Modern-Day Fatherhood and the Health of Dads

Erin Spain: This is Breakthroughs, the podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, editor on the monthly breakthroughs newsletter. Today we're talking about dads, the evolution of fatherhood and some important scientific findings about modern-day fatherhood that might surprise you. Joining me as someone who is not only a dad himself, he's a pediatrician and a scientist who's published dozens of papers about fatherhood.

Craig Garfield: My name is Craig Garfield. I am an associate professor of pediatrics and medical social sciences at Northwestern's Feinberg School of Medicine and an attending physician at Lurie Children's Hospital of Chicago.

Erin Spain: Your life's work as a pediatrician revolves around helping children and the health of children, and specifically you spend a lot of time with preemies and the neonatal unit at Prentice Women's Hospital. How did you transition into studying dad?

Craig Garfield: That's a good question. Children thrive when parents thrive, so if you can help parents be the best that they can be, most likely you're going to end up with the kids having the best outcome that they could ever possibly have. And I started getting an interest in father's after residency. I had a baby during residency. My wife was a medical student and we moved back here to Chicago for her to start her residency at Children's Memorial, which now is Lurie Children's. I had finished three years of residency in pediatrics but never really experienced the hands on of being a parent yet. So much of my advice affected mothers and fathers taking care of their kids. So, knowing that my wife was going to be in her most intensive time of her life as an intern, I said, well, let me just be at home with him and I'll stay at home and be a stay at home dad and see what this world of parenting is all about.

Erin Spain: When was it when you were home with your little one?

Craig Garfield: It was 1999 to 2000.

Erin Spain: About 18 years ago.

Craig Garfield: That was a huge eye-opening experience for me. I went from June 30th, so the end of my residency, where I was senior in the house at Mass General Hospital, like the most senior resident in pediatrics, and I flew home and the next day was on the playground with my son all by myself, as the only dad on the playground, and it opened up this incredible world to me over the next year. I was trying to find activities to do with him, so I looked for, you know, what classes we might do together and all the classes were called mom and tots classes. So I called the mom and tots coordinator. I said, “Hey, are dad's allowed at this class?” And she said, “Yeah, I don't see why not.” And it was fascinating, about six months into that mom and tots class, a mom came up to me and very quietly said, “You know, we have a play group that meets on Thursdays if you wanted to join us.”

Erin Spain: Oh, you broke into the inner circle.

Craig Garfield: I felt like I had finally broken into the group and I became close with all those ladies, women, all those moms. That really opened my eyes to like what, what's going on here with fathers in health in families and what part can I play in this? And when we had been in Boston, we had a pediatrician who is a very well respected pediatrician, and I would take, you know, arrange my schedule to make it to the pediatricians visits and I would sit there and the pediatrician would pay no attention to me. I realized that if I was not getting any feedback from the healthcare system, most likely many other men weren't either. And I think what happens with men who are trying to figure out what their role is as they become a father, if you get no feedback from the healthcare system, the education system, then you just turn to places where you do get feedback, which typically is work, right? So, then you get a paycheck and so instead of being at home and being with your kid, which maybe is what you kind of want to do, society is sending you messages that you know where you need to be as at work. So, when I had finished this year at home with my son, I was started a fellowship at the University of Chicago, a Robert Wood Johnson Clinical Scholars Program, which was two years of research time to think about studying an issue, and I originally was going to do it on violence prevention in the ER, and realized that this, this idea of fatherhood, was really interesting and something that I wanted to study. So, I spent those next two years working on that, on projects, looking at fatherhood and how fathers are involved in pediatrics. And that was really the start of the whole career trajectory.

Erin Spain: Children with involved fathers do better. Can you tell me about that?

