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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: J Fam Soc Work. 2020 Nov 5;24(3):245–260. doi: 10.1080/10522158.2020.1824954

Association between caregiver depression and child after-school program participation

Nora J Daly a,b,*, Michael Parsons c, Courtney Blondino a, James S Clifford a, Elizabeth Prom-Wormley a
PMCID: PMC8259540  NIHMSID: NIHMS1632466  PMID: 34239279

Abstract

Depressive symptoms in parents and caregivers to children are associated with adverse biopsychosocial outcomes for caregivers themselves and the children in their custody. Higher overall and parenting-related stress, including stress over children’s unsupervised after-school time, is associated with increased caregiver depression risk. Child after-school program participation is a form of social support that may mitigate parenting-related stress and reduce caregiver depression risk. This study tested for the association between child after-school program participation and caregiver depression in a sample of 486 caregivers in Richmond, Virginia. Child after-school program participation was associated with a significant reduction in the likelihood of a past caregiver depression diagnosis (OR = 0.58, 95% CI = 0.39 – 0.86, p = 0.007). This relationship remained significant after adjusting for the influence of caregiver anxiety, stress, financial hardship, and sociodemographic characteristics (OR = 0.49, 95% CI = 0.27 – 0.86, p = 0.015). Child after-school program participation may function as a protective factor that reduces caregiver depression risk. More research is needed to determine whether the observed association is causal in nature and dosage dependent. Findings from this and future studies may be used to inform evaluation of the impact of after-school programs at the family-level.

Keywords: depression, caregiver depression, stress, parenting-related stress, social support

Background

Depression affects millions of U.S. adults each year, posing an estimated economic burden of $210.5 billion, including $98.9 billion in direct medical costs (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015). Roughly 7.5 million of the U.S. adults who experience a depressive episode each year share a household with one or more children under age 18, and an estimated 15 million U.S. children live with caregivers who have major or severe depression (National Research Council and Institute of Medicine, 2009). Children in the custody of caregivers living with depression face an increased risk of adverse biopsychosocial outcomes, including reduced school attendance, increased emergency department use and health care expenditures, and reduced mental health outcomes (Boyd, Joe, Michalopoulos, Davis, & Jackson, 2011; Chung, McCollum, Elo, Lee, & Culhane, 2004; Guevara, Mandell, Danagoulian, Reyner, & Pati, 2013; Manuel, Martinson, Bledsoe-Mansori, & Bellamy, 2012; Olfson, Marcus, Druss, Pincus, & Weissman, 2003). Consequently, caregiver depression represents a profound and costly risk factor to both caregivers and the children in their custody, and is an important area to address to promote positive outcomes for children and families.

Who is a Caregiver?

The term “caregiver” is used here to refer to “all individuals who take care of a child or children in a variety of family structures” (National Research Council and Institute of Medicine, 2009). According to recent estimates, less than 50% of U.S. children live in households with two biological parents who are married. Instead, an increasing number of U.S. children are raised in diverse family structures, including living with same-sex parents, adoptive parents, foster parents, in kinship care, and in single parent households. In addition, not all caregiving relationships are based on a formal legal custody agreement. For example, “informal kinship care” arrangements may be made without involvement from the child welfare system (Wirth & Lowenback, 2012), creating a disconnect between primary caregiver status and legal guardianship. For this reason, we focus on individuals who share a household with children under age 18, rather than emphasizing legal custody. Employing a more inclusive definition of “caregiver” increases the generalizability of our findings, and addresses a gap in knowledge regarding the risk and protective factors for depression in non-maternal caregivers.

Risk and Protective Factors for Child Caregiver Depression

Much of the research related to caregiver depression focuses on maternal caregivers (Davé, Petersen, Sherr, & Nazareth; 2010; Davé, Sherr, Senior, & Nazareth, 2009; National Research Council and Institute of Medicine, 2009). Mothers are often children’s primary caregivers and are more likely to experience depression than male caregivers (Davé et al., 2010; Guevara et al., 2013). However, evidence suggests mothers and fathers do not differ significantly in their susceptibility to the impact of parenting-related stress on psychological well-being (Barnett & Gareis, 2006), and that depression in either parent contributes to adverse child outcomes (Davé et al., 2009; National Research Council and Institute of Medicine, 2009).

