INVISIBLE FATHERS: PATERNAL PERINATAL DEPRESSION - Clinical picture, risk factors, and implications for the family system

Article written in collaboration with @mondopsi

Abstract: 

Paternal Perinatal Depression (PDD) is a psychopathological condition that is still little recognized, despite affecting approximately 1 in 10 fathers. Underdiagnosis is often linked to gender stereotypes that hinder the recognition of male psychological suffering in the context of parenting. This article offers an integrated review of the literature on DPP, starting from a definition of the construct and the analysis of the role of the father in maintaining and protecting the family system (father – mother – child). The main symptoms, causes and risk factors of PPD are described, highlighting the mutual influences between paternal and maternal mental health in the perinatal period. The article also delves into the assessment tools currently available, with reference to the Edinburgh Postnatal Depression Scale. Finally, possible clinical interventions and prevention perspectives are discussed, emphasizing the importance of greater involvement of fathers in birth support pathways (CAN) and perinatal mental health monitoring programs. 

Keywords: perinatal mental health, paternal perinatal depression, postpartum depression, transition to parenthood, family system, child psycho-emotional development, perinatal psychological assessment. 

Introduction

When it comes to perinatal mental health, the focus almost always falls on the mother. Even for fathers, however, the birth of a child represents a significant change, which can lead to intense and negative emotional experiences such as anxiety, sadness, and confusion. When these experiences become significant, we can speak of a real pathological condition: Paternal Perinatal Depression (PDD). 

DPP affects an average of 10% of fathers, with peaks of 30% in particular risk situations (Paulson & Bazemore, 2010). These data should be considered partial: currently, in fact, most parenting services are aimed at the mother and the newborn (Ramchandani et al., 2011). Fathers are rarely screened, and therefore DPP remains a poorly understood and underdiagnosed condition. The main culprits appear to be gender stereotypes regarding male mental health and parenting (Seidler et al., 2016), which cause, on the one hand, poor health care towards fathers, and on the other, a low propensity of those directly involved to request specialist support in case of emotional distress (Addis & Hoffman, 2017).

This article aims to contribute to disseminating knowledge of the characteristics of Paternal Perinatal Depression and the possibilities for intervention, to ensure the health not only of fathers but of the entire family system.  

The paternal function in the family system. 

For a long time, psychological research was dedicated to the study of maternal functions, as mothers were believed to possess innate skills of attunement to the child's physiological and psycho-affective needs. The evidence and protocols, therefore, were based predominantly on the rigidly dyadic mother-child interaction. The father remained at most a backdrop, the guarantor of the family's economic stability (Saraceno, 2017). 

Ethology, like psychology, has also dealt predominantly with the maternal figure. The reasons are connected to an evolutionary consideration: according to the principles of natural selection, if females must invest time and resources in gestating, giving birth, and caring for their young, males are often free to mate with other females to multiply the chances of survival of their genes (Masson, 2000). As evidence of this, “paternal care is observed in only 3-5% of mammalian species” (Swain et al., 2014); in most cases, fathers adopt “absent” or even “bossy” attitudes towards their young (Swain et al., 2014). However, some examples cannot be ignored: the emperor penguin, which keeps the egg safe between its feet for about three months; or gestation and childbirth by male seahorses; or tamarins, a species of monkey that carry on their backs even young that are not their offspring (Hrdy, 1999). Furthermore, over the years, humans have also seen an increasing involvement of fathers in parental care, as well as great variability in the effort fathers put into raising their offspring. These considerations have led ethologists to believe that, although there is a “biological” program (Lamb et al., 1987), this cannot be seen from a deterministic perspective; rather, there is a certain plasticity worthy of investigation.

Ethological demonstrations on parenting behavior in fathers have mainly used rats. For example, Rosenblatt carried out an experimental study in rats aimed at understanding which hormones were involved in regulating pup care (Rosenblatt, 1967). The sample consisted of half female rats, ovariectomized and never pregnant, and half male rats, castrated and never mated. The entire sample was placed in continuous contact for 10-15 days with newborn rat pups. The results showed that almost all animals, as early as the fourth day, exhibited parental behavior, regardless of gender. Rosenblatt's study provided two important indications: all rats, and by extension all mammals, possess a basal level of parental reactivity, regulated by brain circuits that are activated whenever the mammal is faced with defenseless pups (Rosenblatt, 1967); and these circuits become more accessible only with their exercise, otherwise they remain silent (Crapkowska & Wold, 2018).

