |||||||||||
| 2007 | Screening for depression in an urban pediatric primary care clinic | Dubowitz et al69 | USA | Urban | Outpatient (primary care) | <6 | Maternal, Paternal | 216 caregivers (203 mothers, 9 fathers) | Observational | • Mothers bringing in children for child health supervision at a primary care clinic completed a screening questionnaire | Parent screening questionnaire (adapted from existing screen), BDI-II | • 12% of mothers met BDI-II cutoff value for clinically moderately depressed. |
| • Mothers then completed the computerized study protocol within 2 mo including parent screening questionnaire and depression measure | ||||||||||||
| • Different combinations of depression questions were evaluated against standard clinical cutoffs | ||||||||||||
| 2011 | Predictors of depressive symptoms in parents of chronically ill children admitted to the pediatric ICU | Fauman et al71 | USA | Not specified | Inpatient (intensive care) | 1.5–18 | Maternal, paternal | 61 parents (37 mothers, 24 fathers) | Observational | • Parents of chronically ill children admitted to a tertiary level PICU completed a background questionnaire and depression measure | BDI-II | • 45.9% of mothers and 16.7% of fathers met cutoff for mild depressive symptoms |
| • Parents with elevated symptoms and/or who requested referral for counseling were referred to a psychiatry intake line or supplied with information on community mental health programs | ||||||||||||
| 2012 | Maternal psychiatric morbidity and childhood malnutrition | Ejaz et al49 | Pakistan | Urban | Inpatient (general) | 0.25–3 | Maternal | 100 mothers | Observational | • 50 mothers of children with moderate and severe malnutrition and 50 mothers of control children of normal wt were screened using HADS | Hospital Anxiety and Depression Scale (HADS) | • HADS scores were significantly elevated (>21) in 50% of mothers of malnourished children vs 46% of controls (OR = 0.85 (95% CI −0.38 to −1.86) |
| 2012 | A randomized controlled trial of screening for maternal depression with a clinical decision support system | Carroll et al63 | USA | Urban | Outpatient (primary care) | 0–1.25 | Maternal | 3520 mothers | Experimental | • Mothers were randomized to 3 groups: (1) PSF completed by mother in the waiting room with physician alert for positive screen, (2) PSF with physician alert screens plus “just in time” (JIT) printed materials to aid physicians, and (3) control group where physicians were reminded to screen on printed worksheet | PHQ-2 | • More mothers were noted to have depressed mood in the PSF (OR 7.93, 95% CI 4.51 to 13.96) and JIT groups (OR 8.1, 95% CI 4.61 to 14.25) compared with control group |
| • More mothers had signs of anhedonia in the PSF (OR 12.58, 95% CI 5.03 to 31.46) and JIT groups (OR 13.03, 95% CI 5.21 to 32.54) compared with control group | ||||||||||||
| • Physicians referred mothers for assistance significantly more often in the PSF (2.4%) and JIT groups (2.4%) compared with the control group (1.2%) (OR 2.06, 95% CI 1.08 to 3.93) | ||||||||||||
| 2013 | Markers of maternal depressive symptoms in an urban pediatric clinic | Sia et al57 | USA | Urban | Outpatient (primary care) | 1–6 | Maternal | 917 mothers | Observational | • Case-control study of mothers screened for depressive symptoms at well child visits at an inner-city pediatric clinic• Mothers with depressive symptoms were compared with controls with no symptoms• Potential markers for maternal depressive symptoms were collected from child’s medical record and grouped by child health and development, child health care utilization, and maternal psychosocial factors• Patients of 3 primary care practices were screened for eligibility | Quick Inventory of Depressive Symptomatology Self-Rated Questionnaire (QIDS-SR) | • Among 917 screened, 23.3% scored in depressive range• Maternal depressive symptoms were significantly associated with reports of concerns or negative attributions about child’s behavior (AOR 2.35, P = .01) as well as concerns about speech (AOR 2.4, P = .04) and sleep (AOR: 7.75, P <.001)• Maternal depressive symptoms were associated with child emergency department visits• Maternal depressive symptoms were associated with a history of maternal depression (AOR 4.94, P = .001), prior social work referral (AOR 1.98, P = .01), and pediatric provider concerns for child abuse or neglect at previous visit |
| 2013 | Building healthy children: evidence-based home visitation integrated with pediatric medical homes | Paradis et al84 | USA | Not specified | Outpatient (primary care) | ≤2 | Maternal | 497 mothers | Experimental | • Families were randomized to treatment versus control groups | Not specified | • At baseline, 22% had significant depressive symptoms |
| • Treatment families received parents as teachers, child-parent psychotherapy, and interpersonal psychotherapy as needed | ||||||||||||
