Paternal Alienation, Paternal Strain, Generativity, Adjustment, and Resilience (P-APGAR): A Conceptual Framework for Fathers’ Perinatal Psychosocial Adjustment

Abstract

Paternal perinatal depression is underrecognized, and existing tools often fail to capture male-specific symptomatic expressions. Fathers experience significant psychosocial changes during the transitional period, yet clinical assessment of paternal mental health remains largely absent from routine clinical practice. This paper introduces a multi-dimensional tool called the P-APGAR. The theory-informed conceptual tool is meant to guide the assessment of fathers’ perinatal adjustment, operationalizing core elements of role-based, relational, and emotional adaptation. The model adapts the logic of the traditional newborn APGAR score to a father-centered context based on Paternal Identity, Alienation, Paternal Strain, Generativity, Adjustment, and Resilience. A theoretical synthesis approach was used to integrate findings from qualitative and quantitative literature on paternal perinatal experiences using established theories of family systems, gender role strain, and transitional resilience. This fusion of nursing theory, sociological constructs, and current research shaped the development of the domains, each meant to reflect fathers’ experiences of connection, stress, meaningful adaptation, and coping. This analysis includes a brief review of established instruments (BDI, CES-D, EPDS, GMDS, PHQ-9, PBQ, F-PHI, EGDS, MGMQ, MDRS, and PAPA). The P-APGAR framework provides a structured, clinically applicable approach to identifying vulnerable paternal psychosocial patterns not adequately detected by existing maternal-driven depression scales. This model offers a pragmatic structure based on grounded theories for clinical conversations, research development, and future measurement, while emphasizing fathers’ relational roles, purposeful actions, and comprehensive adaptive capacities.

This paper is a theoretical synthesis of qualitative and quantitative findings on paternal perinatal depression, preceding the evolution of the Paternal APGAR, the P-APGAR. The P-APGAR is a gender-responsive conceptual framework to guide recognition, assessment, and intervention for fathers with depression. Within this context, the perinatal period is defined as the span of pregnancy through the first year following childbirth to reflect the extended psychosocial transitional time. While extensive research on maternal perinatal depression continues to occur, sound screening instrumentation on paternal depression continues to be poorly validated (Massoudi et al., 2013), reinforcing deficiencies in awareness and conceptual understanding (Paulson et al., 2016). Current screening, assessment, and treatment for paternal depression remain generally maternal-centric, leaving considerable gaps in paternal research (Fisher et al., 2021) and disregarding the familial impacts (Paulson et al., 2016). Screening gaps exist (Paulson et al., 2016) due to limited assessment tools distinguishing male depression manifestations (Rice et al., 2019), leaving those affected without proper screening and identification (Richardson et al., 2025). Inattention to this global issue forces fathers to struggle in silence (Schmitz, 2025), casually disregarding the long-term consequences of mutual maternal and paternal postpartum depression (Paulson et al., 2016), influencing “both parents’ ability to bond with their infant” (Kennedy & Munyan, 2021, p. 2713).

The P-APGAR framework was developed in parallel with an emerging theoretical model of paternal postpartum adaptation, a reciprocal concept of fatherhood as a dynamic process of emotional, relational, and role-based change. The concepts from this tool development were theory-informed from three distinct foundational perspectives: Gender Role Conflict Theory (GRCT; O’Neil, 1981), Transition Theory (TT; Meleis, 2010), and Family Stress Theory (FST; Hill, 1949). The theoretical model provides a conceptual structure for P-APGAR, acknowledging the domains of the theory into a separate, clinically oriented application. The parallel development of P-APGAR ensures concrete coherence to the domains while maintaining organizational independence between theory development and tool conceptualization. The P-APGAR domains were conceptually grounded in GRCT, TT, and FST theoretical frameworks.

