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RESEARCH AND PRACTICE |
Mindy Herman-Stahl, Olivia Silber Ashley, Michael A. Penne, Karl E. Bauman, and David Weitzenkamp are with RTI International, Research Triangle Park, NC. At the time of the study, Molly Aldridge was with RTI International, Research Triangle Park, NC. Joseph C. Gfroerer is with the Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Rockville, Md.
Correspondence: Requests for reprints should be sent to Mindy Herman-Stahl, PhD, RTI International, PO Box 12149, Research Triangle Park, NC 27709-2149 (e-mail: mindy{at}rti.org).
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ABSTRACT |
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Objectives. We compared the prevalence of serious psychological distress among parenting adults with the prevalence among nonparenting adults and the sociodemographic correlates of serious psychological distress between these 2 populations.
Methods. We drew data from 14240 parenting adults and 19224 nonparenting adults who responded to the 2002 National Survey on Drug Use and Health. We used logistic regression procedures in our analysis.
Results. An estimated 8.9% of parenting adults had serious psychological distress in the prior year compared with 12.0% of nonparenting adults of similar age. In both groups, the adjusted odds of having serious psychological distress were higher among adults who were women, younger (between the ages of 18 and 44 years), low income, or receiving Medicaid. We found some differences in the correlates of serious psychological distress between parenting adults and nonparenting adults. The odds of having serious psychological distress were lower among parenting adults after we controlled for demographic characteristics.
Conclusions. Serious psychological distress is fairly prevalent among parenting adults, and high-risk sociodemographic groups of parenting adults should be targeted to ensure access to coordination of services.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Children of parents with psychiatric disorders experience elevated risks for psychiatric disturbance and academic, social, and emotional impairments.3,13,28–32 Rates of psychiatric disorders among children with mentally ill parents range from 30% to 50%,33,34 compared with 20% among children overall.35 Consequences of parental mental health problems include insecure mother–child attachment and delayed development in infants; aggression, destructive behavior, and impaired development in toddlers; and physical and psychological problems, school failure, substance use, suicidal behaviors, social withdrawal, cognitive impairment, and poor overall adjustment for school-aged children.28 Unfortunately, many mental health agencies do not collect basic information on clients’ parenting status, which could be used to assess potential risk to their children,36 and assistance with appropriate parenting skills is rarely provided.30,37–41
Mental illness among parents has drawn national attention in recent years.36,42–44 Data from the National Comorbidity Survey (NCS) show that the lifetime prevalence of psychiatric disorders is similar for mothers and for all women in the general population, but the prevalence for fathers is lower than for all men in the general population.40,44 However, parents in the NCS were older and more educated than the general population, and the data examined biological parents, regardless of the child’s age or whether the child lived with the parent; step-parents, adoptive parents, and foster parents raising children were not included. Another recent analysis of parenting and mental illness used 1987–1988 data,43 which could not address changes in family demographics, social policy, and mental health treatment practices that have occurred during the past 19 years.
Identifying subgroups of parenting adults most vulnerable to mental illness is important for prioritizing risk factors for targeted interventions; it can also be a first step toward identifying parents with co-occurring mental illness and substance use problems. However, correlates of mental illness among parenting adults have not been examined. Among the general population, the prevalence of mental illness is significantly higher among women, young adults (those aged 18–34 years), those with lower income or education, divorced or separated individuals, and Medicaid recipients.40,41,45–48 Findings about the prevalence of mental health problems by race/ethnicity, employment status, and urbanicity have been mixed.41,46,49–51 A recent analysis using a national sample considered multiple risk factors in a regression model and identified younger age (ages 18–49 years), divorced or never married status, poorer perceived overall health, and lack of social support as correlates of mental illness; Black or Hispanic race/ethnicity was a protective factor.14
To better plan for mental health services for parenting adults, we examined the prevalence and sociodemographic correlates of serious psychological distress, which is highly correlated with affective and anxiety disorders,52 among adults interviewed in a nationally representative survey of the US population. We sought to answer 5 questions: (1) What is the prevalence of past-year serious psychological distress among parenting adults? (2) Among parenting adults, what subgroups were most likely to have serious psychological distress? (3) Were there differences between parenting and nonparenting adults in the prevalence of serious psychological distress? (4) Were there differences between parenting and nonparenting adults in the correlates of serious psychological distress? (5) Do differences in prevalence of serious psychological distress between parenting and nonparenting adults exist after control for sociodemographic characteristics?