| • Control families received referral to community services only | ||||||||||||
| • All families were evaluated at baseline and at 12, 24, 36, and 48 mo | ||||||||||||
| 2014 | Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiologic Study across 9 countries | Quittner, et al53 | Belgium, Germany, Italy, Spain, Sweden, Netherlands, Turkey, UK, USA | Not specified | Outpatient (subspecialty) | 0–18 | Maternal, paternal | 4102 parents (3127 mothers, 975 fathers) | Observational | • Patients with CF aged >12 and caregivers of children with CF aged 0–18 at 154 centers in 9 countries completed depression and anxiety screens, | HADS, CES-D | • Symptoms of depression were found in 37% of mothers and 31% of fathers |
| • Psychological symptoms were compared across countries | • Elevated anxiety was found in 48% of mothers and 36% of fathers | |||||||||||
| 2015 | Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial | Fernandez y Garcia, et al72 | USA | Urban, suburban, and rural | Outpatient (primary care) | 0–12 | Maternal | 104 mothers | Experimental | • Mothers with positive depression screens presenting for well-child checks received interventions from research assistant | 2-item depression screen (see Dubowitz et al 2007) | • More mothers in intervention group tried to contact a resource (73.8% vs 53.5%) (95% CI, 0.1% to 38.5%, P = .052) |
| • Intervention included office-based written and verbal depression education, motivational messages encouraging further assessment, and a telephone booster 2 d later | ||||||||||||
| • Measured proportion of mothers in each group who reported trying to contact any resources to discuss the positive screen by 2 wk postintervention | ||||||||||||
| 2015 | Depression and burden among caregivers of children with autism spectrum disorder | Lerthattasilp et al55 | Thailand | Not specified | Outpatient (primary care) | 0–15 | Maternal, paternal relatives | 51 caregivers (35 mother, 10 father, 5 relative) | Observational | • Questionnaire administered to caregivers to assess caregiver depression and burden | CES-D, Thai version | • The prevalence of depression among caregivers was 5.9%, |
| • Assessment of patient's diagnosis obtained from psychiatrists and pediatricians | • 45.1% reported little or no caregiver burden, 45.1% reported mild to moderate burden, 7.8% moderate to severe burden, 2.0% severe burden, • significant positive correlation between caregiver depression and caregiver burden (P = .012) | |||||||||||
| 2016 | Quality of life and psychological screening in children with type 1 diabetes and their mothers | Duru et al50 | Turkey | Not specified | Outpatient (subspecialty) | 8–7 | Maternal | 60 mothers | Observational | • 30 children with type 1 diabetes and 30 controls completed measures of depressive symptoms | State-trait anxiety inventory (STAI), BDI | • Mean BDI score was higher among mothers of children with diabetes compared with controls (P = .004) |
| • 30 mothers of children with diabetes and 30 controls completed measures of depression, anxiety, and health-related quality of life | • Child depression scores of children with type 1 diabetes were positively correlated with the BDI scores of their mothers (P < .001) | |||||||||||
| 2017 | Maternal diabetes distress is linked to maternal depressive symptoms and adolescents' glycemic control | Rumburg et al51 | USA | Not specified | Outpatient (subspecialty) | 10–16 | Maternal | 81 mothers | Observational | • Mothers of youth diagnosed with type 1 diabetes were recruited from a diabetes clinic, • research staff administered screening questionnaire before child’s clinic visit | Patient Health Questionnaire-9 (PHQ-9) | • 49% were above clinical cutoff for mild depressive symptoms, • 25% were above cutoff for moderate depressive symptoms, • diabetes distress strongly related to depressive symptoms (P < .001) |
| 2017 | Psychosocial functioning in pediatric heart transplant recipients and their families | Cousino et al87 | USA | Not specified | Outpatient (subspecialty) | 0–22 | Maternal, paternal, other | 56 parents and guardians (41 mothers, 10 fathers, 1 other, 4 did not respond) | Observational | • Medical assistants administered paper screening tool to parents or guardian of pediatric heart transplants at clinic visit | Psychosocial assessment tool (PAT) | • Few parents or guardians (2%) endorsed clinically significant family problems such as parental depression, anxiety, substance use, or relational problems, but 9% of respondents reported high levels of caregiver stress, |
| • Tool was provided to pediatric transplant behavioral health clinician who used them to guide conversation with family | • PAT score was not associated with demographic or health-related factors | |||||||||||
| • The screening tool was scored to determine psychosocial risk and the associations between risk and demographic, and health-related variables | ||||||||||||