Even in human fathers, involvement from the first months of life appears extremely important to allow the activation of the Parental Care Network, the brain circuit connected to the performance of the parental function (Rilling, 2013). In particular, following the conceptualization of attachment theory, paternal participation in the care of offspring increases parental sensitivity, which can be defined as the ability to recognize and interpret the child's signals and needs and to provide timely and adequate responses (Ainsworth et al., 1978), and paternal involvement, i.e. the time that fathers are willing to dedicate and dedicate positively to their children, both in terms of play and in terms of responsibility (Lamb et al., 1985).

Still from an attachment perspective, as John Bowlby theorized in the middle of the last century, human beings manifest from birth an innate predisposition to form attachment relationships with the figures who care for them (caregivers) (Bowlby, 1988). The more attachment figures the child has, the wider his “secure base” expands, involving more people and counting more reference points. When faced with a sensitive and involved father, it is possible to notice in the child the same distinctive characteristics of an attachment relationship, typically attributed to the mother: search for closeness; protest of separation; cycles of exploration and return to one's caregiver in the phase of autonomous exploration (Weiss, 1991/1995). 

Research has repeatedly demonstrated a positive correlation between paternal involvement and developmental outcomes in children. In particular, greater paternal involvement is associated with positive outcomes on the child's cognitive, social, and emotional development (Pleck, 2010); at the same time, fathers who are more involved in caring show a more positive emotional tone, and this encourages father-child interactions, with positive outcomes on the child's cognitive development (Giannotti et al., 2022). The reverse is also true: less paternal involvement is associated, in the child, with lower psychological well-being, more maladaptive social behaviors, lower intellectual functioning, a delay in language development and a higher incidence of externalizing behaviors (Giannotti et al., 2022). 

A fundamental theoretical contribution to understanding the quality of paternal presence is that offered by the construct of reflective function, developed by Fonagy et al. (1991). Reflective function, or mentalizing ability, refers to the ability to read and interpret one's own mental states and those of others in terms of intentions, desires, and emotions. In the context of parenting, it translates into the parent's ability to keep the child's mind in mind, recognizing their internal states and responding in a tuned way. Subsequent research has shown that high parental reflective function is a protective factor for attachment quality: parents with high RF show greater sensitivity, less intrusiveness, and a better ability to repair relationship breaks (Slade, 2005). Applied to the father figure, this construct highlights how the quality of the father's presence depends not only on the time spent with the child, but on his ability to inhabit the relationship with awareness and emotional responsiveness. A father with reduced reflective function — a common condition in the presence of untreated PPD — tends to misunderstand the child's cues, respond inadequately, or withdraw from the relationship, with significant repercussions on the child's self-development process.

The need to be able to count on a secure basis is not a childlike prerogative, but remains throughout life. This is particularly evident within the couple's relationship, where both partners are called upon to be mutually secure bases, and is even clearer following the birth of a child. Research shows that women frequently experience anxious-depressive emotional reactions during pregnancy and in the postpartum period (Baldoni, 2012).  At this juncture, the father is called upon to serve as a safe base for his partner, for example by addressing practical issues: ensuring a comfortable and safe home; providing financial support; procuring food and other necessary goods; and interacting with the outside family environment, protecting the family and resolving any conflicts. Paternal involvement in partner care appears to promote partner health and positive behaviors, reducing the risk and impact of maternal postpartum depression (Paulson & Bazemore, 2010).

As can be seen, human behavioral systems are interconnected, and influence each other in the creation of family emotional well-being. The role of the father is therefore extremely important from the first months of life, in a triadic conception of the family system (mother – father – child) (Paulson & Bazemore, 2010).

But what happens if the father is not well?

Paternal Perinatal Depression (PDD). 

Paternal Perinatal Depression (PDD) is a form of depression that can occur in fathers between the third month of pregnancy and the first year of the child's life. DPP often presents with milder and less defined symptoms than maternal depressive disorders, making DDP an insidious disease. Diagnosis is made even more complex due to frequent comorbidity with anxiety and behavioral disorders (Baldoni, 2012). 