The P-APGAR framework translates paternal adjustment across six interrelated domains: “P” anchors the paternal identity population that contextualizes all subsequent domains. Alienation “A” domain emphasizes the consequences of isolation, shame, withdrawal, and identity disruption, theoretically informed by GRCT. Feelings of paternal alienation can emerge as a consequence of gender role conflict, particularly when role strain limits fathers’ ability to seek support or express vulnerability. Paternal “P” strain domain highlights stress, guilt, and adaptive or maladaptive coping within the family system, theoretically informed by FST. Paternal strain can be conceptualized within FST as an outcome of the interaction among perinatal stressors available, coping resources, and the fathers’ perceptions of role expectations during the transition to parenthood. Generativity “G” domain encompasses the purposeful nurturing and actions demonstrated within the fatherhood role, theoretically informed by TT. Generativity can reflect a positive developmental response to the fatherhood transition, evidenced by healthy role integration or adaptation. Adjustment “A” domain explains the relational and familial adaptation necessary to assume the new parenting role, theoretically informed by FST. An FST lens underscores the adaptation to evolving roles, relationships, and responsibilities within the reorganizing family following childbirth. Resilience “R” domain reflects the process of risk-buffering, recovery, growth, and hope as fathers navigate psychosocial adjustment, theoretically informed by TT. Resilience supports successful paternal role transition even in the presence of depressive symptoms or other mental-health challenges.

The aim of the P-APGAR screening is meant to be a clinically responsive way to assess the wellbeing of the father by focusing on his paternal alienation, paternal strain, generativity, adjustment, and resilience. Each domain is intended to align with external signs and symptoms of fathers with paternal perinatal depression. Motivating factors for the P-APGAR are driven by the negligible absence of grounded paternal perinatal research, the recognition of mutual depression within the maternal and paternal relationship (Paulson et al., 2016), critical evidence associating this with known risks for children (Schmitz et al., 2025), and this author’s personal experience with depression. Formation of a father-specific framework does not lessen the fundamental importance of maternal depression research; instead, this inclusive step guides new conceptualizations of screening tools for upcoming use in empirical and validation testing, filling a knowledge gap in perinatal research by providing a whole-system approach for both parents (Richardson et al., 2025).

Background: Clinical Gap

Present-day parenting involves more paternal engagement than historically seen (Dhillon et al., 2022; Massoudi et al., 2013), with most fathers contributing as the primary wage earner, as well as being an active participant in parenting along with a considerable number of domestic chores (Kennedy & Munyan, 2021). This reallocated role in modern-day parenting areas reasonably stresses a renewed focus on fathers’ wellbeing (Massoudi et al., 2013) as they take on more increased roles in the home, including more involvement with the children (Kennedy & Munyan, 2021). Recent cultural shifts in gender family norms, along with statistics reporting that 1 in 10 fathers experience paternal postpartum depression (Paulson & Bazemore, 2010), emphasize the scale of the issue.

The National Perinatal Association (NPA) acknowledges the global health issue of postpartum depression, highlighting the importance of maternal and paternal screening for depression and anxiety during the perinatal period (National Perinatal Association, 2021). NPA recommends screening twice annually for the first year, once between months 1 and 3, again between months 6 and 12 (National Perinatal Association, 2021). This recommendation, by NPA, acknowledges the genuine impact of poor mental health on the child and family (National Perinatal Association, 2021). Depression, without any outward or measurable signs, presents unique diagnostic challenges and obstacles to universal treatment, including a lack of customary help-seeking habits (Schuppan et al., 2019). A substantial primary focus on maternal care further delays efforts toward awareness, screening, and treatment. Clinicians practicing in the United States encounter a lack of father-specific perinatal clinical guidance, leaving a professional theory and practice gap (Kennedy & Munyan, 2021).

Comprehensive paternal depression screening guidelines are needed (Álvarez-García et al., 2024; Chu et al., 2014; Richardson et al., 2025). The American College of Obstetricians and Gynecologists (ACOG, 2025) affirms the urgency for clinical practice guidelines that detail the significance of screening prenatal or postpartum individuals for mental-health issues. The United States Preventive Services Task Force (USPSTF, 2019) recommends screening all individuals over the age of 19 for depression, especially high-risk pregnant and postpartum persons. The American Academy of Pediatrics (Earls et al., 2019) established the impact of maternal depression on families, and recommended standard screening intervals, while also endorsing partner screening (Earls et al., 2019). These actions by national clinical standard organizations align more readily with best practice, optimistically, resulting in positive changes for awareness and recognition of paternal perinatal depression diagnoses, yet they fail to realign the maternal-exclusive model to a family-inclusive model. ACOG (2025) does not specifically mention fathers; instead, it says the birth person. This omission limits the uptake of meaningful changes in obstetrical areas. USPSTF (2019) does not offer father-specific screening guidelines; instead concentrates on maternal outcomes, and Earls et al. (2019) supports father screening as optional, likewise restricting routine screening and limiting support for clinicians. Routine screening is paramount to assessment (Schuppan et al., 2019), and fathers’ inclusion is necessary for various reasons, namely, fathers’ mental wellbeing perception is based on their clinical encounters (Hambidge et al., 2021).

