External Publications Using GUI Data

Background
The gold standard for categorisation of weight status is clinically measured body mass index (BMI), but this is often not practical in large epidemiological studies.

Objectives
To determine if a child’s weight perception or a mother’s perception of a child’s weight status is a viable alternative to measured height and weight in determining BMI classification. Secondary outcomes are to determine the influence of a mother’s BMI on her ability to categorise the child’s BMI and a child’s ability to recognise his/her own BMI.

Methods
Cross-sectional analysis of the growing up in Ireland cohort study, a nationally representative cohort of 8568 9-year-old children. The variables considered for this analysis are the child’s gender, BMI (International Obesity Taskforce grade derived from measured height and weight) and self-perceived weight status, and the mother’s weight perception of the child, BMI (derived from measured height and weight) and self-perceived weight status. Cohen’s weighted-kappa was used to evaluate the strength of the agreement between pairwise combinations of the BMI variables. Cumulative and adjacent categories logistic regression were used to predict how likely a person rates themselves as under, normal or overweight, based on explanatory variables.

Results
Mothers are more accurate at correctly classifying their child’s BMI (κ=0.5; confidence intervals (CI) 0.38–0.51) than the children themselves (κ=0.25; CI 0.23–0.26). Overweight mothers are better raters of their child’s BMI (κ=0.51; CI 0.49–0.54), compared with normal (κ=0.44; CI 0.41–0.47) or underweight mothers (κ=0.4; CI 0.22–0.58), regardless of whether the mother’s BMI is derived from measured height and weight or self-perceived. The mother’s perception of the child’s weight status is not an influencing factor on the child’s ability to correctly classify him/herself, but the child’s self-perceived weight status influences the mother’s ability to correctly classify the child.

Conclusions
A mother’s BMI classification of her child is a viable alternative to BMI measurement in large epidemiological studies.

Background
Public health policies attempt to increase parental identification of child overweight and obesity. The objective of the present research was to determine the cross-sectional, prospective and longitudinal associations between parental identification of child overweight and child mental health problems.

Methods
We made use of two cohort studies of Australian (Longitudinal Study of Australian Children, LSAC) and Irish children (Growing up in Ireland Study, GUI) that measured parental identification of child overweight and child mental health problems. Participant included 6502 (LSAC) and 7503 (GUI) children (49% female) and their parents. Child mental health problems were measured using child, parent and teacher-reported Strengths and Difficulties Questionnaires (SDQ) at ages 9/10 years old to 12/13 years old. In all analyses we controlled for child Z-BMI.

Results
In LSAC children whose parents identified them as being overweight at age 10 experienced worse mental health at age 10 (β = 0.21, SE = 0.04) and age 12 (β = 0.13, SE = 0.04) than children whose parents failed to identify them as overweight. In GUI children whose parents identified them as being overweight at age 9 experienced worse mental health at age 9 (β = 0.20, SE = 0.04) and age 13 (β = 0.22, SE = 0.04). In LSAC parental identification of child overweight at age 10 did not significantly predict changes in mental health problems from age 10 to 12 (β = −0.02, SE = 0.03). In GUI parental identification of child overweight was predictive of increases in mental health problems from age 9 to 13 (β = 0.08, SE = 0.03).

Conclusions
Parental identification of child overweight and obesity is associated with worse child mental health, independent of child body weight. Parents should be aware of the potential stigma and mental health difficulties associated with labelling a child as overweight.

Background
There are no early, accurate, scalable methods for identifying infants at high risk of poor cognitive outcomes in childhood. We aim to develop an explainable predictive model, using machine learning and population-based cohort data, for this purpose.

Methods
Data were from 8858 participants in the Growing Up in Ireland cohort, a nationally representative study of infants and their primary caregivers (PCGs). Maternal, infant, and socioeconomic characteristics were collected at 9-months and cognitive ability measured at age 5 years. Data preprocessing, synthetic minority oversampling, and feature selection were performed prior to training a variety of machine learning models using ten-fold cross validated grid search to tune hyperparameters. Final models were tested on an unseen test set.

Results
A random forest (RF) model containing 15 participant-reported features in the first year of infant life, achieved an area under the receiver operating characteristic curve (AUROC) of 0.77 for predicting low cognitive ability at age 5. This model could detect 72% of infants with low cognitive ability, with a specificity of 66%.