Craig Garfield: There's a small but definitely growing body of literature on fathers that show that cognitively children who have involved fathers have better linguistic abilities, they have higher academic readiness. And, ultimately, higher academic achievement, socioemotionally, they have better coping there, show more maturity and more pro social behaviors and have secure attachments. And if you think about the job of a baby or a toddler, their job is to, from a secure base of attachment, explore the world. So if mom and dad are both involved, whether they're married or not, right, because again, 40 percent of a births are to the unmarried, and almost whether or not they're cohabiting or not. So, if they're living in the same house or not, children who have involved fathers are actually going to feel more comfortable exploring their world and that's how children learn and that's how they know what a safe world is and they can go away from the parents go and play off on the corners of the playground, but know that they always have that safe attachment to come back down. And then, children with involved fathers also have fewer risk behaviors such as truancy and substance abuse and stealing. So, all these things combined really make a difference. When we started our research, we really wanted to say to look at our fathers there in the, in pediatrics, right? That was kind of where we started, where you want to look at, are fathers there, if they're there, what do they do, how do they impact children? How do children then impact fathers? Which is a little bit of a twist on the equation. Then started to look at special populations and how you might approach those two. And so we did interviews with 35 couples in Chicago and Milwaukee, very in depth interviews with them, with the father actually,  how they are involved with their children. And then ask them not just the typical question, did you take your child to the doctor? Which is usually how research has assessed father's involvement in health, but we really said “what are the ways that you're involved in the health of your child?” We came up a new survey tool that is more dynamic and more detailed about how fathers are involved, which include things like role modeling for the kid, healthy behaviors, arranging your life in such a way so that you, if the baby or the child needs to be at home…

Erin Spain: If they're sick…

Craig Garfield: If they're sick, that you actually also have flexibility to make a change. And it's not just expected that the mom wouldn't necessarily. And I think a lot of this comes back to your question again of what dads are facing of, the fact that more graduate degrees are going to women, right? And, as more women get into the workplace and start to obtain higher salaries, it may become a very simple calculus for the family to say, you know, what, she can get more money in the workplace, Dad, you step up your involvement at home. And my question always is, are dads ready to do that, right? And they do, they have the role modeling for that? And one thing that I think it's important to understand is that dad's involvement in childcare and in housework has doubled since 1965. So, the lion's share of work is still being done by moms. Of course we have to give them their shout out. But dads are starting to step it up to.

Erin Spain: Modern Day fatherhood here in 2018 probably looks pretty foreign to maybe the grandfathers or great grandfather is out there.

Craig Garfield: Absolutely. Absolutely. And even the way that, if you think about our grandfathers and certainly our great grandfathers, would never have been in the delivery room when their baby was born. And now it's the, it's the rare dad who isn't there in the delivery room whether he wants to be there or not and whether the mom wants him there or not. But at every place dads are expecting to be involved, our research has shown that they go to the doctors with their kid and they have their own unique questions that they want to ask. And they want to be involved in that baby's life, at the very beginning of the baby’s, you know, after the baby's born. And my message really is that they're coming to the door. Let's open the door for them, let's meet them at the door and close it to them at the very beginning.

Erin Spain: How do you feel pediatricians are dealing with that right now? Are they have changes been made where fathers are being a bit more welcomed in the pediatrician office?

Craig Garfield: I think so. I think more and more pediatricians are aware of the value of this extra player on the team. Right. And I think pediatricians are learning how to engage dads and dads are looking for…dads generally are pretty, like many men, are problem solvers, so they may need more direct advice on what to do. Right. So, I talk a lot with dads, particularly when I'm in the neonatal intensive care unit. And I say, “here's what you can do for your partner right now.” And it might be helping with breastfeeding, which many dads are like, what? That's not my job. Right? But there are certain things you can do to help a mom around breastfeeding.

Erin Spain: Can you talk about what your research has shown? Mental Challenges, physical challenges, relationship challenges that can take place once someone becomes a father.

Craig Garfield: Sure. So, in those interviews with the 35 dads in Chicago, Milwaukee, we asked some questions like, how did having a baby effect your life, how did, how did having a child affect your life and your health behaviors? And the vast majority, 80 percent of them said that they actually try and eat better now. They try and exercise more. They try and avoid risky situations, too. They drink less. So, I thought, well, this is really interesting coming from just 35, you know, dads, I wonder what it would be like to look at these kinds of issues and in a bigger study and one that's followed over time. We found some data that had been tracking adolescents from high school all the way into their mid-thirties. We took this data and we broke all men into whether they were a father or not. And then if they were a father, whether they live with a child or whether they didn't live with a child. And we asked the question, you know, from a mental health perspective, was there a change in the dad, in the men's mental health during the transition into fatherhood? We did some very sophisticated and complicated statistics to figure out how long the men had been fathers and when they transitioned into fatherhood. And what we found is that for those dads that actually are living in the house with the baby, that in the five years before they became a father, their depressive symptoms scores, which were measured at four different times across this 20 years, were decreasing. And once they had their baby in the next five years, there was an increase in those depressive symptoms scores. And that increase in the depressive symptoms scores for the average participant in the study was about a 68 percent increase.