Men represent half of the cases of major depressive disorder (Chu et al., 2014), yet make up four to six times the suicide rates when compared to women (Owsiany & Fiske, 2022; Rutz et al., 1995). Nearly all available screening tools created for use in maternal depression fail to account for the externalizing actions of fathers (Walsh et al., 2020) or include gender inadequate cutoff scores reflected in the tools (Massoudi et al., 2013). There are no current validated screening instruments for fathers in perinatal settings (Mancini et al., 2025), markedly affecting poor recognition, leading to the lack of identification and treatment for paternal depression. With national prevalence estimates of postpartum depression affecting approximately 14% of mothers and 10% of fathers (Paulson & Bazemore, 2010), the absence of validated father-specific screening instruments (Walsh et al., 2020) that accurately and consistently incorporate male-specific depression manifestations (Rice et al., 2015), reflect a concerning delay in clinical guidance, inadequately prioritizing a serious public health gap. The Edinburgh Postnatal Depression Scale (EPDS), widely used and extensively validated for maternal populations (Cox et al., 1987; Massoudi et al., 2013), underdetects paternal depression due to its limitations, including variable cutoff scores for men (Matthey & Agostini, 2017). Similarly, the Gotland Male Depression Scale (GMDS) identifies externalizing symptoms but does not capture core challenges of postpartum paternal adjustment, with large studies recommending new father-specific screening approaches to prevent missed diagnoses, and associated risks, like untreated depression or suicide (Owsiany & Fiske, 2022; Rice et al., 2019).

Theoretical Framework

The P-APGAR is built from a primary theory: Reciprocal Adaptation in Postpartum Fathers: A Mid-Range Theory of Role Negotiation, Relational Reciprocity, and Family Adjustment (Schmitz, 2026). This theory, Reciprocal Adaptation in Postpartum Fathers, is informed by established psychosocial and nursing theories: GRCT (O’Neil, 1981), TT (Meleis, 2010), and FST (Hill, 1949). The theory hypothesizes paternal adjustment as a dynamic, relational process where fathers negotiate emotional demands, reciprocate within evolving roles, and adjust to new family demands during the parental transition. Reciprocal Adaptation in Postpartum Fathers (Schmitz, 2026) frames fatherhood as a critical developmental transition marked by identity restructuring and shifting relational expectations, recognizing that paternal wellbeing and relational reciprocity function independently, yet mutually influence the successful or unsuccessful transition. Lack of support or reinforcement leads to alienation, strain, and role acquisition failure. GRCT informs the framework’s attention to masculine role conflict, emotional suppression, and conflict between socialized expectations and lived experience (O’Neil, 1981). TT shapes the idea of identity disruption and role renegotiation during one’s life transitions (Meleis, 2010). FST influences the recognition of stressors, resources, and their impacts on family adjustment (Hill, 1949). Previous evidence shows that male depression is not always recognized, and self-rating scales only provide a brief glimpse into one’s mindset, failing to consider the expertise and clinical picture necessary to make an accurate diagnosis (Sigurdsson et al., 2015). P-APGAR identifies the domains of alienation, paternal strain, connection, adjustment, and resilience, not adequately assessed by existing maternal-focused screening tools. This new conceptualization is grounded in observable domains, patterns of adaptation, relational functioning, and family adjustment, allowing the identification and recognition of fatherhood as an adaptable shift within interpersonal realignments.