| 2018 | Prevalence of depression among fathers at the pediatric well-child care visit | Cheng et al73 | USA | Not specified | Outpatient (primary care) | <1.25 | Paternal | 806 fathers | Observational | • A computer-based decision support system, was used to administer a patient-tailored, 20-item prescreening form on a tablet to parents in clinic waiting room | Modified 3-item version of the EPDS | • Among fathers who answered the prescreening form, 4.4% screened positive |
| • Data were merged with child’s medical record data to create physician worksheet with 6 prompts designed to call pediatrician’s attention to the child’s specific health risks | ||||||||||||
| 2018 | Health-related quality of life, anxiety, depression and distress of mothers and fathers of children on home parenteral nutrition | van Oers et al88 | Netherlands | Not specified | Outpatient (subspecialty) | 0–18 | Maternal, paternal | 62 parents (37 mothers, 25 fathers) | Observational | • Parents with children receiving HPN for ≥3 mo were invited by letter to register on web site | HADS | • 14.7% of mothers and 16.7% of fathers scored in the clinical range for depression |
| • Parents and children completed surveys 1 wk before outpatient consult with clinician | ||||||||||||
| • Answers were discussed during the consultation | ||||||||||||
| 2020 | Evaluation of the psychological status of mothers of children with cystic fibrosis and the relationship between children's clinical status | Unal Yuksekgonu, et al48 | Turkey | Not specified | Outpatient (subspecialty) | 5–23 | Maternal | 36 mothers | Observational | • Patients with cystic fibrosis and primary care givers were recruited from pulmonary clinic to assess psychosocial status of care givers and its relationship with child clinical scores | BDI | • Depression was present in 69.4% of mothers, severity was correlated with poor child clinical status, • increased depression was associated with negative attitudes toward child-rearing (P <.05) |
| 2020 | Long-term trajectories of depression symptoms in mothers of children with cancer | Howard Sharp et al 89 | USA | Not specified | Outpatient (subspecialty) and in-patient | 5–17 | Maternal | 327 mothers | Observational | • Families were approached at either outpatient oncology clinic or inpatient hospital units | BDI-II | • Three trajectories were identified across 5-y study period: “low depression symptoms” (63.3%), “moderate depression symptoms” (31.5%), and “high depression symptoms” (5.2%) |
| • Mothers completed questionnaires in the hospital or at home after diagnosis or relapse and at 1 y, 3 y, and 5 y after enrollment | ||||||||||||
| 2020 | Health-related quality of life and emotional distress among mothers of sons with muscular dystrophy as compared with sex- and age group-matched controls | Jackson et al 90 | USA | Not specified | Outpatient (subspecialty) | Not specified | Maternal | 108 mothers | Observational | • 82 mothers of sons with Duchenne or Becker muscular dystrophies and 26 sex- and age group–matched controls completed self-report measures | HADS | • Elevated symptoms of anxiety were reported by 39% of mothers who had sons with Duchenne or Becker muscular dystrophies compared with 19% among controls |
| • Elevated depressive symptoms were reported by 7% of mothers who had sons with Duchenne or Becker muscular dystrophies compared with none among controls | ||||||||||||
| 2020 | Depression as a predictor of hypoglycemia worry in parents of youth with recent-onset type 1 diabetes | McConville et al56 | USA | Not specified | Outpatient (subspecialty) | 5–9 | Maternal, others not specified | 107 parents (94 mothers) | Observational | • Families of children with recent onset type 1 diabetes were enrolled and completed assessments at baseline, 6 mo, 12 mo, and 18 mo | CES-D | • 25.6% parents met cutoff for depressive symptoms |
| • Multilevel modeling was used to examine 18-mo trajectories of hypoglycemia worry and examine if parental depression modified trajectory | • Parents with elevated depressive symptoms reported higher levels of worry compared with those without (P < .05) | |||||||||||
| 2020 | Psychosocial screening and mental health in pediatric cancer: A randomized controlled trial | Barrera et al 91 | Canada | Urban and Rural | Outpatient (subspecialty) | 8–16 | Maternal, paternal | 122 caregivers (98 female, 24 male) | Experimental | • Caregivers completed the Psychosocial Assessment Tool (PAT) and Hospital Anxiety and Depression Scale (HADS) 2–4 wk after child's cancer diagnosis and were randomized into either intervention (clinical care team received PAT results) or control group | HADS | • No significant difference was found in caregiver depression symptoms between the intervention and control groups at 6 mo overall, |
