ACF OPRE: Early Head Start Research and Evaluation Project (EHSRE)

RESEARCH TO PRACTICE

Depression in the Lives of Early Head Start Families

EARLY HEAD START RESEARCH AND EVALUATION PROJECT

Depression is common in low-income families and, in many cases, depression is linked with poorer child outcomes. The Early Head Start Research and Evaluation Project, a rigorous random-assignment evaluation of 3,001 children and families in 17 programs around the country, collected information on maternal and paternal depressive symptoms. This research presents findings on what was learned about depression in the lives of Early Head Start families. It also describes the importance of focusing on mental health and the role Early Head Start plays in addressing mental health needs.

As a comprehensive child development program, Head Start has traditionally been concerned with supporting the social and emotional well-being of children and families and providing and/or accessing services for those families with mental health needs. In fact, the Head Start Program Performance Standards require each program to obtain a mental health consultant (1304.52), timely and responsive services (1304.24), and family-centered mental health services and education (1304.40)

Parents and staff are working to understand and address the mental health needs of very young children. It has been a particular challenge for Head Start programs serving infants and toddlers (Administration on Children, Youth and Families [ACYF], 2000), as there are relatively few resources available to meet the needs of our youngest children. In order to support programs in this area, ACYF held a national meeting, the Infant Mental Health Forum, in October 2000, which led to the funding of the Early Head Start National Resource Center at Zero to Three to engage in training and technical assistance activities designed to raise awareness and create and disseminate resources for programs (http://www.ehsnrc.org). In addition, ACYF has funded the Early Promotion and Intervention Research Consortium (http://www.acf.hhs.gov/programs/opre/ehs/epirc/index.html) to develop and test approaches that support the mental health of infants and toddlers and their families in Early Head Start.

Why should Early Head Start be concerned with mental health?

Early emotional development, the parent-child relationship in particular, set the stage for a child's exploration and readiness to learn. From the first moments of life, infants begin to develop notions about themselves and the world within the context of relationships. A number of family factors can pose challenges to the development of supportive parent-child relationships. These challenges can put the child at risk for developing social-emotional and learning difficulties. Such factors include biological characteristics of the child and parental mental health issues, domestic violence, lack of social supports, homelessness, and stress associated with poverty. Responsive and supportive early childhood settings, like Early Head Start, can play a critical role in supporting healthy development of the parent-child relationship and promoting the emotional health of children. If problems do arise over time, program staff have the necessary relationships with families to provide or coordinate referrals to needed services.

There was a very high rate of depression in Early Head Start families. Maternal and paternal depression was associated with less optimal child development and family functioning. While Early Head Start did not have an impact on reducing depression in parents or increasing the use of mental health services, families who participated in Early Head Start experienced more positive outcomes than those who did not participate in Early Head Start.

Summary of Findings

The Early Head Start Research and Evaluation Project found a high rate of depression in Early Head Start families. Although Early Head Start did not have a significant impact on reducing depressive symptoms or on increasing the use of mental health services, the program did help parents in relationships with their children. Positive impacts were found for parent-child interaction and children's social-emotional development. Furthermore, among those families in which mothers were depressed at enrollment, Early Head Start had even stronger favorable impacts on parent-child interaction.

While Early Head Start does not reduce symptoms of depression, the program does help parents in their relationships with their children.

Findings from the Early Head Start Research and Evaluation Project

How prevalent was depression in Early Head Start families?

At enrollment, when one quarter of the mothers were pregnant and all children were under 1 year old, more than half (52%) of mothers reported enough depressive symptoms to be considered depressed. One third of mothers of 1-year-olds and one third of mothers of 3-year-olds were depressed. For some women (12%), depression was chronic, that is, these mothers were depressed when their children were both 1 and 3 years old.

Rates of depression for Early Head Start fathers were also notable. Eighteen percent of Early Head Start fathers reported enough symptoms to be considered depressed when children were 2 years old; 16% met those criteria when their children were 3 years old.

Was parental depression associated with impairment?

Although not all parents experiencing depression had difficulty parenting and not all children of depressed parents had developmental difficulties, overall, this study replicated previous research in that maternal and paternal depression were associated with poorer child functioning and increased aggressive behavior in children, as well as increased negative parenting behavior, parenting stress, and family conflict. Families with chronic maternal depression when children were 1 and 3 years old were particularly at risk for all of these problems.

Did families use mental health services?

By the time of exit from Early Head Start, 23% of the families reported that at least one family member had received mental health services. Twenty-one percent reported that a family member had received treatment for an emotional or mental health problem, and 5% reported that a family member had received drug or alcohol treatment.

Thirty-two percent of mothers who were depressed at enrollment reported that at least one family member had received mental health services.

Did Early Head Start have an impact on parental depression or use of mental health services?

While Early Head Start had no effect on maternal or paternal depression or on family use of mental health services, the program did help parents in their relationships with their children. Children in Early Head Start were less aggressive and had more positive parent-child interaction than their peers who did not receive Early Head Start. Early Head Start parents (both mothers and fathers) were also less likely to use harsh discipline strategies; they had a wider array of positive strategies to cope with parent-child conflict.