Conceptual Development: Evolution of the P-APGAR

P-APGAR is purposefully designed as an ultra-brief, father-specific, transition-attached screening concept for empirical testing and validation in clinical settings within the early parenting context. Extending beyond just symptom detection by integrating concepts from paternal transition literature, family systems theory, and contemporary understandings of male-coping patterns. Instead of replicating symptom inventories, P-APGAR centers on the father’s lived experience, offering a more clinically relevant, theoretically aligned, and context-sensitive screening measurement for early identification and referral. P-APGAR offers a conceptual framework for paternal perinatal depression based upon a recent qualitative publication that distinguished discernible paternal themes of trauma, depression, and role conflict derived from stress and relationship adjustment issues of new fathers (Schmitz, 2025). This referenced phenomenological study is the first of its kind in the United States that solely focused on postpartum fathers with depression, underlining a paternal research gap. This 2025 study surveyed fathers’ voices as primary data without framing it around the experiences of maternal postpartum depression, bringing a focus to the underdetection of paternal mental illness within clinical practice. Without this recognition in areas where fathers’ mental health is rarely formally assessed, and without the support of a brief assessment, health care needs go unmet within pediatric, obstetric, and primary-care encounters, leaving vulnerable fathers ignored (Schmitz, 2025). Screening tools that exclusively focus on female-typical manifestations of depression risk missing the symptoms displayed by men (Kennedy & Munyan, 2021). The P-APGAR conceptual framework bridges those gaps by linking together and assessing emotional, behavioral, relational, and coping dimensions.

Present gaps in awareness, conceptual theory, and practical screening areas induced the creation of an APGAR-inspired, father-focused framework. This inspiration, established from previous obstetrical clinical knowledge of the author, originally derived by an esteemed anesthesiologist, Dr. Virginia Apgar, who created the simple 5-point APGAR system now used throughout the globe to score neonatal assessment based on observable signs of distress (Ray et al., 2024). Dr. Apgar’s scoring system reportedly evolved from a handwritten napkin in response to a resident’s inquiry regarding newborn assessment (Ray et al., 2024). During the mid-century, effective obstetric analgesic medication involved respiratory-oppressive medication, prompting newborns to be delivered without immediate crying or breathing (Apgar, 1966). Dr. Apgar believed the impact of general anesthesia in labor and delivery was impacting the neonate in serious ways (Ray et al., 2024). At the same time, infant mortality in the United States was extremely high (Ray et al., 2024), motivating Dr. Apgar to reflect on survivability in newborns (Apgar, 1966). Dr. Apgar’s system analyzed resuscitation methods, based on infants’ observed responsiveness, to predict survival. The original APGAR tool established an evaluation method to score five indicators of newborn health: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respirations (breathing) (Apgar, 1966; Ray et al., 2024). The scoring system conferred between 0 and 2 points based on indicators of life; scores were assessed at 1 minute of life, and again at 5 minutes of life (Ray et al., 2024). An added benefit of the novel scoring system provided a neutral and consistent way to evaluate the condition of the newborn without involving the delivery staff, who might be primarily focused on favorably positive delivery outcomes (Apgar, 1966). Dr. Apgar’s dedicated consideration of the newborn, uncommon for the time, justified the newborn-intensive focus, writing later that the extended focus on the mother warranted a brief minute to assess the newborn (Apgar, 1966).

The long-term revolutionary impacts of newborns’ low APGAR scores accurately calculating future developmental difficulties were not initially apparent (Ray et al., 2024). P-APGAR parallels the current paternal invisibility with the mid-century neonatal invisibility, cited by Dr. Apgar, modeling the clinical logic of the original Apgar score (Apgar, 1966). P-APGAR is designed to capture both internal and external psychosocial indicators: paternal alienation, paternal strain, generativity, adjustment, and resilience, in a clinically recognizable structure, a family-centered metaphor for checking the fathers’ vital signs. The P-APGAR is presented in this manuscript as a theoretically derived conceptual framework that organizes key domains of paternal perinatal psychosocial adjustment. While structurally inspired by the neonatal APGAR, the present work does not introduce a psychometrically validated screening instrument. Rather, the framework is intended to guide systematic item development, empirical testing, and future validation of a father-focused perinatal mental-health-screening tool.