| • Caregivers completed HADS and PAT 6 mo later | • At 6 mo, caregivers in the intervention group showed improvement in depression scores compared with the control group when their psychosocial risk was high near diagnosis | |||||||||||
| 2020 | Rates of depression and anxiety in Italian patients with cystic fibrosis and parent caregivers: implementation of the mental health guidelines | Graziano et al92 | Italy | Not specified | Outpatient (subspecialty) | 0–17 | Maternal, paternal | 186 caregivers (117 mothers, 69 fathers) | Observational | • Caregivers of children diagnosed with CF were approached, consecutively, during routine clinic visits | PHQ-9, GAD-7 questionnaire | • Elevated symptoms of depression were found in 61% of mothers (N = 72), and 49% of fathers (N = 34) |
| • Participants completed the screening tools by paper and pencil via self-report | • 7% of mothers and no fathers endorsed suicidal ideation | |||||||||||
| • Psychologist scored and interpreted the results | ||||||||||||
| • Elevated scores were addressed systematically, and supportive interventions and referrals were provided, if necessary, according to the guidelines | ||||||||||||
| 2021 | From planning to implementation: creating and adapting universal screening protocols to address caregiver mental health and psychosocial complexity | Buchholz et al 93 | USA | Not specified | Outpatient (primary care) | Not specified | Maternal | 14660 mothers | Observational | • A screening process was developed for 3 primary care clinics within 1 hospital system | Internally developed 14-question screen | • Child health clinic: 6.1% screened positive in the psychosocial adversity section of screener (includes caregiver mental health concerns) |
| • Screening workflows were developed and included processes for medical providers to review and discuss screening results with families, determine how and when to access the IBH) team during a family’s visit, and documentation of screening results and recommendations | • Young mother’s clinic: 8.7% screened positive in the psychosocial adversity section | |||||||||||
| • 4 main intervention strategies were implemented across all 3 clinics to address caregiver needs identified through screening | • Special care clinic:13.1% endorsed items in the psychosocial adversity section | |||||||||||
| • Early childhood behavioral health via healthy steps; behavioral health consultation in addition to connecting the family with community mental health resources, short term behavioral health therapy sessions, and care coordination | • Child health and special care clinics: elevated or positive caregiver screenings yielded increased IBH intervention when compared with screenings that were not elevated or positive | |||||||||||
| • Caregivers were referred to community mental health 245 times in the child health clinic and 44 times in the special care clinic) | ||||||||||||
| 2021 | Developmental and behavioral problems of preschool-age children with chronic rheumatic diseases | Yoldas et al94 | Turkey | Not specified | Outpatient (subspecialty and primary care) | 1.5–5.9 | Maternal | 91 mothers | Observational | • 46 children with a diagnosis of FMF or JIA were included in the case group | State-trait anxiety inventory (STAI), BDI | • Maternal anxiety scores were associated with internalizing (P = .002) and total problems (P = .003) in children with FMF |
| • Comparison group included 45 participants recruited from general pediatric outpatient clinics for well-child visits | ||||||||||||
| 2021 | Communicative environmental factors including maternal depression and media usage patterns on early language development | Yoldas and Ozmert et al95 | Turkey | Not specified | Outpatient (subspecialty and primary care) | 1–3.5 | Maternal | 101 mothers | Observational | • 51 children with a diagnosis of language delay were included in the case group | BDI | • Maternal depression scores, duration of TV viewing, background TV were higher in the children with language delay compared with control group (P < .05) |
| • Comparison group included 59 children with typical development | • The total amount of screen viewing (mean 4.1 h) and duration of TV viewing (mean 2.9 h) were higher among children with mothers whose depressive symptoms were above the cut-off (P = .015 and P = .018, respectively) | |||||||||||
| • Developmental pediatrician evaluated general and language development of all children • Maternal depressive symptoms, media usage, and other risk factors were assessed | • Mothers with depressive symptoms under the cut-off also preferred screen for educational purposes and entertainment, mothers with depressive symptoms above the cut-off mostly aimed to keep their child occupied (57.1% vs 21.2%) (P = .011) | |||||||||||
| • Maternal depressive symptoms, media usage, and other risk factors were assessed | ||||||||||||
