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PROSPECTIVE FATHERS’ ADVERSE CHILDHOOD EXPERIENCES, PREGNANCY-RELATED ANXIETY, AND DEPRESSION DURING PREGNANCY THOMAS SKJOTHAUG
University of Oslo; National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway; and BUP-vest Diakonhjemmet hospital LARS SMITH
University of Oslo and National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway TORE WENTZEL-LARSEN
National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway; and Norwegian Centre for Violence and Traumatic Stress Studies VIBEKE MOE
University of Oslo and National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway There is a growing knowledge of the predictors of depressive or anxious feelings during pregnancy among prospective fathers, and the present study investigates how paternal adverse childhood experiences relate to anxious and depressive feelings during pregnancy. Participants were recruited to “The Little in Norway Study (LIN-study)” (2010) at different well-baby clinics in Norway; 976 fathers consented to participate in the study, of which 881 had valid data for adverse childhood experiences. The study reports on the relationship between the Adverse Childhood Experience Scale (ACE Scale; R.F. Anda, A. Butchart, V.J. Felitti, & D.W. Brown, 2010) and depressive feelings, using the Edinburgh Postnatal Depression Scale (EPDS; M. Eberhard-Gran & K. Slinning, 2007), and pregnancy-related anxiety, using the Pregancy-Related Anxiety Scale-Revised (PRAQ-R; A.C. Huizink, E.J. Mulder, D.M.P.G. Robles, & G.H. Visser, 2004). Data collection was comprised of five time points during pregnancy: Time 1 (T1; Weeks 8–34) and four follow-up time points; Time 2 (T2: Weeks 20–25), Time 3 (T3: Weeks 26–31), Time 4 (T4: Weeks 32–34), and Time 5 (T5: Week 36). Fathers’ with higher ACE scores reported more pregnancy-related anxiety than did fathers with lower scores at all time points in pregnancy, except at T5 (36 weeks), while also reporting more depressive feelings during pregnancy. Health providers and community centers should pay more attention to fathers’ mental health during pregnancy, as the whole family system needs to be considered during pregnancy to provide optimal healthcare. Adverse childhood experiences among fathers-to-be may increase depressive and anxious feelings during pregnancy.
ABSTRACT:
El conocimiento de factores de predicci´on de sentimientos de depresi´on y ansiedad durante el embarazo entre potenciales pap´as ha crecido y el presente estudio investiga c´omo las experiencias adversas de la ni˜nez (ACE) se relacionan con sentimientos de depresi´on y ansiedad durante el embarazo. Los participantes fueron reclutados para el estudio “Peque˜no en Noruega” en diferentes cl´ınicas del saludable beb´e en Noruega, con 976 pap´as que consintieron en participar en el estudio, de los cuales 881 ten´ıa informaci´on v´alida con respecto a ACE. El estudio reporta sobre la relaci´on entre la Escala de Experiencias Adversas en la Ni˜nez (escala ACE) y sentimientos depresivos, usando la Escala Edinburgh de Depresi´on Postnatal (EPDS), as´ı como la ansiedad relacionada con el embarazo, usando la Escala Revisada de la Ansiedad Relacionada con el Embarazo (PRAQ-R). La recolecci´on de datos estuvo compuesta de 5 momentos temporales durante el embarazo – T1: semanas 8–34, y 4 momentos de seguimiento: T2: semanas 20–25, T3: semanas 26–31, T4: semanas 32–34 y T5: semana 36. Los pap´as con m´as altos puntajes de experiencias adversas en la ni˜nez reportaron mayor ansiedad relacionada con el embarazo que los pap´as con m´as bajos puntajes, en todos los puntos durante el embarazo, excepto el T5
RESUMEN:
We express our gratitude to the fathers who participated and shared their experiences with the research team. The study was supported by the Norwegian Research Council, The Norwegian National Network for Infant Mental Health at the Regional Centre for Child and the BUP-vest at Diakonhjemmet hospital. Direct correspondence to: Thomas Skjothaug, BUP-vest, Diakonhjemmet hospital, Norway; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 36(1), 104–113 (2015) C 2014 Michigan Association for Infant Mental Health View this article online at wileyonlinelibrary.com. DOI: 10.1002/imhj.21485
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(36 semanas), al tiempo que reportaron m´as sentimientos depresivos durante el embarazo. Los que proveen cuidados de salud y los centros comunitarios deben prestar m´as atenci´on a la salud mental de los pap´as durante el embarazo, ya que todo el sistema familiar necesita ser considerado durante el embarazo para proveerles de un o´ ptimo cuidado de salud. Las experiencias adversas en la ni˜nez entre quienes van a ser pap´as pudieran aumentar los sentimientos depresivos y de ansiedad durante el embarazo. ´ ´ RESUM E:
Les connaissances des pr´edicteurs de sentiments d´epressifs ou anxieuses durant la grossesse chez les hommes allant devenir p`eres s’aggrandissent et cette e´ tude se penche sur la mani`ere dont les exp´eriences adverses d’enfance des p`eres (abr´eg´e en anglais ACE que nous utiliserons ici) sont li´ees a` des sentiments d´epressifs ou anxieux pendant la grossesse. Les participants ont e´ t´e recrut´es dans l’´etude “Petit en Norv`eve” dans diff´erents cliniques de bien-ˆetre du b´eb´e en Norv`ege; avec 976 p`eres consentant a` participer a` l’´etde, sur lesquels 881 ont pu avoir des donn´ees valides pour l’ACE. L’´etude fait e´ tat de la relation entre l’Echelle d’Exp´erience Adverse de l’Enfance (´echelle ACE pour utiliser l’abr´eviation anglaise) et les sentiments d´epressifs, en utilisant l’Echelle de D´epression Postnatale d’Edinbourg (abr´eg´e en anglais par EPDS) et l’anxi´et´e li´ee a` la grossesse, en utilisant l’Echelle d’Anxi´et´e Li´ee a` la Grossesse – R´evis´ee (abr´eg´e en anglais par PRAQ-R). La collection de donn´ees s’est faite a` 5 moments durant la grossesse - T1: semaines 8–34, and 4 moments de suivi: T2: semaines 20–25, T3: semaines 26–31, T4: semaines 32–34 and T5: semaine 36. Les p`eres avec des scores plus e´ lev´es d’exp´erience adverse durant l’enfance ont fait e´ tat de plus d’anxi´et´e li´ee a` la grossesse que les p`eres avec des scores plus bas a` tous les moments de la grossesse, sauf a` T5 (36 semaines), tout en faisant aussi e´ tat de plus de sentiments d´epressifs durant la grossesse. Les services de sant´e et les centres communautaires de sant´e devraient faire plus attention a` la sant´e mentale des p`eres durant la grossesse, dans la mesure o`u tout le syst`eme familial doit eˆ tre pris en compte durant la grossesse afin d’offrir un soin de sant´e optimal. Les exp´eriences adverses de l’enfance chez les hommes allant devenir p`eres peuvent accroˆıtre les sentiments de d´epression et d’anxi´et´e durant la grossesse. Das Wissen hinsichtlich der Pr¨adiktoren f¨ur depressive oder a¨ ngstliche Gef¨uhle w¨ahrend der Schwangerschaft bei zuk¨unftigen V¨atern w¨achst und die vorliegende Studie untersucht, wie negative Kindheitserfahrungen v¨aterlicherseits (adverse childhood experiences; ACE) mit a¨ ngstlichen und depressiven Gef¨uhlen w¨ahrend der Schwangerschaft in Bezug stehen. Die Teilnehmer wurden f¨ur die “Little in Norway” Studie aus verschiedenen Entbindungskliniken in Norwegen rekrutiert. 976 V¨ater waren einverstanden an der Studie teilzunehmen, von denen 881 g¨ultige Daten f¨ur ACE angaben. Die Studie berichtet u¨ ber die Beziehung zwischen der Adverse Childhood Experience Scale (ACE-Skala) und depressiven Gef¨uhlen, die mit der Edinburgh Postnatal Depression Scale (EPDS) erhoben wurden und u¨ ber schwangerschaftsbezogene Angst, die mit der Pregancy-Related Anxiety Scale Revised (PRAQ-R) erfasst wurde. Die Datenerhebung umfasste 5 Zeitpunkte w¨ahrend der Schwangerschaft - T1: Woche 8–34 und 4 Follow-up Zeitpunkte: T2: Woche 20–25, T3: Woche 26–31, T4: Woche 32–34 und T5: Woche 36. V¨ater mit h¨oheren ACE-Werten berichteten zu allen Zeitpunkten in der Schwangerschaft, außer bei T5 (36 Wochen), mehr schwangerschaftsbezogene Angst als V¨ater mit niedrigeren Scores und mehr depressive Gef¨uhle w¨ahrend der Schwangerschaft. Gesundheitsdienstleister und Gemeindezentren sollten mehr Aufmerksamkeit auf die v¨aterliche psychische Gesundheit w¨ahrend der Schwangerschaft richten, da das ganze Familiensystem w¨ahrend der Schwangerschaft in Betracht gezogen werden muss, um eine optimale Gesundheitsversorgung zu gew¨ahrleisten. Ung¨unstige, negative Kindheitserfahrungen bei werdenden V¨atern k¨onnen depressive und a¨ ngstliche Gef¨uhle w¨ahrend der Schwangerschaft erh¨ohen.
