Prioritizing caregiver mental health to promote child health

Stress and mental health disorders among parents and caregivers (hereafter called caregivers) in the U.S. have been rising at an alarming rate. The COVID-19 pandemic underscored the pressing mental health needs of caregivers, who faced heightened financial and childcare pressures, and revealed deep-seated inequities in access to healthcare, disproportionately affecting racial, ethnic, and economically marginalized groups due to structural racism and discrimination. This compounded the existing disparities in caregiver stress faced by marginalized and under-resourced communities. Caregiver stress and mental health disorders have profound effects on children’s health, socioemotional development, and represent an important adverse childhood experience.¹ Recently, the U.S. Surgeon General released a report highlighting the critical need to address stress in caregivers and to support caregiver well-being.² Significant work remains to ensure comprehensive mental health support for caregivers in the prenatal and postnatal periods.

Maternal mental health has profound effects on children

Supporting caregivers with mental health challenges is essential to fostering healthy, positive childhood experiences and promoting long-term well-being for children.³ Maternal mental health is closely tied to child developmental and behavioral outcomes, including social skills,⁴ mental health,⁵ and academic success.⁶ Caregivers with better mental health are more likely to engage in positive parenting practices that promote optimal development.⁷ We have an urgent responsibility to support caregivers and provide multigenerational solutions to ensure optimal caregiver mental health & stress management.

Less is known about the impact of maternal mental health on children’s physical health. In the article by Geiger et al.⁸ the authors sought to evaluate associations between maternal psychosocial stress in the pre-and postnatal periods and child sleep problems and disturbances. The authors utilized data from a national cohort of biological mother-child dyads in the United States, in which maternal stress and child sleep were evaluated via validated measures. Their results demonstrate that maternal prenatal stress is associated with increases in child disturbances and, further, that postnatal maternal stress is a key mediator. These novel findings underscore the impact that caregiver mental health can have on child health and well-being throughout a child’s lifespan, even in the prenatal period. These results also emphasize the importance of promoting policies and programs that support maternal mental health in the perinatal period and beyond.

Supporting fathers and other caregivers is critical

While much of the emphasis on caregiver mental health has centered on mothers, the mental health of fathers and other caregivers is equally vital for child well-being. Geiger et al.’s study⁸ does not account for stress among other caregivers, which is an important limitation. Like mothers, fathers and other caregivers with greater stress and mental health needs may encounter obstacles in fostering positive socioemotional outcomes in children.^9,10 Caregivers, including grandparents and kinship foster parents, often face unique social and emotional demands and benefit from additional community resources and support.¹¹ Addressing the mental health of all caregivers proactively can enhance parenting or co-parenting dynamics and contribute to a nurturing, resilient family environment.

Disparities in caregiver stress

Significant disparity exists in the experience of caregiver stress and mental health. Families who have experienced racial, ethnic, and economic marginalization face structural inequities that increase toxic stress for caregivers and children and contribute to social and environmental influences of health. While the study by Geiger et al.⁸ includes a racially and ethnically diverse cohort, it is not educationally diverse, as more than 83% of participants reported having some college education. Educational attainment is linked to economic and health outcomes; by under-representing people with lower educational attainment, it may miss other poverty-related stressors. Relatedly, many factors can contribute to maternal stress in the perinatal period, including the mother’s life condition, which could magnify the child’s stress, impacting sleep. Social and environmental factors often play an intensified role for communities affected by racial, ethnic, economic, and LGBTQ+ inequities. Both appreciation of these inequities and integration of active approaches to address them and the downstream effects should be foundational to supporting caregiver mental health.

The study by Geiger et al.⁸ highlights the associations of psychosocial stress in the prenatal period with child sleep problems, with postnatal stress acting as an important mediator; these results highlight the need for caregiver mental health support both during the perinatal period and throughout childhood. The American Academy of Pediatrics recommends routine screening and referrals for postpartum depression among mothers during infant preventive care visits,¹² yet many mothers are not screened.¹³ And, there are few structured and evidence-based practices for screening caregivers outside of the perinatal period.¹⁴ To increase impact, we must not only improve identification, but also shift beyond simply screening for caregiver mental health to a broad-based, integrated, and multidisciplinary approach. These efforts should extend beyond the perinatal period to support caregivers of children of all ages.

Models to support caregiver mental health

Pediatric clinicians are well poised to offer integrated resources for caregiver mental health, given their frequent contact with families through recommended well visits and opportunities to build trusted relationships.¹⁵ Several existing models provide integrated mental health services and social support for both caregivers and children (Table 1). Additionally, there is growing momentum toward implementing caregiver mental health services, particularly for maternal postpartum depression, in emergency departments and inpatient hospital settings. These efforts are laudable but can lack universal access; they often focus on screening with referrals or targeted treatment of families who are selected based on income level or other tiered risk assessment.

Table 1 Examples of Models for Supporting Caregiver Mental Health in Pediatrics.

One potential solution for improving caregiver support in pediatric settings is universal education, empowerment, and resource provision. Unlike the traditional “screen and refer” approach, where only caregivers screening positive for mental health concerns receive resources, universal empowerment recognizes that caregiver depression and parenting stress are common, and there may be reasons caregivers do not wish to disclose during pediatric visits. In a universal empowerment approach, all caregivers are provided brief strengths-based information about caregiver mental health and resources, regardless of disclosure. This approach has been used successfully in violence prevention interventions in healthcare settings and is recommended by the American Academy of Pediatrics as the way to support caregiver survivors of partner violence.¹⁶ Future work should develop and test universal empowerment approaches in pediatric settings to support families with mental health concerns and stressors. These approaches should be co-created with families to ensure they are optimally meeting the needs of caregivers and connecting them with resources. Payors must also find ways to reimburse for caregiver mental health universal empowerment, rather than only for screening.

Payment models for caregiver mental health in pediatric care are needed

The National Academies of Science, Engineering, and Medicine (NASEM) recently released a consensus report on promoting lifelong health by improving healthcare for children, youth, and families.¹⁷ The report recommends reforming payment models to support and reimburse clinicians working with families and communities, particularly in relation to integrated mental health screening and empowerment. Dyadic care represents an opportunity for pediatric clinicians to provide services to both children and caregivers simultaneously, a practical approach that can reduce barriers to services.¹⁸ However, current payment structures vary greatly on a state-by-state basis; for example, there are only 32 states that provide Medicaid reimbursement for maternal depression screening during pediatric visits.^19,20 While 42 states report Medicaid payment for dyadic services, few states allow for reimbursement based on the caregiver’s needs or diagnoses, such as for postpartum depression. Thus, programs providing dyadic care specifically in relation to caregiver mental health are often reliant on philanthropic funding that cannot sustain services in a consistent and long-term manner. Reforming payment models to support the mental health of caregivers – and thus support the health of children – is critically needed.

Call to action

Supporting family mental health positively impacts children’s physical and emotional well-being. Expanding services for family mental health requires prioritizing the development, implementation, and sustainability of effective programs. To do this, we must conduct research on best practices and refine implementation strategies that consider the social and environmental influences on the health of the community they serve. To deepen our understanding of caregiver stress and mental health, we must use mixed-method approaches to contextualize caregivers’ experiences and co-create targeted, caregiver-focused tools and interventions alongside caregiver stakeholders. These interventions should be practical, validated for all caregivers, inclusive of historically marginalized groups and the inequities faced, and available in multiple languages. Interventions must be agile and tailored to the particular setting. Lastly, sustainable service provision depends on developing effective and lasting payment models.