On a neurobiological level, the transition to fatherhood is accompanied by significant hormonal changes, similar —although less studied — to those affecting mothers in the perinatal period. Recent research has documented in fathers a reduction in testosterone and an increase in oxytocin, prolactin and vasopressin in association with physical contact with the newborn and the level of involvement in parental care (Feldman et al., 2010; Storey et al., 2000). These hormonal changes appear to play a facilitating role in activating the Parental Care Network, predisposing the father to caring and affective attunement behaviors. In the presence of DPP, this neurobiological setting appears altered: studies on fathers with depressive symptoms show significantly lower oxytocin levels than non-depressed fathers, with a consequent reduction in the child's responsiveness to signals (Gordon et al., 2010). This data highlights how DPP is not exclusively a psychological and relational phenomenon, but also involves biological substrates that deserve clinical attention.

The most common symptoms of Paternal Perinatal Depression are: 

• Depressed mood, sadness and melancholy. These symptoms can worsen, leading a man to experience feelings of helplessness, despair, and despair.  

• Restlessness, irritability and angry outbursts.   

• Loss of interest and motivation.

•  Social isolation.  

• Feeling tired, even after little physical and/or mental activity. 

• Poor sleep quality, or frank insomnia. 

• Somatizations (physical pain and discomfort without medical cause). Somatizations can lead humans to experience hypochondria. 

•  Decline in libido, which can result in less sexual involvement from pregnancy. 

• Exclusion from the family triad and avoidance of contact with the child. At its core there is a feeling of inadequacy that pushes the father to step out. It is important to note that some fathers, on the contrary, can develop high anxiety and constant concern about the pregnancy status and health of the child. At this juncture, DPP is found to be more similar to maternal postpartum depression (Baldoni, 2015).

• Behavioral acting out. The most common are: alcohol and substance abuse; use of food as a calming agent; and escape to sports or work to escape the home environment. 

In some cases, DPP can lead the man to flee the house (often after arguments). It can also lead a man to have extramarital sexual relations as a way of escaping from changed relational conditions with his partner. 

While in the mother the onset of postpartum depression is influenced by biological, psychological, and relational factors, the onset of Paternal Perinatal Depression appears to be mainly linked to emotional and psycho-relational factors (Cicchiello, 2017). In particular, DPP is more likely to develop in men who have already suffered from depressive symptoms or other emotional difficulties (Gao, 2009). Poor marital satisfaction and poor couple communication can also translate into paternal depressive symptoms (Edward et al., 2015). Other relevant psycho-social factors are a poor perception of external social support, unemployment and financial and/or living conditions perceived as stressful (Ballard & Davies, 1996).  Some studies highlight that the young age of the father (< 30 years) and a low level of education are associated with a higher risk of depression (Cicchiello, 2017).  Many studies agree that unwanted pregnancy is a perinatal stressor, with a possible depressive outcome (Baldoni & Landi, 2015).

From a psychodynamic perspective, the hypothesis has been advanced that perinatal affective disorders may be associated with narcissistic wounds and unresolved pre-Oedipal conflicts that reactivate with the experience of fatherhood. From this perspective, psychopathological manifestations vary according to the severity of pre-existing unresolved conflicts (Luca & Bydlowski, 2001). The contribution of sex-affective variations in the onset of PPD cannot be ignored. Research shows that 43% of women and 31% of men experience sexual dysfunction during pregnancy (Cicchiello, 2017); however, changes in sexual desire are often not discussed during perinatal visits (Cicchiello, 2017).  This can translate into frustration of sexual need, lack of communication between partners, and increased relational conflicts, with possible feelings of inadequacy and depression (Cicchiello, 2017). Finally, to return to the idea of intrafamilial behavioral interconnection, many studies report that the emotional states of mothers and fathers tend to influence each other (Paulson & Bazemore, 2010). In 10% of cases, Paternal Perinatal Depression follows Maternal Depression; conversely, Maternal Depression is much more likely to occur when the father has already experienced depressive symptoms (Goodman, 2004). This negatively affects the child's psychological development, as both parents are unable to provide a secure foundation.

Prevention and treatment of DPP.

To prevent and treat perinatal affective disorders, it is important to adopt a triadic family perspective and address the health of both parents. Therefore, it is essential to involve fathers from the beginning of pregnancy, in order to promote their active role (Baldoni & Landi, 2015). Longitudinal studies identify a high incidence of distress in couples during pregnancy, partly due to intimacy problems (Morse et al., 2000). Health care providers are ideally positioned to discuss changes in perinatal and postpartum sex life to facilitate a more peaceful transition to parenthood in both parents (Baldoni, 2012).  To this end, it is hoped that more specific training courses and seminars will be held for healthcare personnel. The involvement of fathers in pre-partum activities should not be underestimated. In particular, the formation of fathers' circles, in which each participant can share his or her experiences, has yielded promising results. Research shows that this type of support can facilitate the transition to fatherhood, with significantly lower levels of depression and distress at 6 weeks postpartum (Castle et al., 2008). 