ZUSAMMENFASSUNG:
dd:dddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddadverse childhood experiences (ACE)dddddddddddddddd dddddddddddddddddddddLittle in Norwaydddddddddddddddddddddddddddddd dd976dddddddddddddddddd881ddddACEdddddddddddddddddddddddddddd(ACE scale)ddddddddddddddthe Edinburgh Postnatal Depression Scale (EPDS)ddddddddddddddddddddddd dPregancy-Related Anxiety Scale Revised (PRAQ-R)ddddddddddddddddddddddddddddddddddddd d5ddddddT1d8–34ddddddd4ddddddddddddT2:20–25ddT3:26–31ddT4:32–34dddddT5:36ddACEd ddddddddddddddddT5(36d)dddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddd ABSTRACT:
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* * * Adverse childhood experiences are a rather common experience and are related to many public health problems later in life such as heart disease and cancer (Anda et al., 2010), autoimmune diseases (Dube et al., 2009), and depressive (Chapman et al., 2004) and anxious states (Pirkola et al., 2005). Adverse childhood experiences are often associated with emotional turmoil (Chapman et al., 2004), and the Adverse Childhood Experience Scale (ACE; Anda et al., 2010) includes categories such as verbal abuse, physical abuse, contact sexual abuse, a battered mother, household substance abuse, houshold mental illness, incarcerated household members, and parental separation or divorce during the respondent’s first 18 years of life. In general, there is agreement that adverse childhood experiences represent a risk for the development of health and social problems (Anda et al., 2010), stress in adulthood (Opacka-Juffry & Mohiyeddini, 2012), and depression (Mcewen, 2000) up to decades after their occurrence (Chapman et al., 2004). Generally speaking, most studies have endorsed single types of childhood abuse and their outcomes, without assessing the cumulative impact of multiple types of abuse (Chartier, Walker, & Naimark, 2010). The distinction between single and cumulative adverse-exposure effects may therefore become apparent years after exposure (Anda et al., 2010). New fathers’ experience of the antenatal period is more stressful than are experiences in the postnatal period (Condon, Boyce, & Corkindale, 2004), and untreated depression and anxiety during pregnancy can have serious consequences for the whole family. Knowledge of the predictors of fathers’ depression and anxiety during pregnancy is important for healthcare services, so that they may provide better support (Fletcher, Matthey, & Marley, 2006). More specifically, research on the predictors of prenatal paternal depression has not been given as much attention as has research on the predictors of prenatal maternal depresssion. Detecting depressive feelings at early time points in pregnancy is important because paternal depression during pregnancy predicts fathers’ subsequent depression postpartum (Matthey, Barnett, Ungerer, & Waters, 2000). Both parents’ personality traits, self-esteem and depression during pregnancy seem to predict parental stress after birth (Saisto, Salmela-Aro, Nurmi, & Halmesmaki, 2008). Luoma et al. (2012) examined 194 fathers right after birth and found that 21% of the fathers and 24% of the mothers scored above the cutoff point for
depressive symptoms, thereby suggesting that depressive feelings may affect fathers as well as mothers. In addition, research also has indicated that depressive symptoms or depression in men are frequently associated with poor relationship satisfaction, low social support (Wee, Skouteris, Pier, Richardson, & Milgrom, 2011) and being unemployed (Ballard & Davies, 1996), and immaturity or unplanned pregnancy (Schumacher, Zubaran, & White, 2008). The similarity between parents’ emotions during pregnancy also has been focused upon in recent research; Field et al.’s (2006) study of 156 mothers and fathers has indicated that the level of depression and anxiety symptoms between the parents is not significantly different during pregnancy. Field et al. suggested that the mothers’ slightly higher depression scores can be explained by and related to increased cortisol levels, which are associated with anxiety and depression. Field et al. also suggested that the mothers’ hormonal state may have a greater effect than does the environmental effect, and that fathers’ depression is more influenced by the mothers’ depressive scores than the other way around, which also has been supported elsewhere (Paulson & Bazemore, 2010). Field et al. found that fathers living with depressed mothers had significantly higher depression and anxiety scores than did those living with nondepressed mothers, and that men with poor partner relationships are at risk for depression as much as are women during the transition to parenthood (Matthey et al., 2000). Moreover, high levels of anxiety and depression seem to be more prevalent in pregnancy than during the postpartum period among prospective mothers (Andersson, Sundstr¨om-Poromaa, Wulff, Astr¨om, & Bixo, 2006) as well as among prospective fathers (Condon et al., 2004). Figueiredo and Conde (2011) documented a higher rate of depression compared to anxiety in women versus men and during pregnancy compared to 3 months’ postpartum. Other studies have shown that elevated anxiety levels are most prominent during the first and last trimester compared to the second trimester (Huizink, Mulder, Robles, & Visser, 2004; Teixeira, Figueiredo, Conde, Pacheco, & Costa, 2009). Preparing for fatherhood includes going through a transformation of emotions (Finnbogad´ottir, Svalenius, & Persson, 2002), with the first transformational phase being mentally preparing for fatherhood early in pregnancy, which may lead to feelings of anxiety (Teixeira et al., 2009). Fathers also are sometimes kept away from the nursery by the argument that men lack a “maternal instinct,” understood as an inborn quality that supposedly makes
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
mothers more sensitive to their babies than are fathers (Solantaus & Salo, 2005). Men’s childhood experiences, their current relationships with their partners, and demographic factors may all influence fathers’ involvement during pregnancy (Flykt et al., 2009) and during their child’s infancy (Shannon, Catherine, & Cabrera, 2006). Heightened levels of anxiety among fathers-to-be seem to be associated with a lack of information about pregnancy, forthcoming childbirth, and poor social support (Condon et al., 2004). To our knowledge, there has been no systematic research on adverse childhood experiences as a predictor of depressive or anxious feelings during pregnancy among prospective fathers. Thus, the present study’s two main objectives are to: •
examine the association between fathers’ adverse childhood experiences and pregnancy-related anxiety and depression during pregnancy; and to
•
investigate if this association varies during the course of pregnancy.