Studies of both maternal and paternal caregivers indicate that young age and financial or material hardship increase caregiver depression risk (Davé et al., 2010; Liang, Berger, & Brand, 2019; Manuel et al., 2012). Single versus coupled partnership status, and high levels of overall and parenting-related stress are also associated with depression risk in maternal caregivers (Liang et al., 2019; Manuel et al., 2012). Higher levels of social support – including assistance with child care – are associated with reduced parenting-related stress (McConnell et al., 2010) and decreased maternal caregiver depression risk (Jee & Davis, 2004; Liang et al., 2019; Manuel et al., 2012; Silver, Heneghan, Bauman, & Stein, 2011). Evidence suggests higher levels of educational attainment may increase maternal depression risk either directly (Manuel et al., 2012), or as a result of an increase in parenting-related stress (Liang et al., 2019). Some studies also suggest having multiple children under the age of five is a risk factor for maternal depression (Manuel et al., 2012), while other studies suggest mothers with multiple young children experience reduced parenting-related stress, which could result in a decrease in maternal depression risk (Liang et al., 2019).

The amount of time children spend unsupervised after school is one source of parenting-related stress shown to negatively impact the psychological well-being of both mothers and fathers (Barnett & Gareis, 2006; Blocklin, Crouter, & McHale, 2012). By providing caregivers with child care assistance and reducing stress related to children’s unsupervised after-school time (Barnett & Gareis, 2006; Blocklin et al., 2012), after-school programs may function as a source of social support that reduces caregivers’ depression risk.

Gaps in the Literature

Adoptive, foster, and kinship caregivers often face exposure to unique risk factors, including heightened stress levels, which may increase depression risk (Cole & Eamon, 2006). However, because few studies have assessed depression using a broader definition of “caregiver” (Davé et al.; 2010; Davé, et al., 2009; National Research Council and Institute of Medicine, 2009), it is unclear whether risk and protective factors for maternal and paternal depression would be detected in adoptive, foster, and kinship caregivers.

The factors associated with depression in Black/African American caregivers remain understudied (Boyd, Joe, Michalopoulos, Davis, & Jackson, 2011; Boyd & Waanders, 2012; Goodman, Rouse, Connell, Broth, Hall, & Heyward, 2011). Evidence indicates that the influence of social and demographic risk factors for maternal depression varies based on race/ethnicity (Boyd et al., 2011). This suggests a need for further research to understand the unique impact of risk and protective factors, including parenting-related stress and social support, on depression among Black/African American caregivers.

Study Objective

This study examines the role of child after-school program participation as a protective factor for depression in a predominantly Black/African American group of caregivers. Specifically, this study tests whether there is an association between child after-school program participation and past depression diagnosis in custody caregivers (i.e., any person who identifies as living with a child under 18) using data from a community-based sample of participants whose experiences are typically underrepresented in research related to caregiver depression and child outcomes. The following research questions were tested: 1) Is there a significant association between past depression diagnosis for caregivers whose children participate in an after-school program two or more days per week compared to caregivers whose children do not participate in such programs? 2) Does the association between past depression diagnosis and child after-school program participation remain significant after controlling for anxiety, stress, financial hardship, and sociodemographic characteristics? We hypothesize that there will be a significant association between child caregiver depression and child after-school program participation. Further, the odds of a past depression diagnosis will be significantly lower among caregivers whose children participate in after-school programs compared to those whose children do not participate in after-school programs.