There were many notable positive impacts for those families in which the mother was depressed at the time of enrollment. Depressed women who were in Early Head Start were more positive and less negative in interactions with their children. Also, their children were more engaged, more attentive, and less negative in interactions than their peers who did not receive Early Head Start. These are important findings because they demonstrate that Early Head Start can and does engage women who are depressed and can have important impacts for them and their children, particularly in the area of parenting.

There was some indication that Early Head Start may have slightly reduced depression in women who were depressed at enrollment and women who were enrolled in programs that fully implemented key elements of the Head Start Program Performance standards early. (For more details on how implementation was assessed, see Pathways to Quality, ACYF, 2002.)

Implications for Program Improvement

Early Head Start programs should continue to focus on the parent-child relationship. It is critically important to help parents support their children's development and to grow in their own roles as parents. A confident mother, father, or caregiver (depressed or not) gives the child an enduring gift of worth and value as a person with every responsive interaction. Programs can help parents see how interactions with their children during everyday routines have a powerful influence on their children's development. Furthermore, the safe and supportive relationships that staff form with parents are a model for how parents can create a nurturing and supportive environment for their children.

Many Early Head Start families are living with depression and other mental illnesses. Programs must find culturally appropriate and effective treatments. There are many ways that programs can access treatment for families, both within the program and in the wider community. Mental health consultants are used to support staff and work with families or provide timely and effective referrals to mental health services. Community partnerships are also critical for maintaining referral sources.

Although Early Head Start staff may not provide mental health therapy to children and families, they can still be therapeutic and supportive in the way they relate to depressed families. A high-quality program that meets the Performance Standards may be beneficial on its own. Providing social support and emotional connections to parents is an important family development goal that may be immensely helpful to those struggling with depression. In particular, home visits and family service staff who recognize the signs of parental depression (and have knowledge of the mental health referral process in their locale) can build relationships with depressed families and may assist them in accepting intervention from mental health professionals.

photo of a woman hugging a child

At enrollment... more than half (52%) of mothers reported enough depressive symptoms to be considered depressed.

In order for staff to provide a nurturing and supportive environment for families, they must be nurtured themselves. Although the work is rewarding, it can often be challenging to work with families facing mental health issues. Programs need to provide supports for staff, including reflective supervision, mental health consultation, training on mental health issues, and community partnerships to facilitate referral sources.

Cultural differences may influence how individuals express their emotions and how they view mental health services. Families may be more comfortable with staff members and mental health professionals who are from the same culture and speak the same language.

In order to fully individualize program services for families, program staff should inquire about mental health issues for mothers and fathers at the time of enrollment and periodically throughout their time in the program. Early care providers are in a unique position to observe families over time and can recognize if problems are fleeting, emerging, or changing over time.

Measuring Depression

There are two main ways to measure depression. Symptoms checklists have cutoff scores indicating levels of risk for depression. Symptom checklists allow the user to track how symptoms change over time and determine when to refer families to a specialist for additional assessment, diagnosis, and possible intervention. Diagnostic interviews use more stringent criteria for meeting diagnosis and require more training to administer and interpret, because interviewers actually determine diagnoses.

For more information on assessment instruments, see Resources for Measuring Services and Outcome in Head Start Programs Serving Infants and Toddlers (ACYF, 2003).

The Study

The Early Head Start Research and Evaluation Project included studies of the implementation and impacts of Early Head Start. The research was conducted in 17 sites representing diverse program models, racial/ethnic makeup, auspice, and region. In 1996, 3,001 children and families in these sites were randomly assigned to receive Early Head Start services or to be in a control group who could utilize any community services except Early Head Start. Children, families, and children's child care arrangements were assessed when children were 14, 24, and 36 months old, and families were interviewed about services at 7, 16, and 28 months after random assignment. Families in the program and control groups were demographically comparable at baseline and assessment points. Information for this research brief includes maternal ratings of depressive symptoms collected using the Center for Epidemiologic Studies Depression Scale (CES-D) when children were 14 and 36 months old and information on service use by 28 months after enrollment. In addition, mothers in eight of the research sites completed ratings of depressive symptoms at the time of enrollment, and fathers in 12 of the research sites also completed ratings of depressive symptoms when children were 24 and 36 months old. Several research briefs have been published based on findings from this study. A prekindergarten followup was completed and a 5th grade followup is currently underway.

Radloff, L.S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

photo of a woman and child preparing food

Web Resources

Child Outcomes Research and Evaluation: http://www.acf.hhs.gov/programs/opre/
Resources at this Web site include the following:
(1) A commitment to supporting the mental health of our youngest children: Report from infant mental health forum (ACYF, 2000)
(2) Early Promotion and Intervention Research Consortium
(3) Full reports from the Early Head Start Research and Evaluation Project
Early Head Start National Resource Center: http://www.ehsnrc.org/
Head Start Information & Publication Center: http://www.headstartinfo.org/
Resources at this Web site include the following:
(1) Head Start Mental Health Tool Kit
(2) Ordering information for Early Head Start research reports
National Mental Health Association: http://www.nmha.org/