| 2021 | Prevalence of depression and anxiety among mothers of children with neuro-developmental disorders at a tertiary care center, Puducherry | Fatima et al96 | India | Not specified | Outpatient (tertiary-care center) | Range not specified, mean 6.9 | Maternal | 120 mothers | Observational | • Mothers of children with selected neuro-developmental disorder (epilepsy, cerebral palsy, intellectual disability, attention deficit hyperactivity disorder, and autism spectrum disorder) attending follow-up clinics for their children were evaluated for depression and anxiety through 2 questionnaires | PHQ-9, Generalized Anxiety Disorder-7 (GAD-7) questionnaire, MINI International Neuropsychiatric Inventory | • 52 mothers were screened positive for depression and 46 (37.5%, 95% CI 29.2–46.4) met diagnostic criteria on the MINI International neuropsychiatric inventory |
| • Those with screens above the cut off were then evaluated with the MINI International Neuropsychiatric Inventory to confirm diagnosis of depression and anxiety | • 91 mothers were screened positive for anxiety and 52 (43.3%, 95% CI 34.7–52.3) met diagnostic criteria on the MINI International Neuropsychiatric Inventory | |||||||||||
| 2021 | Social needs screening during the COVID-19 pandemic | Mayo et al97 | USA | Not specified | Outpatient (general) | 0–21 | Not specified | 328 caregivers | Observational | • Callers collected data from their telephone conversations with families while using the screening tool | Adapted from the Safe Environment for Every Kid (SEEK) Parent Questionnaire-R (PQ-R) | • 53% of the patients' guardians answered the screener's phone calls |
| • Resident physician and medical student volunteers performing phone screening completed a 1-h training session | • Depression symptoms were identified in 18% of those screened | |||||||||||
| • At the time of phone screening, applicable resources were provided to families over the phone | • 81% of caregivers identified with depression symptoms, identified this as a new need during COVID | |||||||||||
| 2021 | Systematic depression and anxiety screening for patients and caregivers: implementation and process improvement in a cystic fibrosis clinic | Goetz et al81 | USA | Not specified | Outpatient (subspecialty) | Not specified | Not specified | Not specified | Experimental | • Year 2 of project: all caregivers of children with CF <18 were screened at the same time as patient screening, | PHQ-2, PHQ-9, GAD-7 | • Year 2: 2% of caregivers screening positive for symptoms of depression, |
| • The review of the caregiver screening was completed and referral for further evaluation outside of the CF clinic was recommended if PHQ-2 was positive, with a handout of resources provided to all caregivers with elevated screens on the back of the screening form | • Year 3: the PHQ-9 was more frequently positive (18.6%) vs PHQ-2 (12%), suggesting the PHQ-9 was more sensitive | |||||||||||
| • Year 3: caregivers were randomized to receive either the PHQ-2 or PHQ-9 and were screened for anxiety | • Annual caregiver screening rates were >95%, screening caregivers for depression and anxiety was generally well accepted | |||||||||||
| • Year 4: all caregivers were screened with the PHQ-9 | • 56% agreed and 6% disagreed that the CF center should be responsible for caregiver depression assessment and treatment |
AOR, adjusted odds ratio; CI, confidence interval; CF, cystic fibrosis; FMF, familial Mediterranean fever; HPN, home parent nutrition; IBH, integrated behavioral health; JIA, juvenile idiopathic arthritis; JIT, just in time; OR, odds ratio; NPV, negative predictive value; NS, not specified; PPV, positive predictive value; PSC, Pediatric Symptom Checklist; PSF, prescreen form; ; UK, United Kingdom.
Results
Geographic and Clinical Setting
Forty-one studies were identified (Table 1), which included a total of over 32 744 parents and caregivers (2 studies did not specify sample size). Twenty-nine of the 41 studies (71%) were conducted in the United States, and the rest occurred elsewhere. Primary care was the most common clinical setting (21 of 41, 51%) with fewer studies conducted in outpatient subspecialty offices (12 of 41, 29%), both outpatient subspecialty and primary care settings (2 of 41, 5%), both outpatient subspecialty and inpatient settings (1 of 41, 2%), outpatient tertiary care centers (1 of 41, 2%), general outpatient settings (1 of 41, 2%), general inpatient settings (1 of 41, 2%), inpatient intensive care units (1 of 41, 2%), and emergency departments (1 of 41, 2%).
Participant Demographic Data
Mothers made up the majority of participating caregivers with 28 of 41 (68%) studies including mothers only. Eight of 41 studies (20%) enrolled both mothers and fathers and 1 of 41 (2%) enrolled fathers only. One study screened mothers and an unspecified caregiver, and 3 papers did not specify which caregivers were enrolled. Additional demographic data for each of the articles are summarized in Supplemental Table 4.
