Statistics from Altmetric.com
What is the likely impact on child mental health?
The December edition of the Archives carried two complementary papers1,2 on need and demand for, and impact of, parenting programmes, reflecting increasing professional and political interest in interventions to improve parenting. This interest is fuelled by the apparent increase in the prevalence of child mental health problems and greater awareness of the long term impact of childhood conduct disorders.3 Interest in and enthusiasm for parenting programmes, however, should not divert from the critical question—what is the likely impact of parenting programmes on the mental health of the child population in this and other similar countries?
THE PARENTING AND CHILD MENTAL HEALTH CONTINUUM
Parenting and child mental health problems are not “all or nothing” phenomena. They represent a continuum along which arbitrary cut off points are used to define “normality” and “abnormality”. This fundamental characteristic, shared with many other socially and culturally related child health problems, helps to explain the difficulties of defining “good enough” parenting4 and the point at which childhood behaviour becomes abnormal. Although often treated as characteristics of individual families or children, they are embedded in societies and cultures and are powerfully influenced by social, economic, and political contexts.4 Recent work on the 1958 British births cohort5 confirms previous work showing close links between educational attainment and psychosocial adjustment in late adolescence and early adulthood,6 showing that family social class exerts its effects on both educational attainment and psychosocial adjustment through material deprivation, parental aspirations, and involvement, as well as school composition.
Rose7 argues that the distribution of risk exposures across a population determines the extent of problems at the lower tail of the distribution. High population levels of alcohol consumption are associated with high levels of alcohol related diseases; high population levels of salt consumption are associated with high levels of hypertension. Similarly, high population levels of material deprivation, low parental educational attainment, and family violence are likely to result in high levels of parenting and child and adolescent mental health problems.
Even if, as Patterson and colleagues1,2 have shown, parental education is acceptable to parents and the programmes are effective in improving conduct disorders, the above characteristics of parenting and child mental health are likely to limit the impact of parent education programmes on child mental health across the whole population. Patterson and colleagues1 acknowledge that parenting programmes are not an alternative to changes in social policy to make the job of parenting easier and reduce the population level of risk exposures. However, there remains a danger that their results, and those of others,8 will be used by politicians intent on a “quick fix” to promote parenting education as an alternative to social change.
PARTICIPATION, DROP OUT, AND GENERALISABILITY
There are additional warning signs in these two papers, and in the wider evidence base used to show the effectiveness of parenting programmes,8,9 that caution against a major public health initiative based on these programmes, at least until a more robust evidence base is established. Only 14% of the 800 parents (10% of all 1155 approached) responding to the postal questionnaire expressed a definite interest in attending a parenting group.1 When parents were invited to participate in the randomised controlled trial (RCT),2 only 30% agreed, despite the fact that their children were above the mean score on the Eyberg Intensity Scale. These results suggest that both interest and participation in parenting programmes is likely to reach only a minority of families with children. The authors argue, with some justification2 that an uptake of 30% “represented a significant level of interest in the intervention”. However, the question remains: would these levels of participation be sufficient to make a real impact on child mental health across the whole population?
Among those agreeing to participate in the RCT and randomised to the intervention group, only 57% attended 50% or more of the sessions, raising further questions about the potential impact if these programmes were universally available.
The social patterning of participation also raises a question over the likely impact on population rates of child mental health problems. Not only were the parents responding to the initial questionnaire more likely to come from higher social groups,1 but 11.4% of participants in the RCT were in social classes IV and V compared with 14.9% of non-participants. The social class of those attending less than 50% of the sessions is not stated, but it is reasonable to assume that the reasons given by the authors for dropping out of the programme2 would be more prevalent among lower social groups.
The study reported in these papers was conducted in a relatively affluent population and it is not clear whether the results are generalisable across the country, especially in severely deprived areas where the problems of parenting and child mental health are most prevalent. The authors argue, appropriately in my view, for a universal rather than a targeted service, but very low participation rates in socially deprived areas would further undermine the likely impact on child mental health.
The RCT shows significant differences between intervention and control groups in mean conduct problem scores at both immediate and six month follow up, and mean Eyberg Intensity scores at six months. There was a significant positive short term effect of the intervention on parental social dysfunction. There were no significant effects on other child or parental domains and the effect sizes on conduct problems, though not reported in the conventional way, are likely to be small judging by the p values (0.041 immediately; 0.034 at six months). These effects should not be dismissed, but further studies in different areas of the country will be advisable before assuming that these results are generalisable. Current evidence of effectiveness of parenting programmes comes from North America and is based on interventions with parents at high risk.8
MORE EVIDENCE OF LIKELY IMPACT NEEDED
In summary, these papers1,2 ae a valuable contribution to the literature on the impact of parenting programmes. However, they raise as many questions as answers. Given the continuum of parenting and child mental health and their sensitivity to societal level influences, parenting programmes alone cannot be expected to have a major impact on child mental health. Whether the problems of low participation, high drop out, and differential social uptake can be overcome, in order to enable universal parenting programmes to contribute effectively to public health, will have to await further evidence.
What is the likely impact on child mental health?