A particularly promising intervention approach in the context of DPP is that based on Attachment-Based Intervention (Attachment-Based Intervention), which aims to strengthen paternal parental sensitivity through work on the father's internal representations of his own attachment history and the child's image. From this perspective, the father is supported in recognizing to what extent his own experiences of care received in childhood influence the ways in which he approaches his child and his partner (Benbassat & Priel, 2012). Alongside this, the most recent literature highlights the effectiveness of co-parenting interventions (coparenting), which work on the quality of cooperation and coordination between parents in child care. Good functioning of the parental couple appears to be a protective factor for both DPP and maternal postpartum depression, and at the same time constitutes a favorable context for the child's socio-emotional development (Feinberg, 2003). Intervening on the parental dyad, not just on the individual father, therefore appears to be a clinical strategy consistent with the triadic vision of the family system adopted in this article.

Regarding the diagnosis of paternal affective disorders, there are currently no specific screening tools. Currently, the most widely used instrument is the Edinburgh Postnatal Depression Scale (EPDS), consisting of 10 items used to assess symptoms of anhedonia, guilt, panic, insomnia, sadness, crying, coping skills and self-harming thoughts (Edward et al., 2015). However, the validation of EPDS concerns maternal postpartum depression, and therefore detects a symptomatic picture different from that emerging in Paternal Perinatal Depression, in which discomfort manifests itself mainly through externalizing behaviors (Baldoni & Landi, 2015). Therefore, we hope to develop specific tools for DDP that take into account gender differences and behavioral manifestations. Research is currently underway to validate the Gotland Male Depression Scale (GMDS) in the parental context (Carlberg et al., 2018).  

In cases where paternal suffering becomes significant, it is necessary to send the patient to a specialist for individual, couple, and/or family psychotherapeutic assistance, with possible pharmacological supplementation. There are several therapies to address Paternal Perinatal Depression, although their application is often limited by poor patient adherence to care. Among the therapies that have obtained the most validation, we find cognitive-behavioral psychotherapy, recommended for fathers with severe symptoms, and Mindfulness programs, useful for alleviating depressive symptoms and parental stress (Cicchiello, 2017). Unlike mothers, fathers appear to appreciate individual and home interventions more than group therapies (Baldoni & Giannotti, 2017).  For this reason, fathers with DPP may benefit more from Parent Training and video feedback techniques. Research shows promising results following the use of VIPP (Video-feedback to Promote Positive Parenting) and COS (Circle of Security) in improving parental sensitivity and the quality of family relationships (Baldoni & Giannotti, 2017). It is clear, however, that effective intervention must be tailored to the needs and specific critical issues of the family system under consideration. 

It is important not to forget that social support can also make a difference, and therefore, we hope to implement community social policies aimed at supporting new parents. In this regard, it is worth mentioning the Paternal Perinatal Depression Initiative (PPDI), a multidisciplinary screening and treatment program born in Australia to support fathers in the transition to parenthood and address their emotional difficulties. Among the PPDI projects currently underway, the following stand out: screening young fathers, with possible referral to mental health centers in case of significant critical issues; SMS support and the provision of online resources for fathers in difficult situations; the involvement of fathers in maternity care according to specific obstetric guidelines borrowed from the UK (Fletcher et al., 2014). Initiatives such as the PPDI are certainly laudable, and it is worth considering a similar implementation in our system to protect the health of families.

Conclusion

Paternal Perinatal Depression represents a significant and still widely underestimated psychopathological condition, despite numerous evidences demonstrating its impact on the father's well-being, the couple's relationship, the child's psycho-emotional development, and the overall balance of the family system. Paternal suffering in the perinatal period cannot be considered a marginal or secondary phenomenon, but must be recognized as an integral part of perinatal mental health. The research highlights how the paternal function plays a fundamental role both in building a safe foundation for the child and in emotional support for the partner, especially at a time of high psychological vulnerability, such as pregnancy and the postpartum period. From this perspective, the father's emotional distress can compromise the delicate relational balances of the father-mother-child triad, amplifying the risk of parental psychopathology and interfering with the child's attachment and psycho-emotional development processes. It therefore seems essential to adopt a clinical and preventive approach that transcends the dyadic vision of parenthood and systematically integrates fathers into birth support programs, screening programs, and psychological support interventions. The lack of specifically validated assessment tools for DPP represents a significant critical issue, which calls for further developments in clinical and psychometric research. Finally, the prevention of Paternal Perinatal Depression requires not only individual and family interventions, but also health and social policies aimed at greater inclusiveness of fathers in perinatal services. Investing in paternal mental health means protecting the well-being of the entire family and promoting healthier and more harmonious development of the new generations.