METHOD Recruitment and Participants
This study used data from the ongoing LIN-study (2010), which is a community-based population study with a prospective cohort design, investigating pre- and postnatal risk and promoting factors influencing early child development and mental health. A total of 1,041 families (1,041 mothers and 981 fathers) consented to participate at enrollment between Weeks 8 to 34 in pregnancy. Enrollment started in September 2011 and ended in mid-October 2012, and data collection up to age 18 months will be finished by November 2014. Participants were enrolled at nine different sites in Norway. One public healthcare nurse was trained as a research assistant from each site, and the sites were chosen after considering demographic characteristics and the size of the population to include participants from both cities and rural districts with a wide distrubution of sosioeconomic conditions. Midwives at the well-baby clinics approached pregnant women at 16 to 26 weeks of gestation with an invitation to participate, but some women were asked as late as Weeks 31 to 34. All prospective fathers were encouraged to participate, though 5 of the enrolled families withdrew their consent right after startup, thus leaving 1,036 mothers and 976 fathers in the cohort. Participating fathers in the present study were enrolled to the “LIN study” and took part as independent informants at five points in time during pregnancy by means of self-report questionnaires while the mothers were included only for control purposes. Among the men, 311 (35%) were married and 552 (62%) were cohabiting; the remaining fathers were classified as single, divorced, or other, and their mean age was 32.3 (range = 16–56, SD = 5.9) years. Median annual personal income ranged from the eqivalent of $48,800 to 81,000 (34%) while 15% had a lower and
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51% had a higher income. Fathers were primarily educated at the university level (37% had 4 years or more at the university level, and 30% had less than 4 years.) while the remaining participants (33%) were at the high-school level or lower. The majority of participants were first-time fathers (56%), some were second-time fathers (33%), and some had two or more previous children (11%). The ethnic majority was Norwegian (95%) while a minority had other ethnic backgrounds (5%). Measures
A comprehensive questionnaire package was given to the prospective fathers at the first meeting, which could take place from Pregnancy Weeks 16 to 34, depending on the specific time of enrollment. All fathers were asked to answer these questions, irrespective of the exact time of inclusion. The mothers also took part, although for the the present study, maternal data were not analyzed but only used for control purposes. Data collection was comprised of five time points in pregnancy (T1: Weeks 8–34, T2: Weeks 20–25, T3: Weeks 26–31, T4: Weeks 32–34, T5: Week 36). The intended timings were Week 22 for T2, Week 26 for T3, Week 32 for T4, and Week 36 for T5. The procedures for T1 (enrollment) had priority at first attendance; therefore, T1 might supersede the procedures designed for T2 to T5. Hence, the numbers of participants vary between the different time points since many of the parents were not enrolled before T3: Weeks 26 to 31. For example, those who were enrolled at T1 at Week 26 only answered outcome questionnaires after that time point [i.e., Weeks 32 (T4) and 36 (T5)], and not time points before Week 26 (i.e., Weeks 22 and 16). The predictor measures were collected at enrollment (T1 or later), and outcome variables were completed at four time points (T2–T5) later in pregnancy. As described earlier, 981 fathers agreed to participate at enrollment, and 5 fathers withdrew their consent right after enrollment (valid N = 976). In the analyses, 95 of the 976 fathers had missing data on the ACE Scale (Anda, Butchart, Felitti, & Brown, 2010) (valid N = 881) at enrollment. T1 Measures. The ACE Scale. The ACE Scale is a parent self-report questionnaire designed to identify possible adverse childhood experiences, with the fathers completing the questionnaire at enrollment. The ACE Scale consists of 10 questions; each may be scored 0 or 1. Their sum scores varied between 0 and 9, and gradiently between “no experienced adversity” up to “10,” indicating a high score on the Adversity scale (and indicating high risk) (Anda et al., 2010). In addition, the questionnaire contained questions about recurrent physical or emotional abuse. Sociodemographic variables. The following sociodemographic variables were included: fathers’ age, parity, education, income, marital status, and ethnicity. Age ranged from 16 to 56 years (M = 32.3 years). Parity was coded on a scale of 0 (first child), 1 (one previous child), or 2 (two or more previous children). Education ranged from elementary school, high school, college,
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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and the university level. Income values were classified on a scale of 1 (no income) to 9 (ࣙ$146,000). Marital status was collapsed into 1 (married), 2 (cohabiting), or 3 (other: single, divorced, or separated). The ethnicity variable was dichotomous with values, asking whether the participant belonged to an ethnic minority or not. T2 to T5 Measures. Edinburgh Postnatal Depression Scale (EPDS; EberhardGran & Slinning, 2007). The EPDS is a maternal self-report measure that has been validated in Norway with postpartum depression being the most common complication of childbearing. The 10-question EPDS is a valuable and efficient way of identifying women (Luoma et al., 2012) and men (Edmondson, Psychogiou, Vlachos, Netsi, & Ramchandani, 2010) at risk for postnatal depression. The scale was originally developed to measure womens’ postnatal depression, but also is a reliable and valid method to assess perinatal depression in fathers (Cox & Holden, 2003; Matthey, Barnett, Kavanagh, & Howie, 2001). The scale measures sleep problems using questions such as “During the last seven days, have you had sleeping problems due to an unhappy state?” and “During the last seven days, have you been crying due to unhappiness?” The Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R; Huizink, Mulder, Robles, & Visser, 2004). The PRAQR is a short form of the Pregnancy-Related Anxiety Questionnaire (PRAQ; Van den Bergh, 1990), which consists of a 10-item questionnaire designed to assess ongoing anxiety related to pregnancy toward birth. It was originally used to measure specific fears and worries related to pregnancy, and when the scale is used for fathers, it is reduced by three items to make it more suitable to assess fathers’ possible anxiety-related stress. Items related to pain in the process of delivery, change in body perception after birth, and fear for gaining weight were removed. Consequently, the PRAQ-R score was based on 10 items for mothers and seven items for fathers. It assesses three subscales of anxiety specific to pregnancy: fear of giving birth, fear of bearing a handicapped child, and pregnancy-related concerns about one’s appearance (not for fathers). For example, the questionnaire contained statements such as “I am worried that the child is mentally retarded or has brain damage.” Both the EPDS and the PRAQ-R used sum scores in the analyses. Statistical Methods. Analyses were performed in two main steps: Step 1, analyses with bivariate correlation, and Step 2, analyses with mixed effects models. In Step 1, correlations between the predictor variable adverse childhood experiences and 16 variables were computed (see Table 2); these variables included age, parity, education, income, marital status, and ethnicity, all of which were completed at enrollment. Spearman and Pearson correlation coefficients were estimated to investigate the relationships between the variables. Furthermore, the association of the enrollment variables
TABLE 1. Means, SDs, and Internal Reliability for Main Variablesa
ACE T1 PRAQ-R T2 T3 T4 T5 EPDST2 T3 T4 T5
N
M (SD)
α
881 106 336 405 483 106 336 404 481
.5 (1.2) 15.6 (5.4) 14.1 (5.6) 14.7 (5.6) 14.8 (5.6) 2.0 (2.9) 2.2 (2.9) 2.3 (3.2) 2.1 (2.6)
.70 .83 .86 .86 .86 .77 .82 .84 .78
ACE scale = Adverse Childhood Experiences Scale; PRAQ-R = Pregancy-Related Anxiety Scale-Revised; EPDS = Edinburgh Postnatal Depression Scale. a All outcome variables had good internal consistency, and Cronbach’s α reliability coefficients were high. They were all included in the mixed effects analyses (Step 2).
with paternal EPDS and the PRAQ-R were assessed at all time points during pregnancy. In Step 2, the relationships between the ACE Scale, the PRAQR, and the EPDS, adjusted for covariates, were computed with 569 prospective fathers. Analyses were performed by linear mixed effect models for modeling the relationship of scores on the paternal EPDS and the PRAQ-R with time and the ACE Scale, including a Time × ACE interaction in a hierarchical setup. It was adjusted for baseline paternal variables (age, parity, education, income, marital status, and ethnicity), maternal PRAQ-R and EPDS scores, respectively, as well as deviations from the intended timing of the T2 to T5 responses. The models included both within- and betweenperson random effects. Valid versus missing values in the PRAQ-R and the EPDS scores during T2 to T5 were analyzed by logistic regression via generalized estimating equations with unstructured correlations to account for clustering. Covariates were time, age, parity, education, income, marital status, and ethnicity. Significant results were determined by p < .05. The mixed effects analyses used the R (The R Foundation for Statistical Computing, Vienna, Austria, 3.0.0 package nlme; Pinheiro, Bates, DebRoy, Deepayan, & The R Development Core Team, 2013) for mixed effects analyses and gee for the logistic regression analyses, and the baseline correlation used SPSS Version 20 (IBM SPSS Statistics 20). RESULTS
Figure 2 shows the participants’ distribution of ACE Scale scores at baseline, T1 Week 8 to 34 in pregnancy. As shown in the figure, most fathers did not report any particular adverse childhood experiences, and more than one to two exposures were quite uncommon. Step 1 Analyses
Table 2 shows intercorrelations between all scales used in the analyses, except for the maternal PRAQ-R and the EPDS. None
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
700 646 600 500 400 300 124 200 57 28 10 100 0
1000 900
884 884 881
Number of parcipants
800 700 600 481 483
500
109
N = 881 8
2
3
2
M = 0.52
1
SD = 1.14
404 405
400
•
336 336
300 200
FIGURE 2. Adverse Childhood Experiences (ACE) Scale scores at Time 1 (T1) in pregnancy.
106 106
100 0 T1
T2
T3
T4
T5:w36
model revealed no significant differences between the time points, p ࣙ 0.341 for the ACE Scale = 0, p ࣙ .093 for the ACE Scale = 1. For the EPDS, there was no significant interaction between the ACE Scale at baseline and time, p = .288, although there was a significant association between the ACE Scale at baseline and EPDS at all time points (see Figure 3). For the ACE Scale = 0, the model revealed no significant differences between the time points: p ࣙ .056. For the ACE Scale = 1, the EPDS was significantly lower at T3, as compared to T4, −0.45, 95% CI −0.80, −0.11, p = .011; there were no other significant time differences, p ࣙ .063. The covariates for valid values in the PRAQ-R are shown in Table 3, and there was a strong tendency for higher response rates later during pregnancy. The response rate was lower for fathers who were neither married nor cohabiting. Results for the fathers’ response rates on the EPDS were virtually identical (data not shown).