Conclusions
Model performance would need to be improved before consideration as a population-level screening tool. However, this is a first step towards early, individual, risk stratification to allow targeted childhood screening.

Impact
• This study is among the first to investigate whether machine learning methods can be used at a population-level to predict which infants are at high risk of low cognitive ability in childhood.
• A random forest model using 15 features which could be easily collected in the perinatal period achieved an AUROC of 0.77 for predicting low cognitive ability.
• Improved predictive performance would be required to implement this model at a population level but this may be a first step towards early, individual, risk stratification.

Background
There are few prospective studies of factors that mediate the association between exposure to adverse childhood experiences (ACEs) and obesity in adolescence. Our aim was to address this limitation.

Methods
We used prospective data from the Growing up in Ireland cohort study, with measurements at 9, 13, and 18 years old. The exposures were 14 adverse experiences before age 9. The main outcome was body mass index (BMI) at 18 years. Mediators were daily activity, diet quality, self-image and behavioural difficulties at 13 years.

Results
Among the 4561 adolescents in the final cohort, 77.2% experienced any adversity, 50.5% were female and 26.7% were overweight/obese at 18 years. BMI Z was higher at ages 9 (0.54 vs 0.43, p < 0.05, 95% CI of difference: −0.22, −0.01) and 13 years (0.50 vs 0.35, p < 0.05, 95% CI of difference: −0.25, −0.06), in those exposed to an ACE, compared to those unexposed. Structural equation models revealed that behavioural difficulties (β = 0.01; 95% CI: 0.007–0.018, p < 0.001) and self-concept (β = 0.0027; 95% CI: 0.0004–0.0050, p = 0.026) indirectly mediate the association between exposure to ACEs and BMI at 18 years.

Conclusions
The association between ACEs and BMI in adolescence is mediated by behavioural difficulties and self-concept.

Impact

• In a previous study, we found modest associations between exposure to a range of adverse childhood experiences and weight gain at 13 years of age.
• The strength of the association between adverse childhood experiences and weight gain was lower at 18 years of age compared to the association observed at 13 years and was no longer significant after controlling for confounding and including possible mediators.
• The association between adverse childhood experiences and BMI in adolescence is indirectly mediated by behavioural difficulties and self-concept.

The microbiome-gut-brain axis plays a role in anxiety, the stress response and social development, and is of growing interest in neuropsychiatric conditions. The gut microbiota shows compositional alterations in a variety of psychiatric disorders including depression, generalised anxiety disorder (GAD), autism spectrum disorder (ASD) and schizophrenia but studies investigating the gut microbiome in social anxiety disorder (SAD) are very limited. Using whole-genome shotgun analysis of 49 faecal samples (31 cases and 18 sex- and age-matched controls), we analysed compositional and functional differences in the gut microbiome of patients with SAD in comparison to healthy controls. Overall microbiota composition, as measured by beta-diversity, was found to be different between the SAD and control groups and several taxonomic differences were seen at a genus- and species-level. The relative abundance of the genera Anaeromassillibacillus and Gordonibacter were elevated in SAD, while Parasuterella was enriched in healthy controls. At a species-level, Anaeromassilibacillus sp An250 was found to be more abundant in SAD patients while Parasutterella excrementihominis was higher in controls. No differences were seen in alpha diversity. In relation to functional differences, the gut metabolic module ‘aspartate degradation I’ was elevated in SAD patients. In conclusion, the gut microbiome of patients with SAD differs in composition and function to that of healthy controls. Larger, longitudinal studies are warranted to validate these preliminary results and explore the clinical implications of these microbiome changes.

Caesarean section (CS) rates are increasing globally and exceed 50% in some countries. Childhood obesity has been linked to CS via lack of exposure to vaginal microflora although the literature is inconsistent. We investigated the association between CS birth and the risk of childhood obesity using the nationally representative Growing-Up-in-Ireland (GUI) cohort. The GUI study recruited randomly 11134 infants. The exposure was categorised into normal vaginal birth (VD) [reference], assisted VD, elective (planned) CS and emergency (unplanned) CS. The primary outcome measure was obesity defined according to the International Obesity Taskforce criteria. Statistical analysis included multinomial logistic regression with adjustment for potential confounders. Infants delivered by elective CS had an adjusted relative risk ratio (aRRR) = 1.32; [95% confidence interval (CI) 1.01–1.74] of being obese at age three years. This association was attenuated when macrosomic children were excluded (aRRR = 0.99; [95% CI 0.67–1.45]). Infants delivered by emergency CS had an increased risk of obesity aRRR = 1.56; [95% CI 1.20–2.03]; this association remained after excluding macrosomic children. We found insufficient evidence to support a causal relationship between elective CS and childhood obesity. An increased risk of obesity in children born by emergency CS, but not elective, suggests that there is no causal effect due to vaginal microflora.