Bibliography

Addis, M. E., & Hoffman, E. (2017). Men’s depression and help-seeking through the lenses of gender. In R. F. Levant & Y. J. Wong (Eds.), The psychology of men and masculinities (pp. 171–196). American Psychological Association. https://doi.org/10.1037/0000023-007

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Lawrence Erlbaum.

Baldoni, F. (2012). Funzione di base sicura e disturbi affettivi paterni nel periodo perinatale. Psicologia e psicopatologia del benessere del bambino, 1, 9–20.

Baldoni, F., & Ceccarelli, L. (2010). La depressione perinatale paterna: Una rassegna della ricerca clinica ed empirica. Infanzia e adolescenza, 9(2), 79–92.

Baldoni, F., & Giannotti, M. (2017). I disturbi affettivi perinatali paterni: Valutazione, prevenzione e trattamento. Il Mulino.

Baldoni, F., & Landi, G. (2015). La funzione del padre nel periodo perinatale: Attaccamento, adattamento e psicopatologia. Quaderno di psicoterapia del bambino e dell’adolescente, 41, 73–96.

Ballard, C., & Davies, R. (1996). Postnatal depression in fathers. International Review of Psychiatry, 8(1), 65–71.

Benbassat, N., & Priel, B. (2012). Parenting and adolescent adjustment: The role of parental reflective function. Journal of Adolescence, 35(1), 163–174. https://doi.org/10.1016/j.adolescence.2011.03.004

Bowlby, J. (1988). Una base sicura: Applicazioni cliniche della teoria dell’attaccamento. Raffaello Cortina.

Carlberg, M., Edhborg, M., & Lindberg, L. (2018). Paternal perinatal depression assessed by the Edinburgh Postnatal Depression Scale and the Gotland Male Depression Scale: Prevalence and possible risk factors. American Journal of Men’s Health, 12(4), 720–729. https://doi.org/10.1177/1557988317749071

Castle, H., Slade, P., Barranco-Wadlow, M., & Rogers, M. (2008). Attitudes to emotional expression, social support and postnatal adjustment in new parents. Journal of Reproductive and Infant Psychology, 26(3), 180–194.

Cicchiello, S. (2017). La depressione perinatale materna e paterna: Fattori di rischio, aspetti clinici e possibili interventi. Cognitivismo clinico, 14(1), 22–45.

Crapkowska, C., & Wold, A. (2018). Praktika: Il metodo svedese per una maternità serena e bimbi felici. Vallardi.

Edward, K. L., Castle, D., Mills, C., Davis, L., & Casey, J. (2015). An integrative review of paternal depression. American Journal of Men’s Health, 9(1), 26–34. https://doi.org/10.1177/1557988314526614

Feinberg, M. E. (2003). The internal structure and ecological context of coparenting: A framework for research and intervention. Parenting: Science and Practice, 3(2), 95–131. https://doi.org/10.1207/S15327922PAR0302_01

Feldman, R., Gordon, I., Schneiderman, I., Weisman, O., & Zagoory-Sharon, O. (2010). Natural variations in maternal and paternal care are associated with systematic changes in oxytocin following parent–infant contact. Psychoneuroendocrinology, 35(8), 1133–1141. https://doi.org/10.1016/j.psyneuen.2010.01.013

Fletcher, R., Dowse, E., Bennett, E., Chan, S., O’Brien, A., & Jones, D. (2014, January). The paternal perinatal depression initiative. Australian Nursing & Midwifery Journal.