Methods

Sample

This analysis is based on data from the 2014 Seventh District Health and Wellness Survey (HWS) (N = 1,102). The HWS used community-based participatory research methods to assess health status, and health care access and utilization among residents in Richmond’s East End Seventh District neighborhood (Prom-Wormley et al., 2020). Residents age 18 and older were eligible to participate in the study, and participants were recruited using convenience sampling methods. The study protocol was approved by the Virginia Commonwealth University (VCU) Institutional Review Board (Prom-Wormley et al., 2020).

Individuals who indicated they did not share a household with any children under age 18 were excluded, reducing the sample size to 486 participants. Although sharing a household with a child is not necessarily indicative of caregiver status, participants who shared a household with one or more children were asked subsequent questions referring to “your children,” and were asked to provide information, such as children’s insurance status and primary health care setting, that is reflective of a primary caregiver’s level of knowledge and involvement in a child’s life. Based on these subsequent questions, and in the absence of a concrete measure of caregiver status, individuals who shared a household with one or more children were assumed to be caregivers for this study.

Measures

After-school program participation

After-school program participation was treated as a binary variable. Children were classified as either participating or not participating in an after-school program based on responses to a single item: “During the school year, do any of the children in the household participate in an after school program 2 or more days per week?” The use of two days per week as a minimum cut-off for after-school program participation is consistent with findings from the 21st Century Community Learning Centers Program showing the average elementary school-aged after-school program participant attends two days per week, while the average middle school-aged participant attends one day per week (James-Burdumy, Dynarski, Moore, Deke, Mansfield, & Pistorino, 2005).

Past Depression Diagnosis

Depression was one of several mental and physical health outcomes listed in a matrix following the question: “Do you think that you or any of your family members have ever been told by a doctor or other health professional that you/they have any of the following (check all that apply)?” Participants indicated whether they or a member of their family received a diagnosis. Based on responses to this question, past receipt of a depression diagnosis was measured as a binary outcome. Caregivers who indicated they had received a depression diagnosis were classified as “past depression diagnosis,” all others were classified as “no past depression diagnosis.” This approach has been used in population-based epidemiological studies previously to assess diagnosed mental health conditions (Miyakado-Steger & Seidel, 2019).

While this measure indicates receipt of a depression diagnosis across caregivers’ lifespans, and some respondents may have experienced symptoms and received a diagnosis prior to becoming primary caregivers, prior history of depression is associated with an increased risk of caregiver depression (Davé et al., 2010), and Black/African American individuals with depression, in particular, are more likely to experience chronic depressive episodes (Bailey et al., 2019; Boyd & Waanders, 2012). Therefore, past receipt of a depression diagnosis bears weight as an outcome of interest, even if the diagnosis was received prior to becoming a primary caregiver.

Covariates

The literature on maternal and caregiver depression points to several other covariates that may influence caregiver depression independently of child after-school program participation. A number of these factors were included in these analyses as detailed below.

Past receipt of an anxiety diagnosis was included as a covariate because it is often comorbid with depression (Möller, Bandelow, Volz, Barnikol, Seifritz, & Kasper, 2016; Van Oppen et al., 2007). Past anxiety diagnosis was measured using the same item as self-reported diagnosed depression, and was similarly treated as a binary outcome (“past anxiety diagnosis” and “no past anxiety diagnosis”).

Sex was measured as a binary, categorical variable (“male” or “female”) based on caregivers’ response to the question: “What is your sex?” Sex was included as a covariate, because female caregivers in general, and mothers of young children in particular, are more likely to experience depression than male caregivers (Davé et al., 2010; Guevara et al., 2013).

Age was recorded as a continuous variable measured by the question: “What is your current age?” Age was included as a covariate because young age is positively associated with maternal and paternal depression (Davé et al., 2010; Liang et al., 2019). Evidence also suggests parents aged 25 and younger have significantly lower social support than parents aged 26 and older (Jee & Davis, 2004); in turn, reduced social support is associated with increased risk of caregiver depressive symptoms (Jee & Davis, 2004; Liang et al., 2019; Manuel et al., 2012; Silver et al., 2011).