We were particularly interested in comparisons between parenting and nonparenting adults by race/ethnicity, employment status, and urbanicity, because the literature on the general population is inconclusive about these potential correlates. On the basis of NCS findings, we hypothesized that any differences between parenting and nonparenting adults would not be statistically significant after we controlled for sociodemographic differences. To our knowledge, comparisons between parenting and nonparenting adults regarding past-year risk of serious psychological distress and high-risk subgroups have not been addressed in previous research.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The survey assessed current household composition and relationships of household members to the respondent. We based our estimate of the number of parenting adults on the subsample of adults aged 18 to 49 years living with at least 1 biological, step-, adopted, or foster child 17 years or younger (n=14240). We compared parenting adults with nonparenting adults from the same age group (n = 19224). Excluded from both groups were adults who reported having only unrelated children living with them and adults who reported having only adult children living with them. The NSDUH does not ask about relationships with individuals not living in the household, so we were unable to consider the status of adults in either group who may have children not living with them.
Study Variables
The 2002 NSDUH assessed past-year serious psychological distress using the K6 Scale of NonSpecific Psychological Distress.56,57 The K6 was originally designed for use in the core of the redesigned US National Health Interview Survey to measure the frequency of commonly occurring symptoms of psychological distress.58 It measures a heterogeneous set of cognitive, behavioral, emotional, and psychophysiological symptoms that are commonly high among adults with a wide range of mental disorders.57 A 5-point Likert scale (Cronbach 
= .89) was used to rate the frequency of experiencing 6 symptoms, ranging from none of the time (0) to most of the time (4). Symptoms included the following: feeling (1) nervous, (2) hopeless, (3) restless or fidgety; (4) being so sad or depressed that nothing could cheer one up; (5) a feeling that everything was an effort; (6) being "down" on oneself, feeling that one is no good or worthless.
Respondents rated the frequency of the 6 symptoms during the 1 month out of the past 12 when they felt the most depressed, anxious, or emotionally stressed. Responses were combined to produce a score ranging from 0 to 24, with a score of 13 or above indicating probable serious mental illness.52,57 Subsequently, the NSDUH renamed the K6 measure "serious psychological distress" because it was not considered a sufficiently reliable predictor of serious mental illness but a measure of psychological distress.59 Social, demographic, and geographic characteristics assessed by the NSDUH included age, gender, race/ethnicity, total annual household income, education, marital status, employment status, Medicaid status, type of county of residence (rural or urban), and region of residence. Independent variables were coded as categorical.
Data Analysis
We analyzed the data using SUDAAN version 8.0 (Research Triangle Institute, Research Triangle Park, NC), which applied a Taylor series linearization method to account for the NSDUH’s complex design features. First, we calculated the prevalence of serious psychological distress among parenting adults aged 18 to 49 years. We used the 
2 test and logistic regression procedures to identify sociodemographic correlates of serious psychological distress among parenting adults. We calculated bivariate (unadjusted) odds ratios by fitting 1 sociodemographic covariate to serious psychological distress at a time. We then used multivariate logistic regression procedures to include in 1 model all sociodemographic characteristics (i.e., adjusted model) predicting serious psychological distress among parenting adults.