Erin Spain: These are men who are living with their child and  they weren't depressed. And as matter of fact, it was less likely that they were depressed until they had the child. Then they are at risk for depression?

Craig Garfield: So, if they were scoring really low on the, on this depression scale that we have, then a 68 percent increase is not really going to bump them up into a worrisome area, but if they have some past mental health problems, if they were scoring high already on the depressive scale, a 68 percent increase may kick them into some, area and they may be then at risk for depression and really should be seeing someone. And those first five years are really important years for children and the attachment that we talked about and how they, the baby and the toddler needs to know that they have a good base from which they can then explore the world around them. And for the men themselves, and the enjoyment that they get out of parenting as well.

Erin Spain: So, that's important to know because we do have more screenings in place for mothers after the birth of a child, but now it sounds like fathers need that type of screening to?

Craig Garfield: Yeah, and the good news is, is that there are screens available, even the many of the same tools that we use for mothers can be used for fathers too. The issue becomes, and again, this is a nut that we have not cracked quite yet, is what do you do as a pediatrician when you find out that a mother is depressed, right? So there are a number of resources that are out there now to help pediatricians deal with mothers.  For fathers, not so much, right? And so that's something that I think the field needs to think about, is what do you do when you actually identify the dad's having a hard time with his transition into fatherhood? And that transition for both parents is hard. It's a loss of control, it's a loss of sleep for many men, the work family balance is very, very difficult and we don't have a really comprehensive approach as most other countries due to family leave that can help men in this transition into fatherhood.

Erin Spain: So, you had an interesting study a few years ago with a headline that is a little funny about “dad bods.” Dad bods is a real thing. When men have a baby, oftentimes their BMI rises. Is that right?

Craig Garfield: Yeah. So, we were looking at what the transition to fatherhood, what the effects of the transition of fatherhood might be on men. So, we did the one looking in mental health. And one of the things that you hear anecdotally is that dads ended up well eating less healthy foods because there's a couple of leftover nuggets on your kid’s plate, so you just take those. There's pizza crust around the house and you just start eating that, and you just might have different food in the house and if you were just living without children. So, we looked into sample of over 10,000 men. We broke that sample, they had been studying for about 20 years, and at four different points in that 20-year time period they had been weighed and their BMI, their body mass index, had been calculated, and we looked at those men who were not fathers and compared them with men who were fathers and men who are fathers who lived with their babies and then those who didn't live with their children. We looked at what happened to their BMI over that time period. And we controlled for the fact that for everyone BMI is going to go up anyways. We controlled for marriage. We controlled for all the things that you would think would be associated with changes in weight. So what we found is that for men who are fathers who do live with their child on average in this sample, they gained about three and a half pounds after controlling for all other factors. Once you become a dad, in resident fathers, so those men who actually live with their children, gain on average, about four and a half pounds. What I love about this study is that we actually take anecdote, what people just talk about on the street and say, yeah, this happened to me and actually we're able to show that there is an association between becoming a father and gaining weight after you become a father. So, what that really tells me is that the transition to fatherhood is a place that when you're looking at men's health, you could intervene, it could be a lever for change for these dads and it's an important area for the baby, for the mother, but also for the dad himself.

Erin Spain: Something else you're really interested in is using technology to help parents and dads take care of their children. Everyone's using apps on their phones. They have their baby monitors on their phones there are different ways that we're using technology. Tell me about some of the latest tools that you've created to use technology to help parents, specifically dads.