Relationship status, originally measured as a 12-level categorical variable in the HWS, was condensed into two categories: “partnered” and “not partnered.” Relationship status is another factor associated with caregiver social support and depression risk (Jee & Davis, 2004; Liang et al., 2019; Manuel et al., 2012). Caregivers derive social support from relationships with significant others regardless of marital or cohabitating status (Jee & Davis, 2004). Information on the sex and gender of caregivers’ partners was not collected. Future studies may want to control for differences between same-sex and opposite sex couples.

Educational attainment, originally measured in the HWS as a 10-level categorical variable, was condensed into a three-level categorical variable, measured as: “less than a high school diploma”; “high school diploma/GED, some college, or associate’s degree”; and “bachelor’s degree or higher.” These cut-offs were selected based on evidence suggesting the risk of depression increases significantly for mothers who complete 12 years or more of education (Manuel et al., 2012), while the odds of parenting-related stress – a risk factor for maternal depression – increase significantly for caregivers who complete a bachelor’s degree or higher (Liang et al., 2019). Evidence also shows higher education levels are a risk factor for maternal depression in Black/African American mothers, in particular (Boyd et al., 2011).

While some studies suggest mothers with multiple children under the age of five face an increased risk of depression (Manuel et al., 2012), Liang, Berger, and Brand (2019) found single mothers with more than one dependent child had lower levels of parenting-related stress, which in turn may lead to reduced depression risk. Conversely, the cost of raising multiple children could increase caregivers’ exposure to financial hardship, an experience shown to increase depression risk (Liang et al., 2019; Manuel et al., 2012). Number of dependent children was measured as a four-level categorical variable (“family size”) based on caregivers’ response to the question: “How many children under the age of 18 live in your household?” Responses were distributed across the following categories: “one,” “two,” “three,” and “four or more.”

Financial hardship may provide a more complete picture of economic disadvantage than household income alone (Manuel et al. 2012; Michael et al., 1997). For example, a family may earn an income above the federal poverty level, but face significant medical expenses due to the chronic illness of one or more family members. Paying these expenses may lead to food or housing insecurity despite appearing to be economically stable based on annual household income. For this reason, the following three measures of material financial hardship were used in lieu of household income: difficulty paying health care costs (“Was there any time during the past year when you needed medical, dental, vision services, or prescription drugs but didn’t get them because you couldn’t afford it?”), difficulty finding employment (“Thinking about the past 3 years, has anyone in your household struggled to find work?”), and difficulty paying housing costs (“Thinking about the past 3 years, has your household struggled to keep up with the rent or mortgage?”). Each of these three items was recorded as a binary measurement based on caregivers’ responses of “yes” or “no.”

Stress was measured as a three-level ordinal variable using an item that asked respondents how much of a problem stress was for themselves, their families, and others in their neighborhood. Responses were measured on the following three-level scale: “not at all,” “a little,” and “a lot.” Stress was included as a covariate because of the documented relationship between unsupervised after-school time, stress, and psychological distress (Barnett & Gareis, 2006; Blocklin et al., 2012), and the relationship between stress and caregiver depressive symptoms (Liang et al., 2019; Manuel et al., 2012; Silver et al., 2011).

Race was not included as a covariate due to the unequal distribution of HWS participants by race. Approximately 92% of participants in these analyses identified as Black/African American (Table 1).

Table 1.