P-APGAR Domains and Scoring

This conceptual framework derives key domains and constructs from Reciprocal Adaptation in Postpartum Fathers: A Mid-Range Theory of Role Negotiation, Relational Reciprocity, and Family Adjustment (Schmitz, 2026) as documented psychosocial areas of paternal perinatal depression. P-APGAR translates paternal adjustment across interrelated domains: Paternal identity is the anchoring population; Alienation, reflecting emotional, and physical isolation, identity disruption, and internalized shame; Paternal Strain, describing perceptions of guilt, role conflict, impaired coping, and overpowering emotions; Generativity, representing fathers’ capacity for emotional presence, bonding, nurturing, and validation; Adjustment, reflecting relational and family system functioning; Resilience, denoting risk-buffering, growth, recovery, hope, and sustained functioning despite psychosocial risk. Alienation clarifies the role negotiation, and identity strain new fathers face as they disconnect from self, infant, and partner to form a new role, especially when role expectations are unclear or possibly unsupported. Paternal strain causes family system disequilibrium, driving maladaptive coping in the face of psychological and relational overload. Generativity reflects the growth that marks the progression of the new father identity development, and the critical, purposeful emotional investment. Adjustment confirms the adaptive patterns fathers must form as they transition to fatherhood, for some inadequate relational or family support leaves the father vulnerable. Resilience details coping trajectories, representative of the risk-buffering, specifically the resource mobilization within the family system that leads to recovery. The framework is designed to recognize the dynamic trajectory of a process instead of a concise checklist, positing several phases of validation. These domains will regress to 40 items that will be micro-piloted to reduce unclear items or items that fail to fully assess the correlating domain within the process, resulting in a 15-item instrument, to be validated during phase one. Phase 2 will involve field expert review of each remaining item, with the goal of a 10-item instrument, keeping only items that offer optimum reliability for determining adjustment domains, ensuring at least one item falls into each of the key domains. The resulting 10-item screening instrument will be piloted with approximately 150–250 postpartum fathers for proper validation, psychometric measurement, and analysis.

Each of the domains aligns with the current existing literature for the lived experience of fathers with perinatal depression. Alienation is a common theme across various studies; fathers reconcile traditional masculine ideals with caregiving roles. Beestin et al. (2014) highlighted the uncertainty evoked when traditional masculine boundaries during early fatherhood are eroded, attributing the role societal expectations play in limiting emotional openness. Fathers equate vulnerability with weakness, loneliness, and guilt; insufficient inclusion within perinatal care systems worsens feelings of isolation (Álvarez-García et al., 2024; Schmitz, 2025). Paternal strain underlines a paradox; fathers often manage emotional pain through suppression shaped by stigma or gendered expectations. Depressed fathers express exhaustion, channeling distress into withdrawal and work or areas deemed societally more acceptable as coping strategies (Schmitz, 2025). Generativity demonstrates a pivotal opportunity for fathers to instill values or a cultural identity in their child, as part of their relational traditions, and create meaning from their adversities during their adaptation (Erikson & Erikson, 1998). Paternal perinatal coping patterns are shaped by adjustment to relational disconnection and social pressures; if a father perceives a lack of partner support, he can emotionally distance himself to adjust (Schmitz, 2025). Resilience echoes the demanding process fathers experience as they become more flexible and persevere despite identity changes, relationship challenges, societal pressures, and coexisting mental-health issues.

The future P-APGAR screening instrument is meant to be a brief, integrated tool grounded in male-typical distress patterns. Individuals will assign a Likert-type-rating of 0–3, 0 = Not at all, 1 = Several days, 2 = More than half the days, 3 = Nearly every day. The point designations will be refined with additional data, but the initial 40-items support a maximum point score of 120. Initial cutoff points and risk categories include: 0–30 Low Risk, 31–70 Moderate Risk, and 71–120 High Risk. Clinical red flags that trigger immediate clinical action will not be part of the domains; instead, there will be one or two questions that elicit suicidal ideation or self-harm. Red flag questions will require clinical evaluations, immediate safety checks, and crisis referrals as appropriate. Fathers meeting moderate or high risk will require a focused clinical assessment: measuring irritability, anger, agitation, sleep disruption, withdrawal or emotional numbing, role strain, risk-taking or substance-use patterns, relationship distress or conflict, and suicidal ideation. After the piloting, the newly revised 10-item instrument will comprise a maximum score of 30 points, and cutoffs for this revised instrument will include: 0–10 Low Risk, 11–19 Moderate Risk, and 20–30 High Risk.