Craig Garfield: We realized that when you start looking at populations of fathers, one of the most terrified populations of fathers are fathers in the neonatal intensive care unit and that comes -- it's terrifying for mothers as well, right, for the whole family. This is not necessarily the delivery or the baby that they were expecting, right? These are often very little babies that are very medically fragile and vulnerable. And for Dads, it's a little bit worse. Dads, even with a full term big baby fear that they can break this baby and now you have a baby who's, you know, much smaller and instead of 40 weeks of gestation is only 25, 26 weeks of gestation or even 30, but definitely not what they had expected. And these babies stay in the NICU from weeks to even months or longer compared to just a two day stop in the hospital before going home with a full-term baby. So there's a lot of information that parents can benefit from it. This particular place in the hospital, it's a very unique setting.  And so we realized that one of the things that we thought that parents could benefit from was that period when they're getting ready to go home and then actually going home. So we developed the first version of the APP that focused on the discharge process. So as soon as the baby graduated from an incubator and into the regular air that we all breathe in and the regular temperature that we all are in, that's usually about two weeks before they're going to go home. And so, we started our intervention at that point and we did a randomized trial, so half the people in the sample got the phone and half the people just got the usual care and we compared what the benefit of using the app was. And what we found in that study was that the parents that got the phones, with the app on it, were more confident in taking care of their baby after they took the baby home, more prepared for discharge. And if they use the app more, they had a shorter length of stay. So, based on that, those findings, which are really remarkable, we talked to all the parents that finished this study and said, you know, what would be used more useful in this app? And they all said we wished we had this when we got admitted to the NICU, right. We got the app and we were going home because that was the study, but they wish they had to it at admission. So, based on our findings, based on this feedback, uh, we went and now are testing an APP, a smartphone app in the NICU, called NICU2Home, which goes from admission all the way through to discharge  and we've kind of tailored and personalized what information is going out to each person, each baby and each parent based on their unique clinical situation. We've been funded by Friends Prentice to develop this and we're rolling it out at Prentice Women's Hospital, in the NICU. There's a number of features that we built specifically for Dads and we call dads out on this. We have a content that says, welcome to the NICU, Dad. We've done a number of videos and still photos that include dads and moms, because previously the research had focused just on moms and their experience in the NICU. And this comes from studies that we did looking at a stress in the NICU where we actually collected salivary hormone from moms and dads in the NICU from, uh, being in the NICU to going home. So, we looked at stress levels from discharge into going home for babies in the NICU. And what we found, which was remarkable because we didn't really expect this, is that moms actually have a high levels of stress based on their salivary cortisol levels while in the NICU. And when they go home, they remain high. Dads actually have high levels of stress while in the NICU, and when they go home, it actually increases, and no one had looked at this during the transition to home. But it's remarkable because what that we hypothesize is that these dads are actually maintained the status quo, right? The baby's taken care of in the NICU. They often have a routine where mom may be there during the day, dad's at work trying to get things finished up because baby is getting ready to go home and then they meet kind of at the bedside at the end of the day. Now, all of a sudden, they're at home and dad is trying to take care of the baby and be a good partner with his wife. His wife is now home as well and she has to deal with the stress of being home with the baby now and he's trying to balance work as well. And take care of himself. When you think about where that mom is going to get her primary support from, it's from that Dad, right? So if we didn't know that dad was more stressed out than he may not be at his best in terms of helping that mom. So if we can identify and prepare and help that dad with that stress of discharge of going home, then he might be a better support for the mom in the stressful period of going home as well.

Erin Spain: What other changes are on the horizon right now for dads?

Craig Garfield: Yeah, so there are about 66 million men who are fathers in the United States, so it's a tremendous population and 40 percent of those births are to unmarried couples and we're starting to understand the differences in those populations of men and I think a lot of the work in fatherhood now is understanding subpopulations of fathers. This falls kind of on the fact that men are not just being looked at as breadwinners in the family, but are actually looking at participants in raising that child and that they're looking to not be a male mother, but they're actually looking to be an engaged father and fatherhood and the way fathers interact with their kids is different than that of mothers. For example, you can just imagine when you're walking down the street, that fathers might describe the scene in front of them differently than mothers might, right? They might call out, in the stereotypical way, maybe a dad would describe kind of “look at the trucks and look at this building that's being built.” A mom might describe, “look at these beautiful flowers and look at this tree” and all that language goes to help the child develop more vocabulary and a better receptive and expressive language when moms and dads are both contributing to that particular language. And dads themselves actually have been really increasing their involvement in childcare and in housework.