Fonagy, P., Steele, M., Steele, H., Moran, G. S., & Higgitt, A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12(3), 201–218. https://doi.org/10.1002/imhj.21471

Gao, L. L., Chan, S. W., & Mao, Q. (2009). Depression, perceived stress and social support among first-time Chinese mothers and fathers in the postpartum period. Research in Nursing & Health, 32(1), 50–58. https://doi.org/10.1002/nur.20306

Giannotti, M., Gemignani, M., Rigo, P., Venuti, P., & De Falco, S. (2022). The role of paternal involvement on behavioral sensitive responses and neurobiological activations in fathers: A systematic review. Frontiers in Behavioral Neuroscience, 16, Article 820884. https://doi.org/10.3389/fnbeh.2022.820884

Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 26–35. https://doi.org/10.1046/j.1365-2648.2003.02857

Gordon, I., Zagoory-Sharon, O., Leckman, J. F., & Feldman, R. (2010). Oxytocin and the development of parenting in humans. Biological Psychiatry, 68(4), 377–382. https://doi.org/10.1016/j.biopsych.2010.02.005

Hrdy, S. B. (1999). Mother nature: A history of mothers, infants, and natural selection. Pantheon Books.

Lamb, M. E., Pleck, J. H., Charnov, E. L., & Levine, J. A. (1987). A biosocial perspective on paternal behavior and involvement. In J. B. Lancaster et al. (Eds.), Parenting across the life span: Biosocial dimensions (pp. 111–142). Aldine.

Lamb, M. E., Pleck, J. H., Charnov, E. L., & Levine, J. A. (1985). Paternal behavior in humans. Integrative and Comparative Biology, 25(3), 883–894. https://doi.org/10.1093/icb/25.3.883

Luca, D., & Bydlowski, M. (2001). Dépression paternelle et périnatalité. Le Carnet Psy, 67, 28–33.

Masson, J. M. (2000). L’abbraccio dell’imperatore: Riflessioni sulla famiglia e la paternità nel mondo animale. Baldini Castoldi Dalai.

Morse, C. A., Buist, A., & Durkin, S. (2000). First-time parenthood: Influences on pre- and postnatal adjustment in fathers and mothers. Journal of Psychosomatic Obstetrics & Gynecology, 21(2), 109–120. https://doi.org/10.3109/01674820009075616

Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression. Journal of the American Medical Association, 303(19), 1961–1969. https://doi.org/10.1001/jama.2010.605

Pleck, J. H. (2010). Paternal involvement: Revised conceptualization and theoretical linkages with child outcomes. In M. E. Lamb (Ed.), The role of father involvement in child development (pp. 58–93). Wiley.

Ramchandani, P. G., Psychogiou, L., Vlachos, H., Iles, J., Sethna, V., Netsi, E., & Lodder, A. (2011). Paternal depression: An examination of its links with father, child and family functioning in the postnatal period. Depression and Anxiety, 28(6), 471–477. https://doi.org/10.1002/da.20814

Rilling, J. K. (2013). The neural and hormonal bases of human parental care. Neuropsychologia, 51(4), 731–747. https://doi.org/10.1016/j.neuropsychologia.2012.12.017

Rosenblatt, J. S. (1967). Nonhormonal basis of maternal behavior in the rat. Science, 156(3781), 1512–1514. https://doi.org/10.1126/science.156.3781.1512

Saraceno, C. (2017). L’equivoco della famiglia. Laterza.

Seidler, Z. E., Dawes, A. J., Rice, S. M., Oliffe, J. L., & Dhillon, H. M. (2016). The role of masculinity in men’s help-seeking for depression: A systematic review. Clinical Psychology Review, 49, 106–118. https://doi.org/10.1016/j.cpr.2016.09.002

Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & Human Development, 7(3), 269–281. https://doi.org/10.1080/14616730500245906

Storey, A. E., Walsh, C. J., Quinton, R. L., & Wynne-Edwards, K. E. (2000). Hormonal correlates of paternal responsiveness in new and expectant fathers. Evolution and Human Behavior, 21(2), 79–95. https://doi.org/10.1016/S1090-5138(99)00042-2

Swain, J. E., Dayton, C. J., Kim, P., Volling, B. L., & Mayes, L. C. (2014). Progress on the paternal brain: Theory, animal models, human brain research, and mental health implications. Infant Mental Health Journal, 35(5), 394–408. https://doi.org/10.1002/imhj.21471

Weiss, R. S. (1995). Il legame di attaccamento nell’infanzia e nell’età adulta. In C. M. Parkes, J. Stevenson-Hinde, & P. Marris (Eds.), L’attaccamento nel ciclo di vita (pp. 17–38). Il Pensiero Scientifico. (Opera originale pubblicata nel 1991)