A focus on fathers in child mental health interventions

'I wanted to work with both the mum and dad, but he was unable to attend our sessions'. Complaints such as this are all too common among practitioners in child mental health services. Fathers (or male caregivers) are much less likely to participate in treatments for child mental health problems than mothers, for a range of reasons. This matters, because research shows that the involvement of both fathers and mothers can be critical to the success of the child mental health interventions. 

Fathers clearly matter to child mental health and have an important role to play in treatment. It is therefore surprising that issues related to the clinical engagement of fathers have received relatively little attention in the literature. There have been specific calls for greater inclusion of fathers in clinical practice across a wide range of populations and therapeutic models in child mental health, including interventions for children with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), anxiety, and conduct problems, such as oppositional behaviour, and aggression (Bogels & Phares, 2008; Fabiano, 2007; Flippin & Crais, 2011; Tiano & McNeil, 2005). 

A major focus of our own research in recent years has been on understanding and overcoming barriers to father engagement in parenting interventions in the Australian context. As we discuss in this article, this has included a focus on the lived experience of fathers, the perspectives of practitioners, and the development of clinical process strategies for promoting father engagement. 

Fathers are underrepresented

Half of mental health problems emerge in childhood (Kessler et al., 2015), so there is an urgent need for widespread provision of early interventions to prevent stable pathways of mental health problems. Many evidence-based interventions for child mental health problems rely on the engagement of parents in the intervention to bring about changes in the family environment, such as decreasing harsh and coercive parenting strategies, increasing effective limit setting, increasing positive attention and quality time with children, and ultimately strengthening the parent-child relationship (Tully, Hawes & Dadds, 2021). This is especially the case for child conduct problems, where evidence-based parenting programs targeting risk and protective factors in the family environment are the gold standard treatment (Kaminski & Claussen, 2017). 

However, research shows that participants in evidence-based interventions for child mental health problems are mostly mothers. The rates of father engagement in interventions and services vary widely, but with few exceptions, they are generally low. For example, one review found only 20% of parents enrolling in parenting interventions were fathers (Fletcher et al., 2011). Another study examining session attendance at ten diverse Australian services for child mental health and well-being found that on average fathers attended only around half of the sessions that were attended by mothers (Dadds et al., 2018). As fathers are less likely to engage in interventions than mothers, this means that interventions for child mental health problems are being delivered primarily to mothers, by a largely female workforce, for problems that are in some instances mostly prevalent in male children (e.g. conduct problems). 

Benefits of including fathers

Importantly, research indicates that the engagement of fathers as well as mothers improves the outcomes of the intervention for children, especially in relation to programs for child conduct problems (Lundahl et al., 2008). It is perhaps not surprising that interventions are more effective when fathers also take part, since engaging both parents undoubtedly enables a more comprehensive approach to assessment and treatment. In relation to assessment of child mental health problems, including both parents in the assessment enables information to be obtained from both parents on factors such as parent-child relationships, quality of co-parenting relationship, individual perspectives on the problems, family history of mental health problems and so on (Tully, Hawes & Dadds, 2021). Obtaining multi-informant perspectives on child mental health problem is critical to thorough case conceptualisation and treatment planning, which may increase the effectiveness of the intervention. 

Similarly, including both parents in the intervention enables a focus on modifying key risk and protective factors that are formulated to maintain the child's problems. This may include factors such as parenting skills, parent mental health and/or aspects of the co-parenting relationship, which research suggests play a role in a range of child mental health problems.

The risk of excluding fathers from interventions is not just a potential for decreased effectiveness of the intervention. Inclusion of fathers is urgently needed to convey to families the importance of fathers to their child's mental health and well-being, and to recognise the unique knowledge and expertise that fathers have in parenting their child. Fathers are more involved in child rearing today than any time in the past, and the inclusion of fathers conveys that they are valued, and as valuable as mothers, both to the intervention success and to their child's development and well-being. 

Fathers are not just missing from clinical services focused on child mental health – they are also missing from research on child development, parenting, child mental health (Panter-Brick et al., 2014). In fact, some of the research examining the effectiveness of interventions for child mental health problems has been primarily conducted with mothers, which has led some to question the extent to which interventions are suitable for fathers. This is a reasonable question, especially as some studies have shown fewer benefits of participation in interventions for fathers when compared with mothers (Fletcher et al., 2011; Sanders et al., 2014). This highlights the importance of involving both fathers and mothers in the development and testing of new interventions for child mental health, to ensure they are appropriate for, and effective with, all parents. 

