Mental Health Trajectories of Fathers Following Very Preterm Birth: Associations With Parenting

Grace E. McMahon, BPSYCH (HONS); Peter J. Anderson; PHD; Rebecca Giallo, PHD; Carmen C. Pace, PHD; Jeanie L. Cheong MD; Lex W. Doyle, MD; Alicia J. Spittle, PHD; Megan M. Spencer-Smith, PHD; Karli Treyvaud, DPSYCH


J Pediatr Psychol. 2020;45(7):725-735. 

In This Article

Abstract and Introduction


Objective: Mothers of infants born very preterm (VPT) are at high risk of mental health difficulties. However, less is known about the course of fathers' depressive and anxiety symptoms over time, and the implications this may have for early parenting behaviors.

Methods: In total, 100 fathers of 125 infants born VPT (<30 weeks' gestation) completed questionnaires assessing depressive and anxiety symptoms shortly after their infant's birth, and when their infant reached term-equivalent age, 3 months, 6 months, and 12 months' corrected age. At 12 months' corrected age, fathers' parenting behaviors were assessed using the Emotional Availability Scales. Longitudinal latent class analysis was used to identify trajectories of fathers' depressive and anxiety symptoms, and linear regression equations examined relationships between these trajectories and fathers' parenting behaviors.

Results: For both depressive and anxiety symptoms, two distinct trajectories were identified. For depression, most fathers were assigned to the persistently low symptom trajectory (82%), while the remainder were assigned to the persistently high symptom trajectory (18%). For anxiety, 49% of fathers were assigned to the persistently low symptom trajectory, while 51% were assigned to the trajectory characterized by moderate symptoms over the first postnatal year. There were no significant differences in parenting behaviors between fathers assigned to the different depressive and anxiety symptom trajectories.

Conclusions: Fathers of infants born VPT are at risk of chronic depressive and anxiety symptoms over the first postnatal year, highlighting the need for screening and ongoing support.


Very preterm (VPT; <32 weeks' gestation) birth is a stressful experience for parents which places them at high risk of depression and anxiety (Pace et al., 2016). Although most research has focused on mothers' mental health symptoms following VPT birth, evidence suggests that fathers of infants born VPT may also be at higher risk of depression and anxiety symptoms than fathers of infants born full-term (Carson, Redshaw, Gray, & Quigley, 2015; Pace et al., 2016). Mental health difficulties in fathers following VPT birth is of concern not only because of the potentially disabling effects on their own and their family's quality of life and functioning, but also because of the possible negative effects on child development (Fletcher, Feeman, Garfield, & Vimpani, 2011). A primary mechanism through which fathers' mental health symptoms may pose a risk to child outcomes is through their adverse effect on a range of parenting behaviors that are important for promoting and supporting child development (Goodman & Gotlib, 1999). Key parenting behaviors associated with more optimal cognitive, language, and social-emotional development include high sensitivity (warmth and responsiveness), and structuring or scaffolding of the child's play (Tamis-LeMonda, Shannon, Cabrera, & Lamb, 2004). Conversely, parenting characterized by high intrusiveness (over-involvement and over-direction) and hostility (negative affect and frustration) has been associated with less optimal child development (Pinquart, 2017; Tamis-LeMonda et al., 2004). Although most research on parenting and child development has occurred within the general population, we have documented similar associations for mothers (Treyvaud et al., 2009, 2016) and fathers (McMahon et al., 2019) within the VPT population.

A considerable proportion (~40%) of fathers experience elevated mental health symptoms in the early weeks following VPT birth (Mackley, Locke, Spear, & Joseph, 2010; Pace et al., 2016). We have previously reported that although symptoms tend to decrease across the early perinatal period, fathers of infants born VPT remain at higher risk of mental health difficulties at 6 months postpartum compared with fathers of infants born full-term (Pace et al., 2016). Similar findings have been reported by studies examining fathers' mental health symptoms at 9 months postpartum (Carson et al., 2015; Cheng, Kotelchuck, Gerstein, Taveras, & Poehlmann-Tynan, 2016). Previous studies examining fathers' mental health within the VPT population have tended to report on the prevalence of fathers reporting symptoms above a pre-defined cut-point at a particular point in time. While this provides an estimate of how many fathers are at risk of mental health difficulties at that time point, it does not capture the change and wide variability often seen in mental health symptom profiles over time.

A better understanding of fathers' experiences of depressive and anxiety symptoms over time within the VPT population is needed, particularly regarding implications of these symptoms for fathers' parenting. To the best of our knowledge, only one study has investigated the relationship between mental health symptoms and parenting behaviors in fathers of infants born preterm or with low birth weight (Zelkowitz, Bardin, & Papageorgiou, 2007). In a study of 70 fathers and their infants born with very low birth weight (VLBW; <1,500 g), higher trait anxiety was associated with less visual contact, awareness and responsivity in the neonatal intensive care unit (NICU; Zelkowitz et al., 2007). Comparatively more research has been conducted in the general population, with a recent meta-analysis (Cheung & Theule, 2019) of 50 studies reporting heterogeneity across studies but overall a small negative relationship between fathers' depressive symptoms and positive parenting behaviors (e.g., warmth, acceptance), and a small positive relationship between fathers' depressive symptoms and less optimal parenting behaviors (e.g., hostility, intrusiveness). While the majority of the published studies in this meta-analysis were cross-sectional, a small number of studies have also reported on the longitudinal implications of mental health symptoms for fathers' parenting behaviors (Giallo et al., 2015; Giallo, Cooklin, Wade, D'Esposito, & Nicholson, 2014). Taken together, these findings suggest that fathers' postnatal mental health symptoms may have a small but persisting influence on their parenting behaviors. Considering the increased risk of mental health difficulties amongst fathers of infants born VPT, and the importance of fathers' parenting behaviors for promoting the developmental outcome of these vulnerable infants, this is an area that requires prompt research attention.

In a longitudinal cohort study of fathers and their infants who were born VPT, this study aimed to: (a) identify subgroups of fathers of infants born VPT as defined by their trajectories of depressive symptoms and anxiety symptoms from shortly after their infant's birth to 12 months' corrected age (CA), and (b) examine the associations between these trajectories of depressive symptoms and anxiety symptoms and a range of fathers' parenting behaviors (sensitivity, structuring, nonintrusiveness, nonhostility) at 12 months' CA. We expected to identify at least two different trajectories that reflect the course and severity of fathers' depressive and anxiety symptoms across the first postnatal year (low and high symptom severity trajectories). We also expected that compared with fathers who reported lower levels of depressive and anxiety symptoms across the first postnatal year, fathers who reported higher levels would show lower sensitivity and structuring, and higher intrusiveness and hostility at 12 months' CA.