Discussion

Comparisons and Limitations of Existing Screening Tools

Across existing measures, no screening tool fully captures the multi-dimensional experience of paternal perinatal mental health. Beck Depression Inventory (BDI) assesses general sadness with some items touching on irritability (Beck et al., 1961), yet omits father-specific domains like identity or bonding (see Appendix). Center for Epidemiologic Studies Depression Scale (CES-D) measures loneliness and some general distress items (Radloff, 1977), but they are unrelated to the core domains of paternal adaptation. The EPDS captures postpartum symptoms (Cox et al., 1987) but does not address fatherhood identity, adaptation, or male manifestations. The Gotland Male Depression Scale (GMDS) evaluates male patterns of distress (Zierau et al., 2002) yet contains no fatherhood-specific, relational, or resilience-oriented content. The PHQ-9 assesses classic depression symptoms (Kroenke et al., 2001), non-specific to the postpartum context, without measuring the contextual stresses of becoming a father. The Blues Questionnaire/Parenthood Blues Questionnaire (PBQ) measures early postpartum mood irritability (Edhborg et al., 2005) but does not assess paternal identity, bonding, or resilience, limiting it to short-term mood changes. The Father’s Postnatal Health Instrument (F-PHI) is not depression-specific, lacking assessment of identity or resilience, addressing role experience, some isolation, stress, and elements of bonding and relational functioning (Jones et al., 2011). The Edinburgh-Godwin Depression Scale (EGDS) is a strong symptom-based tool, adding in anxiety, irritability, and guilt to the modified EPDS (Svenlin et al., 2011), but it still focuses on mood symptoms rather than fatherhood adaptation. The Matthey Generic Mood Questionnaire (MGMQ) is easy to administer and broad, but non-specific for use in fathers, without calculating relational, identity, or resilience functioning (Matthey et al., 2013). The Male Depression Risk Scale (MDRS) strongly identifies the anger, risk-taking, and emotional suppression (Rice et al., 2015) but excludes fatherhood adjustment tasks like generativity or resilience. The Perinatal Assessment of Paternal Affectivity (PAPA) tackles identity, isolation, role stress, bonding, and partner contexts (Baldoni et al., 2018), making it the most comprehensive father-specific tool, yet it does not reflect all core constructs of fatherhood. Several other researchers have provided similar scales, but the additional instruments lack validation studies, therefore limiting widespread perinatal utility or routine uptake in clinical practice.

The P-APGAR framework was intentionally designed to fill this gap by offering a rapid, theory-driven, father-specific assessment that operationalizes the domains identified in contemporary research: alienation, paternal strain, generativity, adjustment, and resilience, anchoring explicitly within the paternal identity. The BDI, CES-D, EPDS, and PHQ-9 assess internalizing symptoms, while GMDS, EGDS, and MDRS assess externalizing symptoms. The PBQ and F-PHI capture only fragments of the paternal experience. This fragmentation reflects a larger conceptual misalignment; fathers are not secondary caregivers, their symptoms are not derived from maternal depression, instead, they are individual beings worthy of a screening instrument tailored to their experience. In addition, at this time, current international tools are not part of major screening guidelines within the U.S. for ACOG, AAP, USPSTF, or APA, further limiting uptake in screening and ignoring the lived realities of fathers, negating the role of negotiation, structural pressures, or shifting family system expectations facing fathers. Empirical testing, validation, and measurement are needed before tool adoption; however, P-APGAR overcomes the long-standing DSM-oriented symptom scales, offers a brief APGAR-style logic, and potential future opportunities to identify and guide early recognition, assessment, and intervention of modern fathers.

Comparison With Family APGAR

At the time of development, the author was unaware of the existence of another instrument called the Family APGAR. The Family APGAR instrument assesses global family functioning and general family satisfaction and support (Smilkstein, 1978). This Family instrument was not designed to evaluate paternal perinatal mental health, and does not capture paternal identity shifts, masculine patterns of emotional expression, father–infant bonding, or role strain. Empirical evaluations of Smilkstein’s APGAR have raised criticisms for its stability over time and poor agreement with clinical assessments (Gardner et al., 2001). While the two frameworks share structural parallels in domain labeling, the P-APGAR is distinctly grounded in contemporary perinatal mental-health research, driven by current clinical insights, and represents a clear-cut conceptual paternal measurement framework application rather than a duplication or adaptation of the original Family APGAR.