Barriers to father engagement

Recent research has explored the barriers to father engagement in treatments for child mental health problems and identified a range of factors that can act as barriers to father engagement. Practical barriers to father engagement include the cost of the intervention, difficulties with transport, childcare availability, lack of time to attend and work commitments. 

Surveys conducted with fathers and practitioners have found that practical factors appear to be the primary barriers to father engagement in interventions. The most commonly endorsed barriers by fathers in one survey included the cost of the service and work commitments, and the most commonly endorsed barriers by practitioners included fathers' work commitments and lack of time (Tully et al., 2017; Tully et al., 2018). In order to address these practical barriers, it is important that practitioners provide flexible delivery options and a range of intervention delivery modalities to make it easier for fathers to attend. The provision of low- or no-cost interventions may also be importance for overcoming financial barriers to father engagement.

Practitioner factors that may act as barriers to father engagement include low levels of confidence and skills to engage fathers, and unhelpful attitudes around father engagement. In a survey of practitioners, while the majority viewed father engagement as important to improving the outcomes of an intervention, about one-third of practitioners reported low levels of confidence in working with fathers (Tully et al., 2018). Of interest, out of 11 factors listed, a survey of fathers found having a male practitioner was regarding as the least important factor to encourage attendance at services for child mental health and well-being (Tully et al., 2017). This provides reassurance for the largely female practitioner workforce that other factors, such as the level of training of practitioners and fathers' feeling that the practitioner understands them, are more important to engaging fathers than simply the sex of the practitioner.  

A range of personal factors and family factors may also act as barriers to father engagement. Personal factors may include fathers' attitudes and beliefs about the program and family factors may include the quality of the co-parenting relationship, and mother encouragement of fathers to attend the intervention. A survey of practitioners found just under one-third thought that mothers did not encourage fathers to attend parenting interventions (Tully et al., 2018). The term 'maternal gatekeeping' which was originally used to describe whether mothers encourage or discourage father involvement in domestic or childcare responsibilities (Allen & Hawkins, 1999) has also been used to describe the extent to which mothers facilitate the participation of fathers in parenting interventions. There has been no empirical research on this issue to date, so the extent to which mothers' attitudes and behaviours influence father participation is unknown. However, where a mother attends an intervention alone, it would seem important for practitioners to explore maternal attitudes and beliefs towards father engagement to determine whether this may pose a potential barrier to father engagement.

There are also organisational factors that may present barriers to father engagement in interventions and these include lack of flexible session times, lack of father-inclusive policies and practices, and low commitment to involving fathers. Some researchers have highlighted that policy frameworks for family-based interventions often assume a 'deficit model' of fathering, whereby fathers are regarded as deficient in their skills and knowledge about child wellbeing (Deinhart, 1999). Organisational support for father inclusive practices appears to be important for ensuring high rates of father engagement and research has found that practitioners ratings of organisational support are predictor of high rates of father engagement (Tully et al., 2018).  

Practitioner strategies

So fathers are important to engage in intervention for child mental health, and there are many barriers to father engagement, but how do practitioners get them to turn up and participate? 

A first step is for practitioners to identify who forms part of the core parenting team. Families may have complex structures and there may be a number of father and mother figures who undertake regular caregiving for the child. As a priority it is important to identify the caregivers who are responsible for providing the majority of caregiving to the child and are important to engage in the intervention (Lechowicz et al., 2019). The discussion about who forms part of the core parenting team should occur as early as possible, such as when the family first contacts the service. For some families, such as those with separated or divorced parents, consideration of whether it is appropriate to engage both parents should take into account a range of factors such as custody arrangements, preferences of referring parent, quality of co-parenting relationship and any potential safety concerns. Parents who have high levels of conflict may still be able to engage in an intervention, if they agree to put a moratorium on the conflict to allow them to jointly focus on the intervention for their child. 