Points of me in Pregnancy
EPDS
FIGURE 1.
PRAQ-R
ACE
Number of paternal participants during pregnancy.
of the predictor variables were so highly intercorrelated to warrant exclusion from the mixed effect models whereas the ACE Scale scores were negatively correlated with education and positively correlated with the EPDS during pregnancy at all time points, but bore no significant relationship to the PRAQ-R scores. Step 2 Analyses
For PRAQ-R, there was no significant interaction between the ACE Scale at baseline and time (p = .132). There was a significant association between the ACE Scale at baseline and the PRAQ-R at T2 to T4 (see Figure 3), and the
TABLE 2. Summary of Intercorrelations Between Independent and Dependent Outcome Variables
1. ACE 2. Age 3. Parity 4. Education 5. Income 6. Marital Status 7. Ethnicity 8. EPDS T1 9. EPDS T2 10. EPDS T3 11. EPDS T4 12. EPDS T5 13. PRAQ-R T1 14. PRAQ-R T2 15. PRAQ-R T3 16. PRAQ-R T4 17. PRAQ-R T5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
.02 .02 −.17∗∗∗ −.08 .08 .08 .20∗∗∗ .41∗∗∗ .21∗∗∗ .24∗∗∗ .15∗∗∗ .07 .12 .05 .12 .04
.40∗∗∗ .30∗∗∗ .42∗∗∗ −.13∗∗∗ .02 −.05 −.06 .01 .01 .08 −.20∗∗∗ .00 −.15 −.06 −.09
−.00 .15∗∗∗ −.16∗∗∗ −.01 .04 −.11 −.01 −.01 .01 −.25∗∗∗ −.31∗∗∗ −.26∗∗∗ −.17∗∗∗ −.22∗∗∗
.36∗∗∗ −.23∗∗∗ −.05 −.10∗∗ −.25 .01 −.02 .00 −.01 −.00 .04 .03 .11
−.14∗∗∗ −.03 −.10∗ −.10 −.06 −.05 −.00 −.07 .13 −.08 .00 .05
−.09 −.01 .18 −.04 .05 .00 .06 .01 .06 −.00 −.02
.16∗∗∗ .19 .16∗ .22∗∗∗ .17∗∗∗ .07 .11 −.02 .03 .03
.69∗∗∗ .68∗∗∗ .52∗∗∗ .58∗∗∗ .29∗∗∗ .28∗ .25∗∗∗ .19∗∗∗ .21∗∗∗
.57∗∗∗ .46∗∗∗ .63∗∗∗ .37∗∗∗ .34∗∗∗ .39∗∗∗ .09 .26∗∗∗
.60∗∗∗ .62∗∗∗ .35∗∗∗ .28 .35∗∗∗ .34∗∗∗ .37∗∗∗
.61∗∗∗ .25∗∗∗ .25 .33∗∗∗ .28∗∗∗ .26∗∗∗
.21∗∗∗ .23 .27∗∗∗ .23∗∗∗ .30∗∗∗
.78∗∗∗ .71∗∗∗ .69∗∗∗ .68∗∗∗
.66∗∗∗ .65∗∗∗ .73∗∗∗
.79∗∗∗ .76∗∗∗
.79∗∗∗
Note. None of the predictor variables were so highly intercorrelated to warrant exclusion from the linear mixed models. Fathers’ education, income, marital status and ethnicity were on an ordinal level, and Spearman’s ρ was used as correlation coeffiecient when these variabels were involved. The other variables were on an interval level, and Pearson correlation coefficients were used for these correlations. ACE = Adverse childhood experiences; EPDS = Edinburgh Postnatal Depression Scale; PRAQ-R = Pregancy-Related Anxiety Scale-Revised. ∗ p < 05. ∗∗ p < .01. ∗∗∗ p < .001 (two-tailed).
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FIGURE 3.
LME models.
DISCUSSION
The primary objective of the present study was to examine the association between the fathers’ retrospectively reported adverse childhood experiences and their pregnancy-related anxiety and depression during pregnancy. Another objective was to investigate if this relationship varied during pregnancy. In the present study of paternal self-reported pregnancyrelated anxiety (PRAQ-R) and depression (EPDS) during pregnancy, we analyzed the possible importance of time during pregnancy to reported adverse childhood experiences (ACE Scale) as well as the ACE × Time interaction. Time differences were investigated for both no adverse childhood experiences and one adverse childhood experience since most fathers reported none whereas one to two experiences were not quite uncommon. We found that at all time points during pregnancy, a higher score for adverse childhood experiences (ACE Scale) was significantly related to higher scores for pregnancy-related anxiety (PRAQR), except at 36 weeks (T5). Furthermore, relationships between ACE and the PRAQ-R scores were strongest at T2 and weakest at T5. This finding for pregnancy-related anxiety concurs with Condon et al.’s (2004) finding that the most important changes occurred relatively early in pregnancy. The prospective fathers participating
in Condon et al.’s study appeared to be ill-prepared for the impact of parenthood in their lives. The present study is comparable with the findings of Teixeira et al. (2009), which described how the first and last trimesters will generate the highest level of anxious and depressive feelings. Note that the Teixeira et al. study and the current one differ in method; Teixeira used the State-Trait Anxiety Inventory (STAI-S; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) while the present study used the PRAQ-R. Both instruments are based on self-reports, but the content of the questionnaires differs only slightly. The PRAQ-R mainly relates to pregnancy-specific questions (Huizink et al., 2004) whereas the STAI-S measures the temporary condition of “state anxiety” (Teixeira et al., 2009). Both studies have confirmed that the first time period of pregnancy is vulnerable with regard to anxious feelings. In addition, the present study suggests that heightened pregnancy-related anxiety scores are related to more adverse childhood experiences. Moreover, there could be a different trajectory path for those with adverse childhood experiences than for those without such experiences. Experiencing adversity in one’s childhood from the parents, a caregiver, or a role model may trigger anxious or depressive feelings during pregnancy because the experienced “ bad fatherhood” experiences are not easily incorporated into one’s own fatherhood values. For example, having the repetitive experience of being hit by one’s parents in childhood may trigger anxiety during pregnancy due to fear of becoming a father who hits his child. There were significant and strong relationships between retrospectively reported adversity in childhood (ACE Scale scores) and depressive feelings (EPDS) during all time points in pregnancy. The analyses suggest that the associations between the ACE-scale and EPDS were strongest early in pregnancy, but were still present in the last part of the pregnancy. Depressive and anxious feelings were lowest at Week 26, which is consistent with the findings of Teixeira et al. (2009). Both the present study and Teixeira et al.’s study used the EPDS as a method to measure depressive symptoms during pregnancy. The difference is that the present study included the influence of adverse childhood experiences at baseline as a predictor. Becoming a parent implies a personal transition from being a man to becoming a father. The prospective fathers’ childhood experiences and memories of their own childhoods may influence how they see themselves as caregivers (Flykt et al., 2009) because when they had difficult relational experiences, these may have induced anxiety and depression during pregnancy. Many contemporary fathers have probably had their own fathers as role models during the current pregnancy; hence, their understanding of “fatherness” needs to be consolidated on a personal level. A woman often identifies with her own mother and her values when becoming a mother herself, so it seems plausible that a prospective father also has such an identification. In the process of becoming a father, many prospective fathers may have experienced conflicting feelings between their own experiences with their parents and how they think of themselves as fathers. As a result, they must handle their previous experiences when choosing what kind of values upon which they will base their own fatherhood. Finnbogad´ottir et al.