Study Designs
Among the included papers, observational designs were the most common (35 of 41, 85%), followed by experimental studies (6 of 41, 15%). A variety of measures were used to assess participant mood disorder symptoms with several studies using multiple tools (Table 1). The most commonly used tool was the Beck Depression Inventory (8 of 41, 20%).
Study Results
The included papers reported a mean of 25.5% of their study populations screening positive for depressive symptoms. The highest reported proportion was 69.4% among mothers of patients with cystic fibrosis in an outpatient pediatric pulmonology clinic in Turkey.48 Single motherhood and parental educational attainment of less than a high school level were associated with increased risk of depressive symptoms. Parental depression was found to be associated with both child behavioral and physical health outcomes, specifically child malnutrition, child anxiety and depression, and HbA1c among children with type 1 diabetes.4,49–54 Additionally, parental depression was associated with increased concern for and negative attribution of child behavior by parents as well as increased caregiver burden and worry among parents of children with neurodevelopmental and/or physical health concerns.51,55–58 Four of the 41 (10%) studies examined acceptability and all of these studies found that screening was acceptable to clinicians and/or caregivers.
Screening Models
Among the included studies, 26 of 41 (63%) were conducted with the purpose of assessing the prevalence of parental depressive symptoms in a particular population and/or correlating those symptoms with child health outcomes. Two of the 41 studies (5%) were designed to determine the psychometric characteristics (sensitivity and specificity) of a screening tool in a particular patient population. The remaining 13 of 41 (32%) described the development and implementation of a structured screening program. Ten of the 13 (77%) studies describing structured screening programs mentioned referring parents for services when they screened positive, but only 4 of 13 (31%) included a follow-up mechanism (Table 2). Overall, 5 of the 41 (12%) studies compared a standardized tool to clinician judgment, finding that screening programs using a standardized screening tool were more sensitive.
Follow-Up Models
| Year | Title | Author | Referral Process | Follow Up Mechanism | Follow Up Results |
|---|---|---|---|---|---|
| 1999 | Impact of screening for maternal depression in a pediatric clinic | Needleman et al98 | • Pediatric social workers rated mother's degree of depression clinically then administered the CES-D | • Follow-up calls were made 1–6 mo following referral to assess completion of referrals | • 26 of 44 mothers referred for mental health assessment and treatment accepted the referral (59%) |
| • Social workers then decided whether to refer mothers for further mental health assessment and treatment | • 3 of 26 of those who accepted referrals reported attending the recommended appointment on follow-up (12%) | ||||
| 2007 | Screening for maternal depression in a low education population using a 2 item questionnaire | Cutler et al74 | • Mothers who screened positive on either the PHQ-2 or EDPS were referred to a social worker for further assessment | • Research staff contacted mothers by phone 3 mo following referral to determine whether further assessment had taken place | • Of the 26.6% of mothers who screened positive on at least 1 screening instrument, 88% accepted a referral for further mental health assessment |
| • Researchers were able to reach 68.2% of referred mothers by phone at follow up of whom 26.7% reported that the recommended assessment had taken place | |||||
| 2013 | Building healthy children: evidence-based home visitation integrated with pediatric medical homes | Paradis et al84 | • Families in the treatment (BHC) group received behavioral health services provided by pediatric social workers and outreach workers at a series of home visits | • All enrolled families were evaluated at baseline and at 12, 24, 36, and 48-mo with measures of socioemotional and familial functioning, child development, and parent-child interaction | • 128 mothers in the BHC group who exhibited depressive symptoms were referred for IPT |
| • Mothers in the BHC group who screened positive for depressive symptoms were referred for interpersonal therapy (IPT) | • At follow-up, 60% of those referred for IPT were engaged in therapy, had achieved their treatment goals, and reported reduced depressive symptoms | ||||
| • Control families received referral to community services only | |||||
| 2015 | Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial | Fernandez y Garcia et al72 | • Mothers in the intervention group received office-based written and verbal targeted depression education and motivational messages encouraging further assessment as well as a semi structured telephone “booster” 2 d later | • Up to 6 attempts were made to contact mothers by telephone at 2 wk and 8 wk postintervention to determine how many mothers had attempted to contact 1 of the provided resources | • Despite 6 contact attempts, 10 intervention and 9 control mothers were lost to follow-up |
| • Mothers in the control group received nonspecific written and verbal messages with an attention control telephone survey 2 d later and both groups received a list of depression care resources | • 73.8% of mothers in the intervention group reported trying to contact 1 of the provided resources compared with 53.5% of control mothers |
| Year | Title | Author | Referral Process | Follow Up Mechanism | Follow Up Results |
|---|---|---|---|---|---|
| 1999 | Impact of screening for maternal depression in a pediatric clinic | Needleman et al98 | • Pediatric social workers rated mother's degree of depression clinically then administered the CES-D | • Follow-up calls were made 1–6 mo following referral to assess completion of referrals | • 26 of 44 mothers referred for mental health assessment and treatment accepted the referral (59%) |
| • Social workers then decided whether to refer mothers for further mental health assessment and treatment | • 3 of 26 of those who accepted referrals reported attending the recommended appointment on follow-up (12%) | ||||