Inviting fathers to attend the service or participate in the intervention is an important step of engaging fathers. Research has found that some fathers hold the belief that services are only appropriate for mothers, so it is important for practitioners to set an expectation that fathers are core business, and to communicate to families that fathers are as important as mothers to their children and to the success of the intervention. Both fathers and mothers should be routinely invited to attend the service or intervention. Fathers can be invited directly to participate in an intervention, or contacted indirectly through mothers. Direct communication is preferable and often recommended where a mother expresses uncertainty about father involvement because of barriers to as work commitment or lack of interest. Fathers are more likely to attend when they feel their role is valued and their involvement is important. Key points for practitioners to emphasise in an initial conversation with fathers may include points such as the unique knowledge and expertise the father has about their child, and the importance of the father participation to effectiveness of the intervention. A direct approach can also help practitioners to better understand the barriers preventing father attendance.

Even with a direct approach to fathers, it may not be possible for some to attend sessions with mothers. Where fathers are not able to attend, it is important for practitioners to not assume that the non-attending father is not interested or disengaged (Lechowicz et al., 2019). Many services for children and families continue to operate only during working hours, which often provides a barrier to father participation. Services and practitioners can adopt a flexible approach which may enable the involvement of fathers through different methods, such as via phone calls or telehealth sessions. It is also possible to set up an indirect approach to father engagement, whereby information is provided to mothers, and mothers are supported to share this information at home with the father, and also bring questions and homework from fathers back to the session. However, this indirect approach is more likely to be successful where parents are already working well as a parenting team. 

When both parents attend sessions, it is important for practitioners to actively engage both parents equally. This means balancing the time spent talking to each parent to ensure both parents' perspectives are taken into account (Tully, Hawes & Dadds, 2021). Even if a parent expresses controversial views it is important for practitioners to remain neutral and empathic, and explore each parents' story with interest and curiosity. At times, there may be conflict between couples, and it can be helpful for practitioners to discuss with parents at the outset how conflict will be managed. Many practitioners report that they feel less confident to manage couple conflict than other clinical issues (Tully et al., 2018), so training in working with couple conflict is an important step for practitioners to increase confidence in engaging fathers. While having a father attend does not mean conflict will occur, it is simply the case that working with two parents instead of one means that conflict in session is more likely. Practitioner training programs have been developed for increasing skills and confidence in engaging fathers and managing couple issues, such as conflict, and such programs have found improvements in practitioner confidence and skills, along with perceived improvements in rates of father engagement (Burn et al., 2019). Thus, there is a need to better disseminate such training for practitioners working to improve child mental health, as increasing practitioners' confidence and skills in engaging fathers may be critical to high rates of father engagement.

Organisational strategies

The policies and practices of services and organisations are also critical to routine and effective engagement of fathers. A survey of practitioners found that those who perceived their organisation to be highly supportive of father inclusion were six times more likely to reported that fathers often attended their services (Tully et al., 2017). Services can encourage father engagement by regarding fathers as core business, implementing father-inclusive policies and practices, and providing training for practitioners in father engagement. Even simple strategies such as advertising that services are suitable for fathers as well as mothers may be enough to increase rates of father engagement (Lechowicz et al., 2018). Given the low rates of father engagement, organisations should collect routine data on rates of father involvement, as this is critical to evaluate the implementation of strategies to enhance father engagement. 

The way forward

Despite the undeniable importance of fathers, they are consistently under-represented in services and interventions for child mental health. There is a need for practitioners to actively encourage father engagement when working with families to improve child mental health and well-being. There is also a need for greater awareness and support for engaging fathers at the organisational level, through father-inclusive policies and practices and the provision of training in father engagement. Fathers are more involved in children's lives than ever before, and this should be reflected in clinical practice and research. We strongly believe that fathers should be prioritised as much as mothers in services for child mental health, and research into child mental health interventions. 

- Dr Lucy A. Tully, Prof David J. Hawes and Prof Mark R. Dadds are in the School of Psychology, The University of Sydney. [email protected]

Find more on fathers in our archive.

References

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Dienhart, A. (1998). Reshaping fatherhood. Sage, Thousand Oaks.

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Tully, L. A., Piotrowska, P. J., Collins, D. A., Mairet, K. S., Black, N., Kimonis, E. R., ... & Dadds, M. R. (2017). Optimising child outcomes from parenting interventions: fathers' experiences, preferences and barriers to participation. BMC Public Health, 17(1), 1-14.