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
TABLE 3. Covariates for Responding to the PRAQ-R
Time T3 vs. T2 T4 vs. T2 T5 vs. T2 T4 vs. T3 T5 vs. T3 T5 vs. T4 Father’s Marital Status Cohabit vs. Married Other vs. Married Other vs. Cohabit
Odds Ratio
95% Confidence Interval
4.49 6.32 9.12 1.41 2.03 1.44
3.65, 5.52 5.08, 7.86 7.30, 11.38 1.19, 1.66 1.72, 2.40 1.29, 1.61
0.90 0.36 0.40
0.71, 1.15 0.16, 0.81 0.18, 0.88
p
R
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I
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PROSPECTIVE FATHERS’ ADVERSE CHILDHOOD EXPERIENCES, PREGNANCY-RELATED ANXIETY, AND DEPRESSION DURING PREGNANCY THOMAS SKJOTHAUG
University of Oslo; National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway; and BUP-vest Diakonhjemmet hospital LARS SMITH
University of Oslo and National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway TORE WENTZEL-LARSEN
National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway; and Norwegian Centre for Violence and Traumatic Stress Studies VIBEKE MOE
University of Oslo and National Network for Infant Mental Health in Norway, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway There is a growing knowledge of the predictors of depressive or anxious feelings during pregnancy among prospective fathers, and the present study investigates how paternal adverse childhood experiences relate to anxious and depressive feelings during pregnancy. Participants were recruited to “The Little in Norway Study (LIN-study)” (2010) at different well-baby clinics in Norway; 976 fathers consented to participate in the study, of which 881 had valid data for adverse childhood experiences. The study reports on the relationship between the Adverse Childhood Experience Scale (ACE Scale; R.F. Anda, A. Butchart, V.J. Felitti, & D.W. Brown, 2010) and depressive feelings, using the Edinburgh Postnatal Depression Scale (EPDS; M. Eberhard-Gran & K. Slinning, 2007), and pregnancy-related anxiety, using the Pregancy-Related Anxiety Scale-Revised (PRAQ-R; A.C. Huizink, E.J. Mulder, D.M.P.G. Robles, & G.H. Visser, 2004). Data collection was comprised of five time points during pregnancy: Time 1 (T1; Weeks 8–34) and four follow-up time points; Time 2 (T2: Weeks 20–25), Time 3 (T3: Weeks 26–31), Time 4 (T4: Weeks 32–34), and Time 5 (T5: Week 36). Fathers’ with higher ACE scores reported more pregnancy-related anxiety than did fathers with lower scores at all time points in pregnancy, except at T5 (36 weeks), while also reporting more depressive feelings during pregnancy. Health providers and community centers should pay more attention to fathers’ mental health during pregnancy, as the whole family system needs to be considered during pregnancy to provide optimal healthcare. Adverse childhood experiences among fathers-to-be may increase depressive and anxious feelings during pregnancy.
ABSTRACT:
El conocimiento de factores de predicci´on de sentimientos de depresi´on y ansiedad durante el embarazo entre potenciales pap´as ha crecido y el presente estudio investiga c´omo las experiencias adversas de la ni˜nez (ACE) se relacionan con sentimientos de depresi´on y ansiedad durante el embarazo. Los participantes fueron reclutados para el estudio “Peque˜no en Noruega” en diferentes cl´ınicas del saludable beb´e en Noruega, con 976 pap´as que consintieron en participar en el estudio, de los cuales 881 ten´ıa informaci´on v´alida con respecto a ACE. El estudio reporta sobre la relaci´on entre la Escala de Experiencias Adversas en la Ni˜nez (escala ACE) y sentimientos depresivos, usando la Escala Edinburgh de Depresi´on Postnatal (EPDS), as´ı como la ansiedad relacionada con el embarazo, usando la Escala Revisada de la Ansiedad Relacionada con el Embarazo (PRAQ-R). La recolecci´on de datos estuvo compuesta de 5 momentos temporales durante el embarazo – T1: semanas 8–34, y 4 momentos de seguimiento: T2: semanas 20–25, T3: semanas 26–31, T4: semanas 32–34 y T5: semana 36. Los pap´as con m´as altos puntajes de experiencias adversas en la ni˜nez reportaron mayor ansiedad relacionada con el embarazo que los pap´as con m´as bajos puntajes, en todos los puntos durante el embarazo, excepto el T5
RESUMEN:
We express our gratitude to the fathers who participated and shared their experiences with the research team. The study was supported by the Norwegian Research Council, The Norwegian National Network for Infant Mental Health at the Regional Centre for Child and the BUP-vest at Diakonhjemmet hospital. Direct correspondence to: Thomas Skjothaug, BUP-vest, Diakonhjemmet hospital, Norway; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 36(1), 104–113 (2015) C 2014 Michigan Association for Infant Mental Health View this article online at wileyonlinelibrary.com. DOI: 10.1002/imhj.21485
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(36 semanas), al tiempo que reportaron m´as sentimientos depresivos durante el embarazo. Los que proveen cuidados de salud y los centros comunitarios deben prestar m´as atenci´on a la salud mental de los pap´as durante el embarazo, ya que todo el sistema familiar necesita ser considerado durante el embarazo para proveerles de un o´ ptimo cuidado de salud. Las experiencias adversas en la ni˜nez entre quienes van a ser pap´as pudieran aumentar los sentimientos depresivos y de ansiedad durante el embarazo. ´ ´ RESUM E:
Les connaissances des pr´edicteurs de sentiments d´epressifs ou anxieuses durant la grossesse chez les hommes allant devenir p`eres s’aggrandissent et cette e´ tude se penche sur la mani`ere dont les exp´eriences adverses d’enfance des p`eres (abr´eg´e en anglais ACE que nous utiliserons ici) sont li´ees a` des sentiments d´epressifs ou anxieux pendant la grossesse. Les participants ont e´ t´e recrut´es dans l’´etude “Petit en Norv`eve” dans diff´erents cliniques de bien-ˆetre du b´eb´e en Norv`ege; avec 976 p`eres consentant a` participer a` l’´etde, sur lesquels 881 ont pu avoir des donn´ees valides pour l’ACE. L’´etude fait e´ tat de la relation entre l’Echelle d’Exp´erience Adverse de l’Enfance (´echelle ACE pour utiliser l’abr´eviation anglaise) et les sentiments d´epressifs, en utilisant l’Echelle de D´epression Postnatale d’Edinbourg (abr´eg´e en anglais par EPDS) et l’anxi´et´e li´ee a` la grossesse, en utilisant l’Echelle d’Anxi´et´e Li´ee a` la Grossesse – R´evis´ee (abr´eg´e en anglais par PRAQ-R). La collection de donn´ees s’est faite a` 5 moments durant la grossesse - T1: semaines 8–34, and 4 moments de suivi: T2: semaines 20–25, T3: semaines 26–31, T4: semaines 32–34 and T5: semaine 36. Les p`eres avec des scores plus e´ lev´es d’exp´erience adverse durant l’enfance ont fait e´ tat de plus d’anxi´et´e li´ee a` la grossesse que les p`eres avec des scores plus bas a` tous les moments de la grossesse, sauf a` T5 (36 semaines), tout en faisant aussi e´ tat de plus de sentiments d´epressifs durant la grossesse. Les services de sant´e et les centres communautaires de sant´e devraient faire plus attention a` la sant´e mentale des p`eres durant la grossesse, dans la mesure o`u tout le syst`eme familial doit eˆ tre pris en compte durant la grossesse afin d’offrir un soin de sant´e optimal. Les exp´eriences adverses de l’enfance chez les hommes allant devenir p`eres peuvent accroˆıtre les sentiments de d´epression et d’anxi´et´e durant la grossesse. Das Wissen hinsichtlich der Pr¨adiktoren f¨ur depressive oder a¨ ngstliche Gef¨uhle w¨ahrend der Schwangerschaft bei zuk¨unftigen V¨atern w¨achst und die vorliegende Studie untersucht, wie negative Kindheitserfahrungen v¨aterlicherseits (adverse childhood experiences; ACE) mit a¨ ngstlichen und depressiven Gef¨uhlen w¨ahrend der Schwangerschaft in Bezug stehen. Die Teilnehmer wurden f¨ur die “Little in Norway” Studie aus verschiedenen Entbindungskliniken in Norwegen rekrutiert. 976 V¨ater waren einverstanden an der Studie teilzunehmen, von denen 881 g¨ultige Daten f¨ur ACE angaben. Die Studie berichtet u¨ ber die Beziehung zwischen der Adverse Childhood Experience Scale (ACE-Skala) und depressiven Gef¨uhlen, die mit der Edinburgh Postnatal Depression Scale (EPDS) erhoben wurden und u¨ ber schwangerschaftsbezogene Angst, die mit der Pregancy-Related Anxiety Scale Revised (PRAQ-R) erfasst wurde. Die Datenerhebung umfasste 5 Zeitpunkte w¨ahrend der Schwangerschaft - T1: Woche 8–34 und 4 Follow-up Zeitpunkte: T2: Woche 20–25, T3: Woche 26–31, T4: Woche 32–34 und T5: Woche 36. V¨ater mit h¨oheren ACE-Werten berichteten zu allen Zeitpunkten in der Schwangerschaft, außer bei T5 (36 Wochen), mehr schwangerschaftsbezogene Angst als V¨ater mit niedrigeren Scores und mehr depressive Gef¨uhle w¨ahrend der Schwangerschaft. Gesundheitsdienstleister und Gemeindezentren sollten mehr Aufmerksamkeit auf die v¨aterliche psychische Gesundheit w¨ahrend der Schwangerschaft richten, da das ganze Familiensystem w¨ahrend der Schwangerschaft in Betracht gezogen werden muss, um eine optimale Gesundheitsversorgung zu gew¨ahrleisten. Ung¨unstige, negative Kindheitserfahrungen bei werdenden V¨atern k¨onnen depressive und a¨ ngstliche Gef¨uhle w¨ahrend der Schwangerschaft erh¨ohen.