We analyse parental smoking and cessation (quitting) associations with teenager e-cigarette, alcohol, tobacco smoking and other drug use, and explore parental smoking as a mechanism for social reproduction. We use data from Waves 1–3 of Growing Up in Ireland (Cohort ’98). Our analytic sample consisted of n = 6,039 participants reporting in all 3 Waves. Data were collected in Waves 1 and 2 when the children were 9 and 13 years old and in Wave 3 at age 17/18 years. Generalized Estimating Equations (GEE) models were used to analyse teenage substance use at Wave 3. Parental smoking was associated with significantly increased risk of all teenage substance use, adjusted odds ratios were aOR2.13 (ever e-cigarette use); aOR1.92 (ever alcohol use); aOR1.88 (current alcohol use); aOR1.90 (ever use of other drugs); aOR2.10 (ever-smoking); and aOR1.91 (current smoking). Primary caregiver smoking cessation (quitting) was associated with a lower risk for teenager current smoking aOR0.62, ever e-cigarette use aOR 0.65 and other drug use aOR 0.57. Primary caregiver smoking behaviour had greater associations than secondary, and age13 exposure more than age 9. Habitus seems to play a role and wealth was protective for teenage smoking. The findings suggest that prevention interventions should target both caregivers and their children.

Objectives
To examine the associations between preeclampsia and longitudinal child developmental and behavioural outcomes using data from a nationally representative study of children living in Ireland.

Methods
We used maternal-reported data from the Growing Up in Ireland longitudinal study of children. Data on preeclampsia and preeclampsia + small for gestational age (SGA) were collected when children were 9-months old. Data on child development and behavioural outcomes were collected at 9-months using the Ages and Stages Questionnaire (ASQ), and at 3 years, 5 years and 7–8 years using the Strengths and Difficulties Questionnaire (SDQ). Multivariate logistic regression analysis was used to examine the association between preeclampsia exposure and failure of ASQ domains, and abnormal SDQ domains. Linear spline multilevel models were used to examine the association between preeclampsia and preeclampsia + SGA and repeated measures of SDQ. All models controlled for several perinatal and sociodemographic factors.

Results
A total of 10,692 children were included in the study at baseline, representing a weighted total of 70,791. Multivariate logistic regression suggested that preeclampsia was not associated with failing any ASQ domain. Preeclampsia was associated with abnormal SDQ cut-off of emotional (≥ 5) and hyperactivity (≥ 7) domains at age 5 years only. In the linear spline model, mean SDQ score was higher at each time point in exposed groups.

Conclusions for Practice
While we did not find strong evidence of associations between preeclampsia and child developmental and behavioural outcomes overall, some associations between preeclampsia-exposure and subtle behavioural issues did persist. Further research is needed to replicate these findings, and determine the clinical significance of changes in SDQ scores.

A Tobacco-Free Future – An all-island report on tobacco, inequalities and childhood 2013 reveals declines in smoking rates among both children and pregnant women over the past decade, both North and South of the border. This report published by the Institute of Public Health in Ireland (IPH) and the TobaccoFree Research Institute Ireland (TFRI), shows that while tobacco control measures are being successful, disadvantaged children are at particular risk of tobacco-related harms.

Children growing up in disadvantaged circumstances face a number of threats to their health and development. Protecting children from the burden of tobacco related harm from both active and passive smoking is a priority action in enhancing population health and reducing health inequalities. Population health strategies on the island of Ireland are increasingly focussing on addressing the root causes of health inequality through social determinants of health approaches and through focussing on early childhood as a key period for intervention. At the same time, governments in both jurisdictions are working to enhance their approaches to effective tobacco control.

The World Health Organization considers that there are three key ‘windows of exposure’ in terms of tobacco-related harm in childhood – in the womb (associated with active or passive smoking by the mother), directly through children taking up smoking and through exposure to second hand smoke (SHS) in indoor and outdoor environments.