Summary of Variables by Past Depression Diagnosis

No Past Depression Diagnosis Past Depression Diagnosis
Variable N % N %
After School Program Participation
 No participation 136 48.2 101 61.6
 Participating 146 51.8 63 38.4
Sex
 Female 226 74.6 138 79.3
 Male 77 25.4 36 20.7
Race
 Black 234 94 132 89.2
 Mixed Race 4 1.6 11 7.4
 White 6 2.4 2 1.4
 American Indian/Alaska Native 4 1.6 2 1.4
 Native Hawaiian/Other Pacific Islander 1 0.7 0 0
 Hispanic/Latino 0 0 1 0.7
Education Level
 Less than a HS diploma 117 38.4 62 35.2
 HS, GED, some college/associate’s 163 53.4 107 60.9
 Bachelor’s degree or higher 25 8.2 7 4.0
Partnership Status
 Not partnered 171 58.4 92 54.1
 Partnered 122 41.6 78 45.9
Family Size
 One child 124 40.1 67 37.9
 Two children 94 30.4 50 28.2
 Three children 47 15.2 34 19.2
 Four or more children 44 14.2 26 14.7
Difficulty Paying Health Care Costs
 No difficulty 173 58.8 83 48.3
 Difficulty 121 41.2 89 51.7
Difficulty Paying Housing Costs
 No difficulty 129 45.1 63 36.6
 Difficulty 157 54.9 109 63.4
Difficulty Finding Employment
 No difficulty 99 33.8 30 17.4
 Difficulty 194 66.2 142 82.6
Past Anxiety Diagnosis
 No past anxiety diagonsis 255 82.5 35 19.8
 Past anxiety diagnosis 54 17.5 142 80.2
Perceived Burden of Stress
 None 99 32.0 23 13.0
 A little 98 31.7 36 20.3
 A lot 112 36.2 118 66.7
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Statistical Analysis

Data analysis was performed using R (Version 3.6.0; R Core Team, 2019). Variables were summarized by the frequency and percent of persons reporting a past depression diagnosis at each level of each variable (Table 1). The association between each variable and the outcome of interest (past depression diagnosis) was tested using bivariate logistic regression (Table 2). Multivariate logistic regression assessed the association between after-school program participation and a past depression diagnosis while adjusting for the influence of all covariates (Table 2). Variance due to site clustering during data collection was estimated using a generalized estimating equations (GEE) approach, specifically via an independent working correlation structure to account for site clustering (Liang and Zeger, 1986). Analyses were also weighted to account for the variance attributable to differences by site. All analyses were performed under a 5% significance level, and were summarized with the odds ratio, 95% confidence interval, and p-value.

Table 2.

Associations between After-School Program Participation and Past Caregiver Depression Diagnosis, Unadjusted and Adjusted

Variable OR (95% CI) p AOR (95% CI) p
After School Program Participation
 No Participation Reference
 Participating 0.58 (0.39– 0.86) 0.007 0.49 (0.27, 0.86) 0.015
Past Anxiety Diagnosis
 No Past Anxiety Diagnosis Reference
 Past Anxiety Diagnosis 19.16 (12.08– 31.12) <0.0001 20.6 (11.37, 39.09) <0.0001
Burden of Stress
 None Reference
 A little 1.58 (0.88 – 2.89) 0.13 0.66 (0.26, 1.67) 0.381
 A lot 4.53 (2.73 – 7.78) <0.0001 1.54 (0.69, 3.49) 0.29
Age
0.99 (0.98 – 1.01) 0.769 0.99 (0.97, 1.02) 0.873
Sex
 Male Reference
 Female 1.31 (0.84 – 2.06) 0.244 1.80 (0.91, 3.63) 0.094
Education Level
 Bachelor’s or higher Reference
 HS, GED, some college/associate’s 2.34 (1.03 – 6.05) 0.056 1.99 (0.56, 8.55) 0.316
 No HS diploma 1.89 (0.81 – 4.96) 0.161 2.03 (0.59, 8.53) 0.293
Partnership Status
 Not partnered Reference
 Partnered 0.84 (0.57 – 1.23) 0.374 0.751 (0.42, 1.32) 0.323
Family Size
 One child Reference
 Two children 0.98 (0.62 – 1.55) 0.946 1.11 (0.55, 2.25) 0.764
 Three children 1.34 (0.78 – 2.28) 0.282 2.94 (1.30, 6.78) 0.01
 Four or more children 1.09 (0.61 – 1.92) 0.758 2.20 (0.88, 5.51) 0.091
Difficulty Paying Health Care Costs
 No Difficulty Reference
 Difficulty 1.53 (1.05 – 2.24) 0.027 1.05 (0.59, 1.87) 0.866
Difficulty Paying Housing Costs
 No difficulty Reference
 Difficulty 1.42 (0.97 – 2.10) 0.076 1.05 (0.57, 1.93) 0.879
Difficulty Finding Employment
 No difficulty Reference
 Difficulty 2.42 (1.54 – 3.88) 0.0002 1.63 (0.81, 3.36) 0.177
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Bolded values indicate a significant estimate at p < 0.05.