| 2007 | Screening for maternal depression in a low education population using a 2 item questionnaire | Cutler et al74 | • Mothers who screened positive on either the PHQ-2 or EDPS were referred to a social worker for further assessment | • Research staff contacted mothers by phone 3 mo following referral to determine whether further assessment had taken place | • Of the 26.6% of mothers who screened positive on at least 1 screening instrument, 88% accepted a referral for further mental health assessment |
| • Researchers were able to reach 68.2% of referred mothers by phone at follow up of whom 26.7% reported that the recommended assessment had taken place | |||||
| 2013 | Building healthy children: evidence-based home visitation integrated with pediatric medical homes | Paradis et al84 | • Families in the treatment (BHC) group received behavioral health services provided by pediatric social workers and outreach workers at a series of home visits | • All enrolled families were evaluated at baseline and at 12, 24, 36, and 48-mo with measures of socioemotional and familial functioning, child development, and parent-child interaction | • 128 mothers in the BHC group who exhibited depressive symptoms were referred for IPT |
| • Mothers in the BHC group who screened positive for depressive symptoms were referred for interpersonal therapy (IPT) | • At follow-up, 60% of those referred for IPT were engaged in therapy, had achieved their treatment goals, and reported reduced depressive symptoms | ||||
| • Control families received referral to community services only | |||||
| 2015 | Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial | Fernandez y Garcia et al72 | • Mothers in the intervention group received office-based written and verbal targeted depression education and motivational messages encouraging further assessment as well as a semi structured telephone “booster” 2 d later | • Up to 6 attempts were made to contact mothers by telephone at 2 wk and 8 wk postintervention to determine how many mothers had attempted to contact 1 of the provided resources | • Despite 6 contact attempts, 10 intervention and 9 control mothers were lost to follow-up |
| • Mothers in the control group received nonspecific written and verbal messages with an attention control telephone survey 2 d later and both groups received a list of depression care resources | • 73.8% of mothers in the intervention group reported trying to contact 1 of the provided resources compared with 53.5% of control mothers |
BHC, building healthy children; CES-D, Center for Epidemiologic Studies Depression questionnaire; EDPS, Edinburgh Postnatal Depression Scale; IPT, interpersonal therapy; PHQ-2, patient health questionnaire 2.
Discussion
Parental depression is highly prevalent and significantly impacts the health and wellbeing of both parents and children. In this review, we have identified multiple gaps in the existing literature that have implications for pediatric practice and future research. First, although many parents screened positive for depressive symptoms across all settings and sociodemographic groups in the samples included in this review, structured screening programs outside of the postpartum period in pediatric settings were rare, especially for fathers. Second, although screening for parental depression was accomplished in an acceptable manner, appropriate referral and follow-up of positive screens poses a major challenge, warranting further investigation.
The majority of included papers found high proportions of positive parental depression screens across all pediatric patient populations, including outpatient primary care, inpatient, and subspecialty settings.4,48,50–54,56,57,59–73 Numerous papers advocated for expanding screening for parental depression from the primary care setting, as currently practiced, to a wider range of pediatric clinical settings.4,48,52,57,59,68 Whereas certain demographic variables were associated with an increased risk of parental depression (namely single motherhood and parental educational attainment of less than a high school level), demographic factors in general were poor predictors of risk. Therefore, screening programs based solely on perceived risk have the potential to miss affected parents.60,65–68,70,74,75
Despite the potential negative impacts of parental depression on children and the emphasis placed by numerous papers on the need for increased screening programs, the studies identified in this review make clear that more work is needed. First, most screening programs occurred in primary care and involved children <5 years old. Fewer studies involved subspecialty, inpatient, or emergency department settings, which may provide important opportunities for detection. Given that some families use the emergency department frequently and some families, particularly those of children with complex medical needs, may be seen by subspecialists more frequently than by primary care professionals, expanding screening beyond primary care has the potential to reach families who would not otherwise be screened. Second, among the studies included in this review, the majority only screened mothers with a much smaller number including mothers and fathers, and only 1 paper focused on fathers.73
Numerous studies included in this review have shown that screening for parental depression can be accomplished in the pediatric health care setting.48,52,53,56,59–66,69–71,73,74,76–78 Bright Futures recommends well visits at least annually beyond the child’s first year of life and this regular contact with parents offers a unique opportunity to build on established parent-clinician relationships to address parental depression. Pediatric clinicians acknowledge the importance of screening for parental depression,40,41 yet they often feel uncomfortable screening and only a minority conduct screening.41,64,79–80 One concern has been the acceptability of depression screening in the pediatric setting. However, the screening interventions were found to be acceptable in the included studies that assessed acceptablity.62,64,77,81 Although there was no single agreed upon screening tool,63,74,77 studies consistently found that standardized tools were more sensitive than solely clinical judgement.63,78,82 Health care organizations and clinicians are increasingly expanding efforts to screen for social determinants of health, including focused efforts on identifying adverse childhood experiences.83 Although such screening tools capture information on parental behavioral health concerns, many commonly used tools do not use validated depression screens. Future work should examine to what extent incorporating validated parental depression screening tools into these efforts could identify additional families in need of support.