This report presents findings on these three windows of exposure based on a range of data sources in the Republic of Ireland and Northern Ireland. The central aim of the report is to contribute to knowledge on the exposure of children to the harmful effects of tobacco smoke at various stages of their development. The findings of the report can support policy makers and service providers in their efforts to make tobacco-free childhoods a reality on the island of Ireland.

This paper outlines the development of an index of child well-being using data from the first wave of the Child Cohort in the Growing up in Ireland study. This national longitudinal study explores children’s lives by collecting data from 8,568 nine-year-old children, their caregivers and their teachers. Well-being indices are useful to describe children’s circumstances, to monitor child outcomes, and to create and assess the efficacy of social polices involving children. Traditionally, macro-level data has been used in the construction of child well-being indices. However, micro-level data is used in this paper to provide a child-centered perspective on their well-being. This index is comprised of three domains; physical health, social & emotional functioning and educational attainment. Fourteen measures were used in the creation of these domains utilising data from children, caregivers and teachers on the child’s current development. The domain content, protocol followed and confirmatory pro-cess used in creating this index are discussed. Evidence is provided supporting the inclusion of the domains and the factorial structure of the index. A child well-being index of this sort is valuable as it manages to efficiently summarize the richness of information provided by multiple informants on the multidimensional nature of child well-being into a single index. Consequently, it can be easily used and understood by the various stakeholders involved in services related to child welfare.

The Strengths and Difficulties Questionnaire (SDQ) is a brief 25-item instrument that has been widely employed in clinical and epidemiological studies to assess children’s psychological adjustment. Despite its widespread application in child and adolescent research, concerns have been expressed regarding the construct validity of the instrument and whether it might be tainted by a method factor that may undermine its utility as a diagnostic tool. We employed a confirmatory factor analytic approach to compare the goodness of fit of four competing models suggested by the extant literature for the parent-informant version of the questionnaire using data for 8514 nine-year-old children participating in the Growing Up in Ireland Study – a large population based cohort study in the Republic of Ireland. While analysis of the data provided support for the traditional five-factor conceptualisation of the instrument, a six-factor model which incorporated a method factor was found to fit the data marginally better. Nevertheless, we conclude that the existence of method effects does not present any great threat to the structural validity of the instrument taking account of patterns in the data and model parsimony.

The purpose of this report is to investigate the known correlation between non-traditional family structures and poor outcomes for children.

Discussions of this topic often focus on the distinction between two-parent families and one-parent families but this distinction can be misleading. In the Irish case, the crucial distinction is between children raised by parents who are married and children raised by a lone-parent who has never been married. The focal point here is non-marriage.

This is important since non-marriage appears to be highly selective because the least privileged groups in Irish society are more likely to have children outside of marriage and at a relatively early age.

This argument suggests that selection bias accounts for much of the association between family structure and child outcome i.e. growing up in a non-traditional family has little ‘direct’ or ‘causal’ effect on a child’s outcome. A large body of literature exists which documents a correlation between non-traditional family structure and poorer child development but researchers disagree as to whether this association represents a true causal effect.

The primary objective of the current study, therefore, is to test this selection argument and to examine the extent to which selection effects can account for differences in child wellbeing in various family types.

With screen use becoming more prevalent at a younger age, it is important to research the possible impact screen use has on early cognitive development. The current study examines the screen use of 9001 5-year-olds and their reasoning abilities, using data from the Growing Up in Ireland study. Results show that both the amount of daily screen time, along with the type of screen activity children mostly engage in (video games, educational games, TV/video watching, or a mix of all of these activities), have an impact on 5-year-olds’ reasoning ability. Children who mostly engaged in a mix of activities for under three hours a day scored higher on a reasoning ability task than those who engaged in more than three hours of screen time, or those who engaged in an individual screen activity (e.g., television watching) rather than a mix of activities. However, the results also show screen use plays a very minor role in the development of reasoning ability. Consequently, other factors (e.g., home learning environment, parental education levels) should also be investigated when examining the role of screen use in cognitive development. The implications of these findings may therefore be of interest to parent, educators and policy-makers.

Objective
To explore whether the associations between developmental delays in the first year of life and psychosocial outcomes in preschool children are affected by participation in organized sport.

