It is common knowledge that parents – including their emotions, parenting styles, and more – have an influence on their children. Research has highlighted numerous important mechanisms regarding the type and magnitude of influence parents can have on their offspring, including findings that offspring of parents with mental health disorders are at greater risk of mental illness themselves (McLaughlin et al., 2012). However, historically, the relationship between fathers’ mental health and that of their children has received far less attention than the influence of maternal mental health, a phenomenon that is likely due to gender norms wherein women are assumed to be the primary caregivers.

In acknowledgement of the growing importance of the paternal role in caregiving and the increasing diversity of family structures, there is a developing body of research focused on the influence of paternal mental health on offspring outcomes. This includes research looking at anxiety, which is one of the most common mental health disorders with a prevalence of 2.2%-3.8% in men (World Health Organization, 2017). Paternal anxiety has been shown to be associated with a variety of mental health outcomes in their offspring, including internalizing problems (Connell & Goodman, 2002) and anxiety (Ahmadzadeh et al., 2019).

However, there has yet to be a comprehensive systematic review and meta-analysis which synthesises this body of work, which is a gap that Zecchinato and colleagues (2024) aimed to address.

Methods

The study was pre-registered via PROSPERO and followed the standardised PRISMA guidelines for conducting systematic reviews and meta-analyses.

The authors searched four databases for published studies, as well as two further databases for grey literature. Studies were included if they were quantitative, measured father’s anxiety via self-report or diagnostic interview, and measured emotional and/or behavioural outcomes in the father’s offspring.

After screening, data was extracted, and correlation coefficients were pooled in random-effects meta-analyses. Study quality was assessed using the Newcastle Ottawa Scale and 25% of studies were double-rated. Study quality was generally high, with an average score of 0.68 (after conversion to a 0-1 scale, undertaken by blog author). A meta-regression was also conducted using variables including age and sex of offspring, assessment type, and location.

To account for the nested structure of the data (i.e., multiple effect sizes reported per study, multiple studies drawn from the same sample), the authors employed multilevel model techniques.

Results

Although 155 eligible papers were identified, 57 did not have the data available to be meta-analysed. Hence, 98 studies were included in this meta-analysis, drawn from 83 samples, and representing 322 effect sizes and 54,998 participants.

Meta-analyses of the associations between paternal anxiety and five outcome measure groups (hereafter referred to as ‘groups’) were conducted:

• Emotional and behavioural: Using data from 83 samples, offspring emotional and behavioural problems were significantly associated with paternal anxiety (r = 0.16, 95% CI [0.13 to 0.19], p < .001).
• Behavioural: Using data from 27 samples, offspring depression problems were significantly associated with paternal anxiety (r = 0.19, 95% CI [0.13 to 0.24], p < .001).
• Emotional: Using data from 71 samples, offspring behavioural problems were significantly associated with paternal anxiety (r = 0.15, 95% CI [0.12 to 0.18], p < .001).
• Anxiety: Using data from 52 samples, offspring behavioural problems was significantly associated with paternal anxiety (r = 0.13, 95% CI [0.11 to 0.16], p < .001).
• Depression: Using data from 13 samples, offspring behavioural problems were significantly associated with paternal anxiety (r = 0.13, 95% CI [0.03 to 0.23], p = .01).

The meta-analyses were robust to sensitivity analyses, except for the association between paternal anxiety and offspring depression outcome measures, which became non-significant after excluding one study with especially large effect sizes which drew from the COVID-19 Pandemic Adjustment Survey (CPAS) sample (Westrupp et al., 2023).

A few moderating variables were found to be significant, including:

• Larger effects from Australian studies for the emotional and behavioural group and larger effects from Asia in the behavioural group.
• Larger effects for self-report questionnaires and smaller effects for diagnostic interviews in the emotional and behavioural, emotional, and anxiety groups.
• Larger effects for father-rated than parent-rated offspring outcome measures for emotional and behavioural, emotional, and anxiety groups.

It’s worth noting that it was not possible to perform all moderator analyses across all outcome measures, as not all studies measured all moderator variables analysed here. In particular, it was not possible to conduct the majority of moderator analyses for depression, as there were too few studies.

Conclusions

Anxiety in fathers was associated with a variety of negative emotional and behavioural outcomes in their offspring; hence, paternal anxiety seems to not only be associated with offspring anxiety, but with a range of mental health outcomes. The authors relate this finding to the concepts of multifinality and pleiotropy, wherein the same environment and the same gene, respectively, can lead to multiple outcomes.

The methods for analysing outcomes (i.e., who rated the outcome and how) were particularly impactful moderators of this relationship, although the authors note the potential influence of variability in statistical power across studies. The authors highlight that these findings are largely consistent with previous literature on paternal anxiety and offspring outcomes (Trepiak et al., 2023), with effect sizes comparable to those of maternal anxiety (Connell & Goodman, 2002).

Strengths and limitations

Strengths

• Using multilevel models for the meta-analysis allowed for a more robust estimation of the pooled effect size, as it accounted for multiple effect sizes per study and overlapping samples. This approach also reduced the risk of inflated false positives (Type I errors) and distorted results.
• The authors were able to evaluate the influence of a variety of potentially important moderating variables, including biological relation and location of study, allowing them to assess the extent to which the observed effects were attributable to paternal anxiety or these other factors.
• The study was pre-registered and employed a standardised method of conducting meta-analysis (PRISMA), which means they conducted their analysis in alignment with their original plans and with PRISMA, thus increasing the transparency and rigour of the analysis.
• The inclusion criteria had no limitation on publication language and included studies from the 1990s to the present day, leading to a thorough review of existing literature. This increases the generalisability of the study findings, and also reduces the risk of a language bias.