Erin Spain: What has changed in society during that time that now there's more of an emphasis on fatherhood and fathers being involved?

Craig Garfield: Part of it is cultural and that if you look at who appears on People magazine for example, you'll see Mark Zuckerberg with his baby, right? Mark Zuckerberg took time away from work. Now, granted he has lots of other resources, right? But, nonetheless, he's setting an example. You have Prince William, right? He's, he's a prince. And yet you see him very closely involved with Kate in their children. So much so you see that there actually is a new word that came in the Super Bowl in 2015 when there was so much advertising that happened that involved fathers. That award came into our lexicon called dadvertising, which describes ads on TV or even on radio, focus on fathers and there are ads for cars or ads for soap and shampoo. There's a really funny one for toilet paper. All of these ways that we know dads are involved, but Madison Avenue figured out what's happening on Main Street and they figured out that actually what needs to happen is you need to feature your dads. They may not be the consumers who are buying it, but it completes the picture of real that are out there.

Erin Spain: Many dads here in Chicago might recognize you. You mentioned that you teach a class, a Prentice Women's Hospital for a while now, but six years you've taught a class only for new dads. No Mom's allowed. Why? Why did you decide to start teaching this class? And tell me a little about what the class is like.

Craig Garfield: Sure. So I think dads are really have questions that they want to ask, but it may not be the best environment for them to ask them in a group setting with other moms there who are really experiencing the physical manifestations of pregnancy. So, it's a tough sell for a dad, you know, sitting next to a mom who's 30 weeks pregnant and can't sleep on her stomach and can’t eat sushi and can't drink alcohol to then say, well, you know, raise his hand and say “it's really hard for me to, you know, like, because I'm very nervous about this baby or what do I need to know?” So, we thought there was a great opportunity for just having dads in the room. And it's a really a pretty marvelous group of men when the class gets going, because we sit around the table and we start by asking them kind of, you know, “what are your hopes and fears going into this?” And we talk about that. And men start to realize, you know what? I'm not alone, right, that other people have these same concerns or there are other things that they had not thought about that now they are really looking forward to or concerned about.  An then we talk about again what their super power might be, how they can get involved with helping mom with breastfeeding, how they can get involved with kangaroo care, which is putting the baby just on their skin and doing skin-to-skin, which really is a beautiful thing. It soothes the baby and most of the time it soothes the parent also and everybody ends up falling asleep on the couch. Right? Yeah. Nice low heart rate. We see it in the NICU. We use in the NICU all the time. The other way that I think the class is helpful is it helps dad who are again looking for “tell me directly what to do.” I give very kind of explicit directions both in the class and in the NICU. Your job in breastfeeding is to make sure that the baby latches on at the right level and that might involve bringing pillows to help the mom, get the baby in the right position. Your job is to help mom stay hydrated because it's a lot of liquid that you're giving that baby and your job is to be baby Uber, like to take that baby from wherever the baby's sleeping and bring it to the mom so the mom can feed and that bring the baby back. And I think dad's benefit from knowing there's something that they can do because otherwise, they get in this mindset of “I don't know what I'm doing,” it's all a mystery and it's some secret thing that all moms know and you know, to be honest, not all moms know what either, right? But they are the ones who are going to be providing the breast milk. So dads can help up by help by kind of assisting in the logistics of getting the baby there and getting the baby on.

Erin Spain: And this class is a little intense. It's a couple hours long. There is, a couple dozen men in the room?

Craig Garfield: Yeah, there's 20 dad's each session. We don't take a break because I feel like, again, this is all the information that I, as a pediatrician, would want to impart to a dad, but there's just not enough time when you're actually seeing patients and no one really leaves, right? We don't take a break. Very few people get up. It's at the end of a day of work day for all of us. But they stay. They asked really insightful questions about what's going on and we talk about kind of the research center that's involved with, the upcoming research that's involved in dads and we place dads kind of in a cultural moment here. And then talk a lot about what happens with labor and delivery, but talk beyond that because labor and delivery is kind of one moment when that baby is born and you suddenly get to see this child for the first time, which is a magical moment for, for many dads, but then you have 18 years still to learn about that kid. So, I spend a lot of time talking about that and how do you think about balancing work and family and how to help the family in general and what you can do when that new baby comes home.