A major limitation to screening programs, acknowledged by multiple included studies, is the lack of follow up of positive depression screens. Even among programs with follow through mechanisms in place, many parents who screened positive were lost to follow up.61,62,72,84 The potential harms of screening related to potentially sensitive or stigmatizing topics, such as social determinants in the pediatric setting, have been highlighted by Garg et al, who recommend that screening programs adhere to several key tenets. Namely, screening programs should be population wide, patient- and family-centered, and strengths-focused, and conducted within a comprehensive system that provides linkage to community-based resources.85 Given the sensitivity of disclosure of mental health concerns, parental mental health screening programs should ideally aspire to similar tenets, including robust follow up and linkage to services. However, as indicated by many of the papers included in this study, that goal has been difficult to achieve and follow up remains an important area of further research and innovation. In obstetric and family practice settings, interventions that address patient, clinician, and practice-level barriers through provision of patient resources, clinician education onsite assessments, and access to mental health consultations for clinicians, have been the most successful in ensuring women who screen positive for depressive symptoms in the perinatal period are connected to behavioral health care.86 Lessons derived from these specialties may serve as a helpful starting place for developing follow up protocols for use in pediatric settings.
There are certain limitations to this study. This review was limited to English-language papers only and therefore does not encompass findings that have been published in the non-English literature. Since we focused on parental depression outside of the postpartum period, our findings do not reflect the current state of the literature relating to postpartum depression. Similarly, this paper does not address other forms of parental psychiatric morbidity. Although we used a comprehensive search strategy guided by a medical research librarian, we cannot exclude the possibility that relevant articles may have been missed; this may be especially true when parental depression screening is embedded in broader psychosocial screening efforts.
Conclusions
This scoping review reveals that the current literature clearly documents the high number of parents who screen positive outside of the immediate postpartum period as well as its impact on the wellbeing of parents and children. It identifies several knowledge gaps, specifically that structured screening programs in pediatric settings outside the postpartum period are rare, especially for fathers, and that appropriate referral and follow-up of positive screens is a major challenge. These findings suggest that increased screening for parental depression across a wider age range and in a broader array of clinical settings has the potential to identify families in need of resources. The findings also suggest that additional research is required to assess the best practices for referral and follow-up of parents who screen positive for depressive symptoms to ensure they receive the support they need.
Dr Hunt contributed to the conceptualization and design of the search strategy, screened articles during the literature review process, constructed the initial data extraction table, and drafted the initial manuscript; Ms Uthirasamy screened articles during the literature review process, constructed the initial data extraction table, and drafted the initial manuscript; Dr Porter contributed to the conceptualization and design of the search strategy, screened articles during the literature review process, and critically revised the data extraction table and manuscript; Dr Jimenez contributed to the conceptualization and design of the search strategy, screened articles during the literature review process, and critically revised the data extraction table and manuscript; and all authors approved the manuscript as submitted.
FUNDING: This work was supported by the National Center for Advancing Translational Sciences, a component of the National Institutes of Health under award number UL1TR003017; the US Department of Health and Human Services and Health Resources and Service Administration (HRSA) under award number U3DMD32755; and the Robert Wood Johnson Foundation through its support of the Child Health Institute of New Jersey under grant number 74260. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Health Resources and Service Administration, or the Robert Wood Johnson Foundation. Funded by the National Institutes of Health (NIH).
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.
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