Next, we calculated the prevalence of serious psychological distress among nonparenting adults aged 18 to 49 years, and we ran the adjusted model for this comparison sample. To test our hypothesis that any differences in prevalence of serious psychological distress between parenting and nonparenting adults would not be statistically significant after adjustment for sociodemographic characteristics, we ran a multivariate model using the total sample of all adults aged 18 to 49 years, including an indicator variable for parenting. All results are weighted national estimates.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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presents a comparison of weighted national estimates of population characteristics among parenting and nonparenting adults. Compared with parenting adults, nonparenting adults were disproportionately male, young (between the ages of 18 and 44 years), and single. Parenting adults were more likely than nonparenting adults to have a household income greater than $75 000; however, a larger proportion of parenting than nonparenting adults also received Medicaid.
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The unadjusted odds of having serious psychological distress were highest among parenting adults who were younger, had total annual household incomes of less than $50 000, had less than a college degree, were divorced or separated, or were Medicaid recipients (Table 2). The odds were lowest among parenting adults who were men, Hispanic, married, employed full-time, or residents of large metropolitan areas. Our findings are similar, but not identical, to the 1990–1992 findings from the NCS.40
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). Additionally, the adjusted odds were lowest among male, Hispanic, American Indian/Alaska Native, Black, or married parenting adults. Employment status and urbanicity were not statistically significant correlates of serious psychological distress among parenting adults in the multivariate analysis. Young age and low income were strong risk factors in both the adjusted (multivariate) and the unadjusted (bivariate) models, although the strength of the associations decreased when we controlled for other sociodemographic variables. There were slight differences between the 2 models. In the adjusted model, American Indian/Alaska Native and Black parenting adults were less likely than were White parenting adults to have serious psychological distress. The strength of the protective association between married status and serious psychological distress decreased, but the odds of serious psychological distress among divorced or separated parenting adults increased, when we controlled for other sociodemographic variables. Moreover, full-time workers and parenting adults living in large metropolitan areas were no more or less likely to have serious psychological distress than were unemployed parenting adults and those in nonmetropolitan areas when we accounted for other sociodemographic variables.
Differences in Serious Psychological Distress
Among nonparenting adults aged 18 to 49 years, the prevalence of serious psychological distress in 2002 was 12.0%, higher than the 8.9% among parenting adults. Results from the multivariate logistic regression analyses differed somewhat between parenting and nonparenting adults (Table 2). For example, the strength of the association between low household income and serious psychological distress was greater among parenting adults (odds ratio [OR] = 2.00; 95% confidence interval [CI] = 1.43, 2.80; P < .001) than among nonparenting adults (OR = 1.51; 95% CI = 1.15, 1.98; P < .01). Among nonparenting adults, Asian/Pacific Islanders had a lower risk of serious psychological distress than did Whites, but there was no statistically significant difference between Asian/ Pacific Islander and White parenting adults. American Indian/Alaska Native parenting adults were less likely than were White parenting adults to have serious psychological distress, but the adjusted odds were similar for the 2 groups among nonparenting adults. In addition, among nonparenting adults, the odds of having serious psychological distress were lower for individuals employed full- or part-time than for unemployed individuals. Nonparenting adults who lived in a large metropolitan area were more likely than those living in nonmetropolitan areas to have serious psychological distress, although urbanicity was not associated with serious psychological distress among parenting adults.