Results

Summary Statistics

The majority of caregivers were female (76.3%), partnered (56.8%), and had one or two children (68.9%). Respondents ranged in age from 18 to 90, with a mean age of 37. Difficulty finding employment (72.3%) was the most frequently cited source of financial hardship. Over one-third of caregivers reported past receipt of a depression diagnosis (36.4%), and nearly half (46.9%) had at least one child who participated in an after-school program two or more days per week. Anxiety affected 40.3% of caregivers, and 47.3% indicated the burden of stress was “a lot.” The frequency and percent of persons reporting a past depression diagnosis at each level of after-school program participation and all covariates is summarized in Table 1. The percentage of caregivers whose children participated in an after-school program two or more days per week was higher among caregivers who had not received a past depression diagnosis (51.8%) than among those who had (38.4%).

Unadjusted Bivariate Analysis

Child after-school program participation was significantly associated with past receipt of a depression diagnosis (OR = 0.58, 95% CI = 0.39–0.86, p = 0.007). There was a more than 40% reduction in the odds of self-reported receipt of a depression diagnosis for caregivers with one or more children participating in an after-school program two or more days per week compared to those whose children did not participate in an after-school program two or more days per week (Table 2). Past receipt of an anxiety diagnosis (OR = 19.16, 95% CI = 12.08–31.12, p < 0.0001) and a perceived burden of stress of “a lot” (OR = 4.53, 95% CI = 2.73–7.78, p < 0.0001) were also significantly associated with a past depression diagnosis relative to no past anxiety diagnosis and no perceived burden of stress. The odds of a past depression diagnosis were nearly 20 times higher for caregivers with anxiety compared to caregivers with no anxiety, and nearly five times higher for caregivers who indicated the burden of stress was “a lot” compared to those who reported no perceived burden of stress (Table 2).

Adjusted Multivariate Analysis

The odds of a past depression diagnosis were more than 50% lower for caregivers with children participating in an after-school program compared to those without children participating in an after-school program (OR = 0.49, 95% CI = 0.27–0.86, p = 0.015) after controlling for the influence of stress, past anxiety diagnosis, financial hardship, and sociodemographic characteristics (Table 2).

Discussion

To our knowledge, this is the first community-based study examining the relationship between caregiver depression and child after-school program participation in a majority Black/African American group of caregivers, and employing an inclusive definition of caregiver that encompasses non-maternal, adoptive, foster, and kinship caregivers. Although the adverse effects of caregiver depression on child biopsychosocial well-being are well-documented (Boyd et al., 2011; Chung et al., 2004; Davé et al., 2010; Guevara et al., 2013; Manuel et al., 2012; National Research Council and Institute of Medicine, 2009; Olfson et al., 2003), research on protective factors for caregiver depression is limited, and primarily focused on maternal depression (Davé et al., 2010; National Research Council and Institute of Medicine, 2009). This is problematic as evidence suggests depressive symptoms in caregivers of either sex negatively impact child outcomes (Davé et al., 2009; Olfson et al. 2003). Evidence also suggests that the impact of social and demographic risk factors for maternal depression varies based on race/ethnicity (Boyd et al., 2011). This study helps to fill the gap in literature on risk and protective factors for depression in non-maternal caregivers (Davé et al., 2010; National Research Council and Institute of Medicine, 2009), and Black/African American caregivers (Boyd et al., 2011; Boyd & Waanders, 2012; Goodman et al., 2011).

