Family mental health research – the importance of adopting a family lens in the perinatal period and beyond

In recent years, research on mental health during the perinatal period (i.e. from pregnancy up to one year after birth) has shown great advances, focusing on how to support (expectant) parents in this critical life stage when a family is formed or extended. However, per definition the perinatal period concludes when the family is still in its nascent stages, despite increasing evidence that the familial impact of this time-period holds the potential to span beyond these early years. This editorial thereby proposes that to comprehensively understand the significance of the formative perinatal period, a longitudinal perspective investigating child and family dynamics and outcomes beyond the first postpartum year is needed. In what follows we attempt to define the concept of ‘family mental health’ and outline key research gaps, highlighting how addressing these gaps could enhance early prevention and intervention for family well-being.

To start, there is no one-fits-all definition of family. Thinking broadly and inclusively about our understanding of family is relevant for tackling assumptions and maximising learning. A minimum criterion may involve two people, which may include an individual with their child or a couple without children. A family can be defined both objectively, through legislation that provides social and legal recognition, and/or through biological connectedness (e.g. including parents and grandparents), as well as subjectively, through a feeling of mutual belongingness. It remains a challenge for researchers studying families to balance representativeness with feasibility, such that inclusion of single parents, blended families and families formed using third party reproduction (including LGBTQ+ families), as well as multigenerational households is still lagging.

Based on this broad conceptualisation of family and drawing on systemic family theory, which characterises individuals as integral parts of a larger family system, we propose a two-part definition of family mental health. The first part encompasses multidirectional interfamily interactions and pertains to individual family members’ (typically parents and children) mental health and health-related quality of life influencing and being influenced by others in the family unit. Meta-analytic findings exemplify this interdependence, for instance, by showing in heterosexual couples a positive cross-sectional and prospective association between paternal and maternal depressive symptoms (Thiel et al., 2020). The second part refers to the collective well-being of the family unit as a whole. This includes notions of family well-being (i.e. holistic assessment of how satisfactory family life is), functioning (i.e. how family members communicate, express feelings, solve problems, and provide support), and resilience (i.e. a family’s ability to bounce back from challenges), as well as the quality of intra-family relationships (i.e. couple and parent-child relationships). Highlighting their importance, family functioning has been found to explain the relationship between adversities and child mental health problems (Scully et al., 2020). Thus, we define family mental health as the psychological well-being of the collective family unit and its individual members, including multidirectional interactions and dynamics across time within the family system.

This definition sparks new research questions in perinatal and family mental health research, particularly highlighting the need for a holistic long-term perspective, as outlined subsequently. Firstly, early environments, parenting, and life experiences may have enduring implications for the mental health of parents and their children throughout their lives in the form of long-term or ‘sleeper’ effects (i.e. delayed effects that surface once behaviour is activated). For example, initial research reports small effects of maternal postpartum depressive and anxiety symptoms on paternal anxiety and child emotional problems when the child is aged 11–12 years (Walker et al., 2020). This underscores the need to better understand the most effective paths of prevention and intervention to promote positive longer-term outcomes as well as potential moderating circumstances. This approach requires longitudinal assessments starting in the perinatal period and continuing into adolescence, further allowing investigation of (symptom) trajectories, change patterns, antecedents, and sequelae within family mental health. Secondly, some studies indicate timing effects of exposure, i.e. that effects may be significantly greater if experienced within certain periods (e.g. during the preschool years; Naicker et al., 2012), although the literature is inconclusive to date. Thus, investigations across different age windows in childhood are crucial, as symptom trajectories across later childhood and adolescence may vary depending on the child’s age at initial exposure to parental mental health symptoms or frequency of exposure, including the perinatal period and beyond. Third, examining intra-family relationships and family functioning longitudinally represents an important avenue to identify ways to sustainably support families and foster systemic resilience. Initial findings already suggest healthy family functioning and positive intra-family relationships are important resources and protective factors for the mental health of family members (e.g. Dinh et al., 2017). Yet more research is needed to understand how family relationships and functioning develop during the perinatal period and onwards, also considering changes to family composition in terms of children and caregivers. Finally, we encourage a relational (i.e. focusing on dyadic and triadic effects) as well as a biopsychosocial (i.e. investigating how stress is physiologically related between family members; Dauegaard et al., 2020) perspective. Large longitudinal birth cohort studies that combine multiple methods (i.e. quantitative, qualitative, and biological research) and examine the family as a whole far beyond early childhood, such as the Dresden Study on Parenting, Work, and Mental health (Kress et al., 2019), offer valuable insights into long-term family mental health in the context of nuclear families. This kind of research can meaningfully contribute to a comprehensive understanding of interactional and physiological processes in families and how they impact individual and family well-being across time.

Principles of Thinking Family and the Perinatal Frame of Mind that consider multiple family members’ needs and their interplay (Darwin et al., 2021) are gaining traction in clinical and research contexts, and this editorial illustrates the potential of extending this longitudinally as families develop. Embracing the approach outlined here can contribute to a better understanding as well as development of interventions addressing the complexities of long-term family well-being. Hereby, we move closer to the overarching goal of supporting families by promoting strengths and resilience within family systems from the perinatal period and beyond.

Disclosure statement

No potential conflict of interest was reported by the author(s).