ZUSAMMENFASSUNG:
dd:dddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddadverse childhood experiences (ACE)dddddddddddddddd dddddddddddddddddddddLittle in Norwaydddddddddddddddddddddddddddddd dd976dddddddddddddddddd881ddddACEdddddddddddddddddddddddddddd(ACE scale)ddddddddddddddthe Edinburgh Postnatal Depression Scale (EPDS)ddddddddddddddddddddddd dPregancy-Related Anxiety Scale Revised (PRAQ-R)ddddddddddddddddddddddddddddddddddddd d5ddddddT1d8–34ddddddd4ddddddddddddT2:20–25ddT3:26–31ddT4:32–34dddddT5:36ddACEd ddddddddddddddddT5(36d)dddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddd ABSTRACT:
, (ACE)“”, ,ACE(EPDS), (PRAQ-R),(ACE) – ,: , ,
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* * * Adverse childhood experiences are a rather common experience and are related to many public health problems later in life such as heart disease and cancer (Anda et al., 2010), autoimmune diseases (Dube et al., 2009), and depressive (Chapman et al., 2004) and anxious states (Pirkola et al., 2005). Adverse childhood experiences are often associated with emotional turmoil (Chapman et al., 2004), and the Adverse Childhood Experience Scale (ACE; Anda et al., 2010) includes categories such as verbal abuse, physical abuse, contact sexual abuse, a battered mother, household substance abuse, houshold mental illness, incarcerated household members, and parental separation or divorce during the respondent’s first 18 years of life. In general, there is agreement that adverse childhood experiences represent a risk for the development of health and social problems (Anda et al., 2010), stress in adulthood (Opacka-Juffry & Mohiyeddini, 2012), and depression (Mcewen, 2000) up to decades after their occurrence (Chapman et al., 2004). Generally speaking, most studies have endorsed single types of childhood abuse and their outcomes, without assessing the cumulative impact of multiple types of abuse (Chartier, Walker, & Naimark, 2010). The distinction between single and cumulative adverse-exposure effects may therefore become apparent years after exposure (Anda et al., 2010). New fathers’ experience of the antenatal period is more stressful than are experiences in the postnatal period (Condon, Boyce, & Corkindale, 2004), and untreated depression and anxiety during pregnancy can have serious consequences for the whole family. Knowledge of the predictors of fathers’ depression and anxiety during pregnancy is important for healthcare services, so that they may provide better support (Fletcher, Matthey, & Marley, 2006). More specifically, research on the predictors of prenatal paternal depression has not been given as much attention as has research on the predictors of prenatal maternal depresssion. Detecting depressive feelings at early time points in pregnancy is important because paternal depression during pregnancy predicts fathers’ subsequent depression postpartum (Matthey, Barnett, Ungerer, & Waters, 2000). Both parents’ personality traits, self-esteem and depression during pregnancy seem to predict parental stress after birth (Saisto, Salmela-Aro, Nurmi, & Halmesmaki, 2008). Luoma et al. (2012) examined 194 fathers right after birth and found that 21% of the fathers and 24% of the mothers scored above the cutoff point for
depressive symptoms, thereby suggesting that depressive feelings may affect fathers as well as mothers. In addition, research also has indicated that depressive symptoms or depression in men are frequently associated with poor relationship satisfaction, low social support (Wee, Skouteris, Pier, Richardson, & Milgrom, 2011) and being unemployed (Ballard & Davies, 1996), and immaturity or unplanned pregnancy (Schumacher, Zubaran, & White, 2008). The similarity between parents’ emotions during pregnancy also has been focused upon in recent research; Field et al.’s (2006) study of 156 mothers and fathers has indicated that the level of depression and anxiety symptoms between the parents is not significantly different during pregnancy. Field et al. suggested that the mothers’ slightly higher depression scores can be explained by and related to increased cortisol levels, which are associated with anxiety and depression. Field et al. also suggested that the mothers’ hormonal state may have a greater effect than does the environmental effect, and that fathers’ depression is more influenced by the mothers’ depressive scores than the other way around, which also has been supported elsewhere (Paulson & Bazemore, 2010). Field et al. found that fathers living with depressed mothers had significantly higher depression and anxiety scores than did those living with nondepressed mothers, and that men with poor partner relationships are at risk for depression as much as are women during the transition to parenthood (Matthey et al., 2000). Moreover, high levels of anxiety and depression seem to be more prevalent in pregnancy than during the postpartum period among prospective mothers (Andersson, Sundstr¨om-Poromaa, Wulff, Astr¨om, & Bixo, 2006) as well as among prospective fathers (Condon et al., 2004). Figueiredo and Conde (2011) documented a higher rate of depression compared to anxiety in women versus men and during pregnancy compared to 3 months’ postpartum. Other studies have shown that elevated anxiety levels are most prominent during the first and last trimester compared to the second trimester (Huizink, Mulder, Robles, & Visser, 2004; Teixeira, Figueiredo, Conde, Pacheco, & Costa, 2009). Preparing for fatherhood includes going through a transformation of emotions (Finnbogad´ottir, Svalenius, & Persson, 2002), with the first transformational phase being mentally preparing for fatherhood early in pregnancy, which may lead to feelings of anxiety (Teixeira et al., 2009). Fathers also are sometimes kept away from the nursery by the argument that men lack a “maternal instinct,” understood as an inborn quality that supposedly makes
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
mothers more sensitive to their babies than are fathers (Solantaus & Salo, 2005). Men’s childhood experiences, their current relationships with their partners, and demographic factors may all influence fathers’ involvement during pregnancy (Flykt et al., 2009) and during their child’s infancy (Shannon, Catherine, & Cabrera, 2006). Heightened levels of anxiety among fathers-to-be seem to be associated with a lack of information about pregnancy, forthcoming childbirth, and poor social support (Condon et al., 2004). To our knowledge, there has been no systematic research on adverse childhood experiences as a predictor of depressive or anxious feelings during pregnancy among prospective fathers. Thus, the present study’s two main objectives are to: •
examine the association between fathers’ adverse childhood experiences and pregnancy-related anxiety and depression during pregnancy; and to
•
investigate if this association varies during the course of pregnancy.