Using data from a previous community-based participatory needs assessment, this study found that after-school program participation was associated with a significant reduction in the odds of a past depression diagnosis among a majority Black/African American group of 486 caregivers in the East End neighborhood of Richmond, Virginia. The inverse association between child after-school program participation and past receipt of a depression diagonsis remained significant after adjusting for covariates commonly associated with maternal and caregiver depression. These findings suggest a relationship between child after-school program participation and caregiver depression risk, which warrants further exploration.

Our results align with prior research on the association between caregiver depression and social support. After-school programs provide social support in the form of child care assistance. Research shows that increased social support, including assistance with child care, is associated with a reduction in caregiver depression risk (Jee & Davis, 2004; Liang et al., 2019; Manuel et al., 2012; Silver et al., 2011). This association is the result of both the main effect of social support on depressive symptoms (Jee & Davis, 2004; Manuel et al., 2012), and the impact of social support on stress (Liang et al., 2019; McConnell et al., 2010), which in turn leads to fluctuation in depression risk (Manuel et al., 2012; Silver et al., 2011). Caregivers may use the time when children are participating in after-school programs to work, run errands, and accomplish necessary tasks; to seek parenting support; or to engage in stress-reducing activities such as exercise or socializing with their peers. Participation in after-school programs also reduces children’s unsupervised after-school time. Child unsupervised after-school time is linked to higher levels of caregiver stress and reduced psychological well-being (Barnett & Gareis, 2006; Blocklin et al., 2012).

Adoptive, foster, and kinship caregivers often face exposure to unique stressors, such as navigating the child welfare system, on top of normal parenting-related stressors (Cole & Eamon, 2006). Similarly, Black/African American caregivers are disproportionately exposed to environmental and life stressors, including systemic discrimination (Boyd & Waanders, 2012; Goodman et al., 2011). The increased stress exposure experienced by many Black/African American and non-biological caregivers could lead to heightened depression risk (Boyd & Waanders, 2012; Cole & Eamon, 2006; Goodman et al., 2011). Our findings suggest the association between child after-school program participation and caregiver depression remains significant despite the potential for increased stress exposure and depression risk among Black/African American and non-biological caregivers.

It is possible that the odds of a past depression diagnosis were lower among caregivers whose children participated in an after-school program two or more days per week because the steps required to enroll children in many after-school programs – such as completing an application and traveling to the program site to complete enrollment paperwork – serve as barriers to caregivers experiencing depressive symptoms, resulting in lower enrollment among children of caregivers with depression. If true, enrollment-related barriers may be preventing caregivers with depression from experiencing the benefits of chid after-school participation, including increased social support, and increased time to engage in health-promoting and stress-reducing activities. Future studies will need to establish the time order of receipt of a depression diagnosis relative to child after-school program enrollment in order to determine causality.

Limitations

The findings presented here should be considered in the context of the following limitations. First, this analysis was based on a community-based sample of Black/African-American participants and responses were collected using a convenience sampling approach. These results may not generalize to other populations. Nevertheless, these results are valuable because there are few studies that have provided clear descriptions of the relationship between child after-school program participation and depression in Black/African-American caregivers. Second, the use of two days per week as the cut-off for after-school program participation may limit the generalizability of findings to caregivers of middle school-aged children, who tend to participate in after-school programs at a lower frequency than their elementary school-aged counterparts (James-Burdumy et al., 2005; Roth, Malone, & Brooks-Gunn, 2010). Third, analyses used cross-sectional data and as such we were unable distinguish direction of causality between after-school program participation and a reduction in the odds of a past caregiver depression diagnosis. Fourth, we were unable to detail caregiver characteristics (i.e., the percentage of caregivers who were biological, adoptive, foster, and kinship caregivers), or after-school program characteristics (i.e., whether programs were free or fee-for-service, school-based or private, and whether programs were linked to a specific curriculum). Similarly, this study used a binary measurement reflecting biological sex, which does not provide context related to issues of caregiving and gender. This study also used a binary measurement of relationship status, which does not reflect the degree to which specific types of romantic partnerships may affect caregiver stress and well-being. Future studies are encouraged to include more expansive definitions of sex/gender and relationships where caregiving occurs. Fifth, the measure of caregiver depression (self-reported past depression diagnosis) was subject to recall bias. While we believe it is a reasonable assumption that a doctor or other health professional would administer a validated depression screening tool prior to telling an individual they had depression, we cannot be sure a validated tool was used. The use of past diagnosis as a measure of depression also does not provide any information on the specific symptoms experienced, or the duration, chronicity, and severity of symptoms. However, items like these have been used previously in epidemiological studies with lengthy questionnaires as a way to screen populations across several conditions (Miyakado-Steger & Seidel, 2019). Further, these results encourage future studies that clarify the association between caregiver depression symptomatology and child after-school program participation.