Finally, because parenting and nonparenting adults are very different on demographic variables, we conducted a multivariate analysis of the total population of adults aged 18 to 49 years, including an indicator variable for parenting. Even after we controlled for sociodemographic variables, the odds of having serious psychological distress were lower among parenting than among nonparenting adults of similar age (OR = 0.76; 95% CI = 0.67, 0.88).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Alternatively, adults with greater serious psychological distress may choose not to have or raise children. In our study, parents with the most severe psychological distress may have had to place their children in alternative care and thus would not be included in our sample of parenting adults. In fact, studies have reported rates of child custody loss of as high as 70% to 80% among mentally ill parents.36 Moreover, other researchers have suggested that parenting adults may be more reticent to report symptoms that could be construed as interfering with their parenting roles.60 Because parenting adults in our study were more likely to be married than were nonparenting adults, it is possible that parenting adults enjoyed higher levels of social support (for example, from partners or spouses, grandparents, or in-laws61,62), which are associated with decreased risk of serious psychological distress.14
Consistent with the literature about the general population,40,41 our findings showed that the prevalence of adverse psychological symptoms was generally higher among parenting adults from low-income households. Low income has consistently been linked to psychological symptoms related to high stress, more exposure to crime and violence, inadequate housing, and financial insecurities.14 However, our findings suggest that low income creates more risk for parenting adults (twice the odds of high income) than for nonparenting adults. A review of the literature on poverty, single-parent status, and mental health has shown that the population of single-parent mothers is growing, that they are becoming increasingly poor, and that the stress associated with being a low-income, single parent contributes to psychological distress.63
We found that Asian/Pacific Islander nonparenting adults were less likely to have serious psychological distress than were nonparenting Whites, but Asian/Pacific Islander parenting adults did not enjoy this same protective effect. Asian/Pacific Islander parenting adults have been found to be less likely than White parenting adults to attribute mental illness to physiological causes,64 and this orientation may lead to self-blame for mental illness, increased psychological distress, and decreased help-seeking. Understanding Asian culture and its relation to psychological distress and help-seeking may help providers establish culturally sensitive interventions; decrease family stress; increase positive coping, adaptation, and family function; and improve parenting and child mental health, behavior, and development.65
Interestingly, we found differences in the adjusted odds for experiencing serious psychological distress based on employment status among nonparenting adults, but not among parenting adults. Serious psychological distress may make an individual less likely to choose to have or raise children and also cause significant enough disability to impair the likelihood of success in employment. Alternatively, parenting may interfere with the fulfillment of employment responsibilities,66 thus preventing some parents from keeping a job even when they want to work, regardless of their mental health status. However, functional impairments because of serious psychological distress may be more likely to contribute to unemployment among nonparenting adults. Because a greater proportion of parenting adults than nonparenting adults were married, serious psychological distress may be more strongly related to unemployment among nonparenting adults, who may lack the protective effect of an employed partner or extended family.
Limitations
Several limitations of this study should be considered. The analyses were based on cross-sectional data; thus, they represent a single snapshot in time and cannot capture the dynamic nature of psychological symptomatology. Also, cross-sectional data preclude assessing the temporality of some associations and thereby yield only relational inferences about them, such as that parenting might be a cause or consequence of serious psychological distress, and marital or employment status might be a cause or consequence of serious psychological distress. Furthermore, confounding factors linked to demographic characteristics, parenting status, and serious psychological distress may explain findings.
Second, data in our study were based on self-report. Because of the stigma associated with psychological problems, individuals may be uncomfortable reporting on poor emotional well-being. Third, despite the large and representative sample, the NSDUH excludes active military personnel, homeless people, and individuals living in institutional group settings, such as prisons, nursing homes, and treatment centers. Two of these subpopulations—the homeless and clients of treatment centers—are known to have high levels of psychological problems.67,68 Thus, the prevalence estimates may be conservative.
Our prevalence estimates were lower than the 1-year prevalence rate of psychiatric disorders found by the Epidemiological Catchment Area (ECA) Survey (19.5%)69 and the NCS (29.5%)40 or the best estimate of 1-year prevalence of mental disorders cited by the National Institute of Mental Health (21.0%).70 There are important methodological differences that make direct comparisons across studies difficult. First, the K6 is a screening tool designed to identify those with a high level of serious psychological distress, which is predictive of serious mental illness, whereas the NCS and ECA studies were designed to identify psychiatric conditions assessed by fully structured diagnostic interviews. Second, the NCS and ECA studies included psychiatric disorders not predicted by the K6, such as schizophrenia, nonaffective psychosis, anorexia nervosa, antisocial personality disorder, and severe cognitive impairments. Third, the prevalence rates for the ECA Survey were based on data for adults 18 years or older, and prevalence rates for the NCS on data for individuals aged 15 to 54 years. Fourth, the ECA Survey included institutionalized populations.