METHOD Recruitment and Participants
This study used data from the ongoing LIN-study (2010), which is a community-based population study with a prospective cohort design, investigating pre- and postnatal risk and promoting factors influencing early child development and mental health. A total of 1,041 families (1,041 mothers and 981 fathers) consented to participate at enrollment between Weeks 8 to 34 in pregnancy. Enrollment started in September 2011 and ended in mid-October 2012, and data collection up to age 18 months will be finished by November 2014. Participants were enrolled at nine different sites in Norway. One public healthcare nurse was trained as a research assistant from each site, and the sites were chosen after considering demographic characteristics and the size of the population to include participants from both cities and rural districts with a wide distrubution of sosioeconomic conditions. Midwives at the well-baby clinics approached pregnant women at 16 to 26 weeks of gestation with an invitation to participate, but some women were asked as late as Weeks 31 to 34. All prospective fathers were encouraged to participate, though 5 of the enrolled families withdrew their consent right after startup, thus leaving 1,036 mothers and 976 fathers in the cohort. Participating fathers in the present study were enrolled to the “LIN study” and took part as independent informants at five points in time during pregnancy by means of self-report questionnaires while the mothers were included only for control purposes. Among the men, 311 (35%) were married and 552 (62%) were cohabiting; the remaining fathers were classified as single, divorced, or other, and their mean age was 32.3 (range = 16–56, SD = 5.9) years. Median annual personal income ranged from the eqivalent of $48,800 to 81,000 (34%) while 15% had a lower and
•
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51% had a higher income. Fathers were primarily educated at the university level (37% had 4 years or more at the university level, and 30% had less than 4 years.) while the remaining participants (33%) were at the high-school level or lower. The majority of participants were first-time fathers (56%), some were second-time fathers (33%), and some had two or more previous children (11%). The ethnic majority was Norwegian (95%) while a minority had other ethnic backgrounds (5%). Measures
A comprehensive questionnaire package was given to the prospective fathers at the first meeting, which could take place from Pregnancy Weeks 16 to 34, depending on the specific time of enrollment. All fathers were asked to answer these questions, irrespective of the exact time of inclusion. The mothers also took part, although for the the present study, maternal data were not analyzed but only used for control purposes. Data collection was comprised of five time points in pregnancy (T1: Weeks 8–34, T2: Weeks 20–25, T3: Weeks 26–31, T4: Weeks 32–34, T5: Week 36). The intended timings were Week 22 for T2, Week 26 for T3, Week 32 for T4, and Week 36 for T5. The procedures for T1 (enrollment) had priority at first attendance; therefore, T1 might supersede the procedures designed for T2 to T5. Hence, the numbers of participants vary between the different time points since many of the parents were not enrolled before T3: Weeks 26 to 31. For example, those who were enrolled at T1 at Week 26 only answered outcome questionnaires after that time point [i.e., Weeks 32 (T4) and 36 (T5)], and not time points before Week 26 (i.e., Weeks 22 and 16). The predictor measures were collected at enrollment (T1 or later), and outcome variables were completed at four time points (T2–T5) later in pregnancy. As described earlier, 981 fathers agreed to participate at enrollment, and 5 fathers withdrew their consent right after enrollment (valid N = 976). In the analyses, 95 of the 976 fathers had missing data on the ACE Scale (Anda, Butchart, Felitti, & Brown, 2010) (valid N = 881) at enrollment. T1 Measures. The ACE Scale. The ACE Scale is a parent self-report questionnaire designed to identify possible adverse childhood experiences, with the fathers completing the questionnaire at enrollment. The ACE Scale consists of 10 questions; each may be scored 0 or 1. Their sum scores varied between 0 and 9, and gradiently between “no experienced adversity” up to “10,” indicating a high score on the Adversity scale (and indicating high risk) (Anda et al., 2010). In addition, the questionnaire contained questions about recurrent physical or emotional abuse. Sociodemographic variables. The following sociodemographic variables were included: fathers’ age, parity, education, income, marital status, and ethnicity. Age ranged from 16 to 56 years (M = 32.3 years). Parity was coded on a scale of 0 (first child), 1 (one previous child), or 2 (two or more previous children). Education ranged from elementary school, high school, college,
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and the university level. Income values were classified on a scale of 1 (no income) to 9 (ࣙ$146,000). Marital status was collapsed into 1 (married), 2 (cohabiting), or 3 (other: single, divorced, or separated). The ethnicity variable was dichotomous with values, asking whether the participant belonged to an ethnic minority or not. T2 to T5 Measures. Edinburgh Postnatal Depression Scale (EPDS; EberhardGran & Slinning, 2007). The EPDS is a maternal self-report measure that has been validated in Norway with postpartum depression being the most common complication of childbearing. The 10-question EPDS is a valuable and efficient way of identifying women (Luoma et al., 2012) and men (Edmondson, Psychogiou, Vlachos, Netsi, & Ramchandani, 2010) at risk for postnatal depression. The scale was originally developed to measure womens’ postnatal depression, but also is a reliable and valid method to assess perinatal depression in fathers (Cox & Holden, 2003; Matthey, Barnett, Kavanagh, & Howie, 2001). The scale measures sleep problems using questions such as “During the last seven days, have you had sleeping problems due to an unhappy state?” and “During the last seven days, have you been crying due to unhappiness?” The Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R; Huizink, Mulder, Robles, & Visser, 2004). The PRAQR is a short form of the Pregnancy-Related Anxiety Questionnaire (PRAQ; Van den Bergh, 1990), which consists of a 10-item questionnaire designed to assess ongoing anxiety related to pregnancy toward birth. It was originally used to measure specific fears and worries related to pregnancy, and when the scale is used for fathers, it is reduced by three items to make it more suitable to assess fathers’ possible anxiety-related stress. Items related to pain in the process of delivery, change in body perception after birth, and fear for gaining weight were removed. Consequently, the PRAQ-R score was based on 10 items for mothers and seven items for fathers. It assesses three subscales of anxiety specific to pregnancy: fear of giving birth, fear of bearing a handicapped child, and pregnancy-related concerns about one’s appearance (not for fathers). For example, the questionnaire contained statements such as “I am worried that the child is mentally retarded or has brain damage.” Both the EPDS and the PRAQ-R used sum scores in the analyses. Statistical Methods. Analyses were performed in two main steps: Step 1, analyses with bivariate correlation, and Step 2, analyses with mixed effects models. In Step 1, correlations between the predictor variable adverse childhood experiences and 16 variables were computed (see Table 2); these variables included age, parity, education, income, marital status, and ethnicity, all of which were completed at enrollment. Spearman and Pearson correlation coefficients were estimated to investigate the relationships between the variables. Furthermore, the association of the enrollment variables
TABLE 1. Means, SDs, and Internal Reliability for Main Variablesa
ACE T1 PRAQ-R T2 T3 T4 T5 EPDST2 T3 T4 T5
N
M (SD)
α
881 106 336 405 483 106 336 404 481
.5 (1.2) 15.6 (5.4) 14.1 (5.6) 14.7 (5.6) 14.8 (5.6) 2.0 (2.9) 2.2 (2.9) 2.3 (3.2) 2.1 (2.6)
.70 .83 .86 .86 .86 .77 .82 .84 .78
ACE scale = Adverse Childhood Experiences Scale; PRAQ-R = Pregancy-Related Anxiety Scale-Revised; EPDS = Edinburgh Postnatal Depression Scale. a All outcome variables had good internal consistency, and Cronbach’s α reliability coefficients were high. They were all included in the mixed effects analyses (Step 2).
with paternal EPDS and the PRAQ-R were assessed at all time points during pregnancy. In Step 2, the relationships between the ACE Scale, the PRAQR, and the EPDS, adjusted for covariates, were computed with 569 prospective fathers. Analyses were performed by linear mixed effect models for modeling the relationship of scores on the paternal EPDS and the PRAQ-R with time and the ACE Scale, including a Time × ACE interaction in a hierarchical setup. It was adjusted for baseline paternal variables (age, parity, education, income, marital status, and ethnicity), maternal PRAQ-R and EPDS scores, respectively, as well as deviations from the intended timing of the T2 to T5 responses. The models included both within- and betweenperson random effects. Valid versus missing values in the PRAQ-R and the EPDS scores during T2 to T5 were analyzed by logistic regression via generalized estimating equations with unstructured correlations to account for clustering. Covariates were time, age, parity, education, income, marital status, and ethnicity. Significant results were determined by p < .05. The mixed effects analyses used the R (The R Foundation for Statistical Computing, Vienna, Austria, 3.0.0 package nlme; Pinheiro, Bates, DebRoy, Deepayan, & The R Development Core Team, 2013) for mixed effects analyses and gee for the logistic regression analyses, and the baseline correlation used SPSS Version 20 (IBM SPSS Statistics 20). RESULTS
Figure 2 shows the participants’ distribution of ACE Scale scores at baseline, T1 Week 8 to 34 in pregnancy. As shown in the figure, most fathers did not report any particular adverse childhood experiences, and more than one to two exposures were quite uncommon. Step 1 Analyses
Table 2 shows intercorrelations between all scales used in the analyses, except for the maternal PRAQ-R and the EPDS. None
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
700 646 600 500 400 300 124 200 57 28 10 100 0
1000 900
884 884 881
Number of parcipants
800 700 600 481 483
500
109
N = 881 8
2
3
2
M = 0.52
1
SD = 1.14
404 405
400
•
336 336
300 200
FIGURE 2. Adverse Childhood Experiences (ACE) Scale scores at Time 1 (T1) in pregnancy.
106 106
100 0 T1
T2
T3
T4
T5:w36
model revealed no significant differences between the time points, p ࣙ 0.341 for the ACE Scale = 0, p ࣙ .093 for the ACE Scale = 1. For the EPDS, there was no significant interaction between the ACE Scale at baseline and time, p = .288, although there was a significant association between the ACE Scale at baseline and EPDS at all time points (see Figure 3). For the ACE Scale = 0, the model revealed no significant differences between the time points: p ࣙ .056. For the ACE Scale = 1, the EPDS was significantly lower at T3, as compared to T4, −0.45, 95% CI −0.80, −0.11, p = .011; there were no other significant time differences, p ࣙ .063. The covariates for valid values in the PRAQ-R are shown in Table 3, and there was a strong tendency for higher response rates later during pregnancy. The response rate was lower for fathers who were neither married nor cohabiting. Results for the fathers’ response rates on the EPDS were virtually identical (data not shown).