Future Research and Practice Implications

These results highlight two major areas of future research. First, future studies are needed to determine the degree to which there is a causal relationship between child after-school program participation and a reduction in caregiver depression risk. Such knowledge will be able to disentangle whether child after-school program participation influences caregiver depression, or if child participation in after-school programs is more likely to occur among children of caregivers with lower levels of depression. Second, this work also encourages additional research on understanding the amount of engagement with after-school programs needed to support caregiver mental health. Although research suggests that intensity of after-school program participation (i.e., number of days attended per week, number of weeks attended per year, etc.) has limited effects on child outcomes (Roth et al., 2010), the relationship between intensity of participation and caregiver outcomes is unstudied.

Future studies should also consider important factors such as after-school program characteristics (i.e., whether programs were free or fee-for-service, school-based or private, and whether programs were linked to a specific curriculum), caregiver characteristics (i.e., biological, adoptive, foster, or kinship caregivers), and caregiver activities during after-school care which may reduce stress and/or enhance well-being. Inclusion of these factors will be important for fully understanding the relationship between caregiver depression and child after-school program participation. For example, free and low-cost after-school programs may alleviate the financial hardship otherwise associated with the cost of out-of-school time child care. Such a reduction in financial hardship could help explain a corresponding reduction in depression risk (Davé et al., 2010; Liang et al., 2019; Manuel et al., 2012).

These results also have implications for after-school care providers. Specifically, additional monitoring of caregiver well-being across multiple time points (e.g., at the beginning and end of a semester) is encouraged to establish program impact more broadly. Measures to monitor include current stress level, psychological well-being, and depression status. These reflect important measures of after-school program impact more broadly to include caregivers.

Conclusion

To our knowledge, this study was among the first to use data from a community-based participatory needs assessment to examine the relationship between caregivers’ past receipt of a depression diagnosis and child after-school program participation in a majority Black/African American group of caregivers, inclusive of both biological and non-biological caregivers. Evidence from this study suggests that there is a significant, inverse association between past caregiver depression diagnosis and child after-school program participation, independent of caregivers’ sociodemographic characteristics, anxiety, experience of financial hardship, and the perceived impact of stress. Our findings help to address a gap in literature on risk and protective factors for depression in non-maternal caregivers and Black/African American caregivers. More research is needed to establish whether the association between child after-school program participation and caregiver depression is causal in nature and dosage dependent, and whether it varies based on caregiver characteristics, after-school program characteristics, or the nature and severity of depressive symptoms. Further research on this topic may enable after-school care providers to better understand and assess program impact at the family-level.

Acknowledgements

The authors gratefully acknowledge and thank the East End community residents who participated; the Richmond Memorial Health Foundation for funding to support the resident research team members; tenant councils; churches; and civic associations for their support of this project in Creighton, Fairfield, Mosby, Whitcomb, and Fulton neighborhoods; and the members and organizations of Seventh District Health and Wellness Initiative/Peter Paul Community Action Network who donated their time, resources and energy to developing the data collection effort.

This publication was supported by CTSA award No. UL1TR000058 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.

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