Our estimates are more comparable to the estimate of frequent mental distress as assessed by the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (8.6%)45 but higher than estimates of serious psychological distress found by the National Health Interview Survey (3.1%), which measured serious psychological distress during the past month58 rather than during the worst month of the past year. When comparing our estimates of serious psychological distress with other estimates based solely on past-year affective disorders, we found that our estimates were higher than that of the ECA Survey (7.1%) but similar to that of the NCS (11.3%).40,69
The K6 validation study was conducted on a convenience sample of 155 adults from the Boston metropolitan area, and the results may not be generalizable to suburban or rural populations or representative of the racial/ ethnic, socioeconomic, or educational distribution of the nation.52 Additional research is needed to validate the K6 on more-diverse samples and compare it with other measures of serious psychological distress designed for large-scale community samples. In addition, although measures like the K6 are useful for weeding out individuals unlikely to have psychiatric disorders, psychiatric interviews are still the gold standard for identifying and diagnosing psychological problems.71
Finally, our study was limited by our inability to assess the global functioning of parents, their coping resources, and other psychosocial information. The impact of serious psychological distress on parenting and family life varies with the age at onset, severity, and duration of psychological problems; the nature of any consequent impairment in parental functioning; and the strengths and resources of parents and family members.36 Parents with strong social support networks, stable partnerships, and access to effective treatment may enjoy a higher level of functioning and may recover more quickly, thus attenuating the effects of their psychological symptoms on their children.
Conclusions
Screening may need to be emphasized for adults without direct (in-home) child-rearing responsibility, because these adults are at higher risk for serious psychological distress than are parenting adults and because the number of nonparenting adults exceeds the number of parenting adults. However, serious psychological distress is fairly prevalent among parenting adults, affecting an estimated 5.6 million of them in the United States. We recommend implementing screening, education, early intervention, and treatment referral procedures within agencies or organizations that have frequent contact with the highest-risk group of parents, low-income parents (e.g., Medicaid agencies, Temporary Assistance for Needy Families offices, Head Start, housing authorities, and Special Supplemental Nutrition Program for Women, Infants, and Children).
A recent study found a high rate of depression in Early Head Start families; at enrollment, when one quarter of all children served were younger than 1 year, 48% of mothers reported a high enough level of affective symptoms to be considered depressed.72 The study concluded that programs should identify effective, culturally appropriate treatments; establish community partnerships to maintain referral sources; train staff on how to recognize signs of parental mental illness and refer parents to treatment; and reach out to families dealing with mental illness.
It is also important for all providers to note that keeping a job does not protect parents from serious psychological distress as it does nonparents; potential sources of referral for services for parents should take care not to use employment as a crude screening mechanism to "rule out" mental illness when assessing parent and family needs. Because Asian/ Pacific Islander parents do not exhibit the same decreased risk of serious psychological distress that Asian/Pacific Islander nonparents show, it may be beneficial to implement outreach or screening efforts among agencies or providers serving Asian parents raising children. Increased screening, access, and coordinated and culturally appropriate mental health treatment that address parenting issues for high-risk groups of parenting adults are crucial for reducing the public health burden of parent mental illness.
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Acknowledgments |
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We thank Mary Ellen Marsden and Carol Offen for helpful reviews and editing.
Human Participant Protection
The original National Survey on Drug Use and Health study procedures were approved by RTI’s Committee for the Protection of Human Subjects as well as the Office of Management and Budget.
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Footnotes |
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Contributors
M. Herman-Stahl led the writing of the article and contributed to the study design and implementation. O. S. Ashley led the design and implementation of the study and contributed to writing the article. M. A. Penne conducted the statistical analysis. K. E. Bauman assisted with study design and reviewed drafts of the article. D. Weitzenkamp assisted with statistical analysis. M. Aldridge assisted with writing and interpretation. J. C. Gfroerer conceptualized the study and reviewed drafts of the article.
Accepted for publication January 30, 2007.
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