Points of me in Pregnancy
EPDS
FIGURE 1.
PRAQ-R
ACE
Number of paternal participants during pregnancy.
of the predictor variables were so highly intercorrelated to warrant exclusion from the mixed effect models whereas the ACE Scale scores were negatively correlated with education and positively correlated with the EPDS during pregnancy at all time points, but bore no significant relationship to the PRAQ-R scores. Step 2 Analyses
For PRAQ-R, there was no significant interaction between the ACE Scale at baseline and time (p = .132). There was a significant association between the ACE Scale at baseline and the PRAQ-R at T2 to T4 (see Figure 3), and the
TABLE 2. Summary of Intercorrelations Between Independent and Dependent Outcome Variables
1. ACE 2. Age 3. Parity 4. Education 5. Income 6. Marital Status 7. Ethnicity 8. EPDS T1 9. EPDS T2 10. EPDS T3 11. EPDS T4 12. EPDS T5 13. PRAQ-R T1 14. PRAQ-R T2 15. PRAQ-R T3 16. PRAQ-R T4 17. PRAQ-R T5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
.02 .02 −.17∗∗∗ −.08 .08 .08 .20∗∗∗ .41∗∗∗ .21∗∗∗ .24∗∗∗ .15∗∗∗ .07 .12 .05 .12 .04
.40∗∗∗ .30∗∗∗ .42∗∗∗ −.13∗∗∗ .02 −.05 −.06 .01 .01 .08 −.20∗∗∗ .00 −.15 −.06 −.09
−.00 .15∗∗∗ −.16∗∗∗ −.01 .04 −.11 −.01 −.01 .01 −.25∗∗∗ −.31∗∗∗ −.26∗∗∗ −.17∗∗∗ −.22∗∗∗
.36∗∗∗ −.23∗∗∗ −.05 −.10∗∗ −.25 .01 −.02 .00 −.01 −.00 .04 .03 .11
−.14∗∗∗ −.03 −.10∗ −.10 −.06 −.05 −.00 −.07 .13 −.08 .00 .05
−.09 −.01 .18 −.04 .05 .00 .06 .01 .06 −.00 −.02
.16∗∗∗ .19 .16∗ .22∗∗∗ .17∗∗∗ .07 .11 −.02 .03 .03
.69∗∗∗ .68∗∗∗ .52∗∗∗ .58∗∗∗ .29∗∗∗ .28∗ .25∗∗∗ .19∗∗∗ .21∗∗∗
.57∗∗∗ .46∗∗∗ .63∗∗∗ .37∗∗∗ .34∗∗∗ .39∗∗∗ .09 .26∗∗∗
.60∗∗∗ .62∗∗∗ .35∗∗∗ .28 .35∗∗∗ .34∗∗∗ .37∗∗∗
.61∗∗∗ .25∗∗∗ .25 .33∗∗∗ .28∗∗∗ .26∗∗∗
.21∗∗∗ .23 .27∗∗∗ .23∗∗∗ .30∗∗∗
.78∗∗∗ .71∗∗∗ .69∗∗∗ .68∗∗∗
.66∗∗∗ .65∗∗∗ .73∗∗∗
.79∗∗∗ .76∗∗∗
.79∗∗∗
Note. None of the predictor variables were so highly intercorrelated to warrant exclusion from the linear mixed models. Fathers’ education, income, marital status and ethnicity were on an ordinal level, and Spearman’s ρ was used as correlation coeffiecient when these variabels were involved. The other variables were on an interval level, and Pearson correlation coefficients were used for these correlations. ACE = Adverse childhood experiences; EPDS = Edinburgh Postnatal Depression Scale; PRAQ-R = Pregancy-Related Anxiety Scale-Revised. ∗ p < 05. ∗∗ p < .01. ∗∗∗ p < .001 (two-tailed).
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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T. Skjothaug et al.
FIGURE 3.
LME models.
DISCUSSION
The primary objective of the present study was to examine the association between the fathers’ retrospectively reported adverse childhood experiences and their pregnancy-related anxiety and depression during pregnancy. Another objective was to investigate if this relationship varied during pregnancy. In the present study of paternal self-reported pregnancyrelated anxiety (PRAQ-R) and depression (EPDS) during pregnancy, we analyzed the possible importance of time during pregnancy to reported adverse childhood experiences (ACE Scale) as well as the ACE × Time interaction. Time differences were investigated for both no adverse childhood experiences and one adverse childhood experience since most fathers reported none whereas one to two experiences were not quite uncommon. We found that at all time points during pregnancy, a higher score for adverse childhood experiences (ACE Scale) was significantly related to higher scores for pregnancy-related anxiety (PRAQR), except at 36 weeks (T5). Furthermore, relationships between ACE and the PRAQ-R scores were strongest at T2 and weakest at T5. This finding for pregnancy-related anxiety concurs with Condon et al.’s (2004) finding that the most important changes occurred relatively early in pregnancy. The prospective fathers participating
in Condon et al.’s study appeared to be ill-prepared for the impact of parenthood in their lives. The present study is comparable with the findings of Teixeira et al. (2009), which described how the first and last trimesters will generate the highest level of anxious and depressive feelings. Note that the Teixeira et al. study and the current one differ in method; Teixeira used the State-Trait Anxiety Inventory (STAI-S; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) while the present study used the PRAQ-R. Both instruments are based on self-reports, but the content of the questionnaires differs only slightly. The PRAQ-R mainly relates to pregnancy-specific questions (Huizink et al., 2004) whereas the STAI-S measures the temporary condition of “state anxiety” (Teixeira et al., 2009). Both studies have confirmed that the first time period of pregnancy is vulnerable with regard to anxious feelings. In addition, the present study suggests that heightened pregnancy-related anxiety scores are related to more adverse childhood experiences. Moreover, there could be a different trajectory path for those with adverse childhood experiences than for those without such experiences. Experiencing adversity in one’s childhood from the parents, a caregiver, or a role model may trigger anxious or depressive feelings during pregnancy because the experienced “ bad fatherhood” experiences are not easily incorporated into one’s own fatherhood values. For example, having the repetitive experience of being hit by one’s parents in childhood may trigger anxiety during pregnancy due to fear of becoming a father who hits his child. There were significant and strong relationships between retrospectively reported adversity in childhood (ACE Scale scores) and depressive feelings (EPDS) during all time points in pregnancy. The analyses suggest that the associations between the ACE-scale and EPDS were strongest early in pregnancy, but were still present in the last part of the pregnancy. Depressive and anxious feelings were lowest at Week 26, which is consistent with the findings of Teixeira et al. (2009). Both the present study and Teixeira et al.’s study used the EPDS as a method to measure depressive symptoms during pregnancy. The difference is that the present study included the influence of adverse childhood experiences at baseline as a predictor. Becoming a parent implies a personal transition from being a man to becoming a father. The prospective fathers’ childhood experiences and memories of their own childhoods may influence how they see themselves as caregivers (Flykt et al., 2009) because when they had difficult relational experiences, these may have induced anxiety and depression during pregnancy. Many contemporary fathers have probably had their own fathers as role models during the current pregnancy; hence, their understanding of “fatherness” needs to be consolidated on a personal level. A woman often identifies with her own mother and her values when becoming a mother herself, so it seems plausible that a prospective father also has such an identification. In the process of becoming a father, many prospective fathers may have experienced conflicting feelings between their own experiences with their parents and how they think of themselves as fathers. As a result, they must handle their previous experiences when choosing what kind of values upon which they will base their own fatherhood. Finnbogad´ottir et al.
Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
Prospective Fathers’ Adverse Childhood Experiences
TABLE 3. Covariates for Responding to the PRAQ-R
Time T3 vs. T2 T4 vs. T2 T5 vs. T2 T4 vs. T3 T5 vs. T3 T5 vs. T4 Father’s Marital Status Cohabit vs. Married Other vs. Married Other vs. Cohabit
Odds Ratio
95% Confidence Interval
4.49 6.32 9.12 1.41 2.03 1.44
3.65, 5.52 5.08, 7.86 7.30, 11.38 1.19, 1.66 1.72, 2.40 1.29, 1.61
0.90 0.36 0.40
0.71, 1.15 0.16, 0.81 0.18, 0.88
p