Study design
Data were obtained from the infant cohort of the Growing Up in Ireland project. Parents reported on child development (Ages and Stages Questionnaire) at age 1 year, psychosocial characteristics (Strengths and Difficulties Questionnaire) at ages 3 and 5 years, and engagement in organized sport at age 5 years. Data were analyzed using mixed models.

Results
At age 1 year, 15% of the cohort was classified as having developmental delays. These children exhibited more behavioral difficulties (0.55, ±0.27; mean difference, ±95% confidence limits [CL]) (P < .0001) and fewer prosocial behaviors (−0.54, ±0.11) (P < .0001) at age 3 years. For boys in this group, engagement in sport was associated with a significant decrease in behavioral difficulties between ages 3 and 5 years (−0.44, ±0.39) (P = .03). Compared with those classified as lacking regular engagement (ie, never engaging, or engaging <1 hour/week), the relative effect of sport on changes in behavioral difficulties for boys with developmental delays was statistically significant (0.70, ±0.59) (P = .02). Participation in sport was not associated with significant changes in behavioral difficulties for girls, or a significant change in prosocial behaviors for boys or girls.

Conclusions
Regular participation in sport by boys could attenuate some of the behavioral difficulties associated with early development. Lack of opportunities for engaging in sport could negatively affect boys’ behavioral regulation in the preschool period.

The paper examines the effects of socioeconomic background (SES) – measured by social class, family income and parental education – cognitive ability, and gender on a variety of key outcomes from a large longitudinal study based on a representative sample of thirteen-year-olds. The data analysed comprised 6216 children who participated in waves 1 to 3 of the Growing Up in Ireland (GUI) longitudinal survey. The outcome measures drawn from wave 3, when respondents were aged about seventeen, were: examination results and several cognitive measures, life difficulties, and quality of relationships. Three regression models were compared with and without, SES measures (occupational class, household income and parental education) and cognitive ability. On academic and cognitive attainments, cognitive ability at age 13 had substantially more explanatory power than the SES measures together. On measures of adolescent difficulties and on family relationships, cognitive ability was important, but gender and to a lesser extent, household income and parental education had some effects. Claims that class background and family income are of central importance for adolescent outcomes are not supported.

This retrospective cross-sectional paper examines the relationship between early breastfeeding exposure and children’s academic test scores at nine years of age independent of a wide range of possible confounders. The final sample comprised 8226 nine-year-old school children participating in the first wave of the Growing Up in Ireland study. The children were selected through the Irish national school system using a 2-stage sampling method and were representative of the nine-year population. Information relating to breastfeeding initiation and exposure duration was obtained retrospectively at nine years of age via parental recall and children’s academic performance was assessed using standardised reading and mathematics tests. Hierarchical linear regression analysis with robust standard errors to control for clustering at the school level was used to quantify the effect of breastfeeding on children’s test scores. Propensity score matching was used to compare treatment effects across groups defined by their propensity to breastfeed. In unadjusted analysis, children who were breastfed scored 8.67 percentage points higher on reading and 7.42 percentage points higher on mathematics compared to those who were never breastfed. While the breastfeeding advantage attenuated appreciably when adjusted for a range of child, maternal, socio-economic and socio-environmental characteristics, children who were breastfed continued to enjoy a significant test score advantage of 3.24 (p < 0.001) and 2.23 (p < 0.001) percentage points on reading and mathematics respectively compared to those who were never breastfed. Any amount of breastfeeding was associated with significantly higher test scores than no exposure, but evidence of a dose-response relationship was weak. The results of the propensity score matching analysis indicated that the test score advantage of breastfed children is robust and that the magnitude of the effect varies across groups defined by their propensity to breastfeed, being largest amongst the most socially disadvantaged and falling to near zero among the most advantaged group.