Limitations

• Including both cross-sectional and longitudinal studies makes it more difficult to draw conclusions about the directionality of the relationship between paternal anxiety and offspring mental health. Nevertheless, the authors do avoid making any inferences about causality, and study type (longitudinal vs. cross-sectional) was not found to be a significant moderator variable in the analyses.
• Some potentially important moderating variables could not be investigated due to lack of available data. Moreover, it was not possible to investigate the potential confounding influence of some mediating variables known to influence the relationship between parental and offspring mental health (e.g., socioeconomic status; Oliver-Parra et al., 2020), as not all studies reported unadjusted and adjusted coefficients. While the authors acknowledge this limitation, it would still have been informative for adjusted coefficients of mediating variables to be reported in the summary table where available, and/or for moderators and mediators to be analysed in a narrative synthesis.

Implications for practice

This research adds robust meta-analytic support to the evidence-base for the relationship between fathers’ anxiety and the mental health of their offspring. Clinicians and social care professionals working with children should consider assessing fathers’ mental health (where possible) as part of their assessment of a child’s background, as it is likely to have influenced their child(ren) and could provide important context. The moderating effect of assessment type and informant on outcomes should also be considered, as it indicates that both researchers and clinical professionals should be using a variety of methods to obtain the most comprehensive picture of paternal anxiety. In turn, increasing assessment of paternal mental health should shed light on how family intervention programmes can more effectively assess and treat mental health problems in young people, as highlighted in a recent editorial on this paper (Strawn & Peris, 2024).

The results from the analyses of moderator variables also have practical implications. As the included studies comprised data from offspring from 10 months old to 328 months (i.e., over 27 years). ), the lack of a moderating effect of age indicates that paternal anxiety may influence offspring across the lifespan. Additionally, the lack of a moderating effect of biological relation underscores the influence of fathers’ anxiety via environmental mechanisms, as the main effects were seen at comparable levels across both fathers genetically related and not genetically related to their offspring.

More broadly, the authors highlight the need for fellow researchers to expand beyond the “Eurocentric, heteronormative, and nuclear family” context of the majority of the research analysed here. This comment acknowledges not only the lack of diversity in terms of location and family structure of the included studies, but also a more overarching cultural framework of how parental influence is understood. This underscores the need for further research on the relationship between the mental health of parents and their children across all cultures, genders, and family structures.

Statement of interests

No conflicts of interest to declare.

Acknowledgements

I would like to thank Dr. Alice Wickersham for her incisive support in preparing this blog.

Links

Primary paper

Zecchinato, F., Ahmadzadeh, Y. I., Kreppner, J. M., & Lawrence, P. J. (2024). A Systematic Review and Meta-Analysis: Paternal Anxiety and the Emotional and Behavioral Outcomes in Their Offspring. Journal of the American Academy of Child & Adolescent Psychiatry.

Other references

Ahmadzadeh, Y. I., Schoeler, T., Han, M., Pingault, J. B., Creswell, C., & McAdams, T. A. (2021). Systematic review and meta-analysis of genetically informed research: associations between parent anxiety and offspring internalizing problems. Journal of the American Academy of Child & Adolescent Psychiatry, 60(7), 823-840.

Connell, A. M., & Goodman, S. H. (2002). The association between psychopathology in fathers versus mothers and children’s internalizing and externalizing behavior problems: a meta-analysis. Psychological Bulletin, 128(5), 746.

World Health Organization (2017). Depression and Other Common Mental Disorders: Global Health Estimates. https://iris.who.int/bitstream/handle/10665/254610/w?sequence=1

McLaughlin, K. A., Gadermann, A. M., Hwang, I., Sampson, N. A., Al-Hamzawi, A., Andrade, L. H., … & Kessler, R. C. (2012). Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys. The British Journal of Psychiatry, 200(4), 290-299.

Oliver-Parra, A., Dalmau-Bueno, A., Ruiz-Muñoz, D., & García-Altés, A. (2020). Relationship between parents’ mental disorders and socioeconomic status and offspring’s psychopathology: a cross-sectional study. PLoS One, 15(10), e0240681.

Strawn, J. R., & Peris, T. S. (2024). Paternal Anxiety and Children’s Anxiety and Related Symptoms: An Overlooked Risk Factor. Journal of the American Academy of Child & Adolescent Psychiatry.

Trepiak, P., Trepiak, T., Guérin-Marion, C., Kristen, A., & Deneault, A. A. (2023). A systematic review and meta-analysis of the associations between father and child anxiety and depression. Psychology of Men & Masculinities, 24(4), 325.

Westrupp, E. M., Bennett, C., Berkowitz, T., Youssef, G. J., Toumbourou, J. W., Tucker, R., … & Sciberras, E. (2023). Child, parent, and family mental health and functioning in Australia during COVID-19: comparison to pre-pandemic data. European Child & Adolescent Psychiatry, 32(2), 317-330.

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