Conclusion

The P-APGAR is a conceptual framework designed to guide clinical recognition, assessment, and treatment in paternal perinatal mental health. Unlike existing depression psychosocial tools that emphasize only internalizing or externalizing symptoms, P-APGAR evaluates father-specific processes that current instruments omit. The P-APGAR is presented as a theoretically grounded conceptual framework designed to advance recognition of paternal perinatal mental-health needs and guide development of father-inclusive assessment approaches. While structurally inspired by the neonatal APGAR, the current work establishes a conceptual foundation rather than a psychometrically validated clinical screening instrument. Future research will involve systematic item development, pilot testing, and psychometric validation to hopefully operationalize the P-APGAR as a reliable and clinically applicable screening tool. By offering a unique framework grounded in nursing and psychosocial theory, P-APGAR has the potential to improve identification of paternal distress, inform family-centered perinatal care, and support more inclusive mental-health-screening practices as empirical testing progresses.

Even the most father-focused measures acknowledge early psychosocial changes but fail to integrate deeper constructs such as identity disruption, alienation, relational reciprocity, or adaptive growth. Across all available tools, resilience remains unmeasured, and no measurement synthesizes the interaction of paternal strain, relational functioning, coping trajectories, and adjustment during the transition to parenthood. Growing qualitative and quantitative research demonstrates that paternal perinatal depression frequently includes distinct male-typical externalizing and trauma-related responses, underscoring the need for a gender-responsive assessment model capable of capturing affective, behavioral, and relational symptoms. P-APGAR translates reciprocal adaptation theory into a clinically usable structure, positioning paternal mental health as an essential, equivalent component of perinatal care. Recognition of this pathway offers opportunities for more accurate paternal screening, targeted support, and improved family outcomes (Dhillon et al., 2022). Although paternal perinatal depression is associated with adverse socioemotional outcomes (Schmitz et al., 2025), routine screening remains absent, representing a major gap in U.S. perinatal mental-health systems.

Given the significant influence of paternal mental health on partner functioning, infant development, and overall family stability (Walsh et al., 2020), a new proposed framework offers a clinically meaningful approach to improving early recognition of paternal depression during a vulnerable transitional period and brings long-needed visibility to a historically understudied population. Current screening instruments lack coverage of male-typical depressive symptoms, limiting recognition of paternal distress and delaying opportunities for assessment or intervention. Even psychometrically sound measurements have failed to achieve widespread clinical use due to proprietary barriers that limit dissemination, digital integration, and adoption. Open-access father-specific tools are essential for overcoming gendered stigmas, facilitating early recognition, and enabling equitable access to care, and national uptake depends on instruments being freely available and validated to align with AAP, ACOG, and USPSTF guidelines.

Developed through a rigorous theoretical construct based on paternal lived experiences, P-APGAR will intentionally avoid proprietary constraints that impede feasibility testing, psychometric validation, and routine implementation. A central commitment of this work is to maintain the P-APGAR as an open-access framework with planned future validation research. Open availability is intended to reduce barriers to implementation, promote equitable screening practices, and support widespread empirical testing as well as integration of father-inclusive perinatal mental-health assessment across clinical and community settings.

Appendix

Table A1.

Depression Tools Relevant to Fathers.

Instrument	Year created	Developers/citation Citation	Country	Comparison to P-APGAR
BDI	1961	Beck a	United States	Identifies depression, not father adjustment
CES-D	1977	Radloff b	United States	Identifies depression symptoms, not adjustment or function
EPDS	1987	Cox et al. c	Scotland	EPDS focuses on detection, not prevention
GMDS	1991	Zierau et al. d	Denmark	Focuses on the male, not on the transitional role
PHQ-9	2001	Kroenke et al. e	United States	Identifies depression, not risk or adjustment
PBQ	2005	Edhborg et al. f	Sweden	PBQ gives a snapshot of emotional distress, not the landscape of adjustment
F-PHI	2011	Jones et al. g	United Kingdom	Identifies individual wellbeing, not broader relationship adjustment
EGDS	2011	Svenlin et al. h	Sweden	Identifies depression, not risk or adjustment
MGMQ	2013	Matthey i	Australia	Evaluates mood state vs. adjustment process
MDRS	2013	Rice et al. j	Australia	Male mental-health risk vs. fatherhood adjustment
PAPA	2018	Baldoni et al. k	Italy	Closest alignment to P-APGAR but assesses attachment rather than adjustment construct

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