Whether breastfeeding is protective against the development of childhood overweight and obesity remains the subject of considerable debate. Although a number of meta-analyses and syntheses of the literature have concluded that the greater preponderance of evidence indicates that breastfeeding reduces the risk of obesity, these findings are by no means conclusive. The present study used data from the Growing Up in Ireland study to examine the relationship between retrospectively recalled breastfeeding data and contemporaneously measured weight status for 7798 children at nine-years of age controlling for a wide range of variables including; socio-demographic factors, the child’s own lifestyle-related behaviours, and parental BMI. The results of the multivariable analysis indicated that being breastfed for between 13 and 25 weeks was associated with a 38 percent (p < 0.05) reduction in the risk of obesity at nine-years of age, while being breastfed for 26 weeks or more was associated with a 51 percent (p < 0.01) reduction in the risk of obesity at nine-years of age. Moreover, results pointed towards a dose–response patterning in the data for those breastfed in excess of 4 weeks. Possible mechanisms conveying this health benefit include slower patterns of growth among breastfed children, which it is believed, are largely attributable to differences in the composition of human breast milk compared with synthesised formula. The suggestion that the choice of infant feeding method has important implications for health and development is tantalising as it identifies a modifiable health behaviour that is amenable to intervention in primary health care settings and has the potential to improve the health of the population.

The incidence of adiposity in the early years of life has outgrown the prevalence in older children and adolescents globally; however, the factors influencing weight gain are predominantly studied in adults. This study examines the relationship between changing economic conditions during the Irish recession and child weight in a nationally representative sample of 10,011 Irish children studied at 9 months, 3 years and 5 years old. This study is the first to use longitudinal anthropometric measurements to estimate the impact of direct parental unemployment on children’s weight. Fixed effect logistic regression is used to examine the effects of parental unemployment on weight using the Growing up in Ireland infant cohort from 2008 to 2013. Weight and length/height measured by trained interviewers and child growth charts are used to quantify children’s weight status according to BMI-for-age and weight-for-age measures. For BMI-for-age, the probability of a child being classified as overweight/obese is 8 percentage points higher if either parent experiences unemployment. A sensitivity analysis of weight-for-age indicates that the probability is of similar magnitude across several alternative growth charts and definitions of adiposity (the WHO standard, British Growth Reference, and Centers for Disease Control). The analysis is repeated, cross-sectionally, for physical activity and diet to clarify mechanisms of effect. The probability of a child consuming healthy food and physical activity with an implied cost is lower if either parent becomes unemployed. A focus on overweight/obesity in the early years is of crucial importance as if current trends are not addressed, a generation of children may grow up with a higher level of chronic disease.

It is well-established that participation in shared book reading interactions with caregivers supports children’s early language and literacy development. Most of this literature focuses on reading experiences during the preschool period. Less is known about the nature and importance of such practices during infancy. Therefore, the goal of this study was to examine literacy practices between parents and infants in a large cohort study, Growing Up in Ireland. Interview, survey, and direct measurements of children’s language skills were used to examine whether parent-report of book reading practices when children were 9-months predicted child expressive vocabulary at 36-months (N = 9171). Regression analysis indicated that approximately 80% of 9-month-old Irish children are read to by parents. Characteristics of families who were more likely to report reading with children emerged: those with higher educational attainment, fewer depressive symptoms, and those who report a high-quality home language environment (e.g., reported talking more to children during everyday activities). Furthermore, children who were read to at 9-months had stronger expressive vocabulary skills at 36-months, even after accounting for socio-demographic and home literacy environment covariates measured at both 9- and 36-months. Results are discussed using a bioecological framework to describe how proximal and distal factors in the child’s environment converge to impact early childhood literacy development.

Epidemiological evidence suggests that poor physical health and depression are highly co-morbid. To date, however, no study has considered whether depression in parents caring for children with developmental disabilities is partly driven by poor physical health. Using data from the Growing Up in Ireland national cohort study (2006 to date), 627 parents of children with developmental disabilities were compared with 7941 parents of typically developing children on scores from the Centre for Epidemiological Depression Scale, chronic health conditions, socio-demographic and child behavioural characteristics. Having a child with disabilities was associated with a higher risk of depression (odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.43, 2.35) compared to parents of typically developing children. Adjusting for the presence of chronic health conditions accounted for some of this excess risk (OR = 1.77, 95% CI: 1.38, 2.27). The association between having a child with disabilities and increased risk of depression was explained, however, by adjusting for the child problem behaviours (OR = 1.07, 95% CI: 0.81, 1.43). This study has confirmed, in a population-based sample, the high risk of depression in parents caring for children with developmental disabilities after adjusting for the presence of a chronic health condition. Importantly, given that poor mental health in these parents is associated with a battery of negative health and social family outcomes, it is imperative that health professionals pay attention to the mental health needs of these parents.