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Improving parenting: the why and the how

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Parenting is often in the news these days because it is recognised as being key to the prevention of crime and educational failure. Parenting skills therefore feature prominently in initiatives to support the government’s Respect Agenda and improve educational outcomes. Both the new children’s centres and extended schools are charged with providing parenting support to all families, particularly those living in deprived areas and those who are seen to be in difficulty. Pilot initiatives from the Department for Education and Skills (now the Department for Children, Families and Schools) such as Early Intervention Pathfinders and Parent Support Advisors in England, and Flying Start in Wales have provided funding for some local authorities to offer parenting programmes, and parenting support more generally, to parents in need in their localities. The English government has also commissioned a National Academy for Parenting Practitioners and this is currently being set up. Developed out of a collaboration between two of the major national charities with an interest in parenting (Parenting UK and the National Family and Parenting Institute) together with King’s College London, the Academy is charged with increasing the amount and quality of provision of parenting support throughout England, by offering good quality training to those who run parenting programmes and support parenting, and by undertaking research to extend the evidence base relating to parenting interventions.

The programmes which have been approved for funding under the above initiatives are restricted to the group-based behaviour management programmes for which randomised control trial (RCT) level evidence demonstrates impact on children’s behaviour and conduct disorder.1 They include the Incredible Years programme developed in the USA by Carolyn Webster Stratton and Triple P developed in Australia by Matt Sanders.

These programmes were developed in the context of social learning theory and aim to help parents set boundaries and maintain them with positive discipline. The latter involves rewarding good behaviour and responding to transgressions that cannot be ignored with age and misdemeanour appropriate, previously identified penalties like time out or withdrawal of privileges. Both the latter programmes also offer parents insight into ways in which they could improve their relationship with their children, by, for example, spending more time with them and letting them take the lead in joint activities, but this is not their primary focus. These programmes are definitely worthwhile and no parent should be expected to raise their children without the skills they teach.

Although it may come as a surprise, what they offer appears to be news to a large number of parents who are not “in difficulty” and parents from all walks of life seem to value what they learn on them.2

While behaviour problems are very important for children, families and society, they are not the only area of development on which parenting has an impact. An increasing body of literature suggests that parenting also has a role to play in the development of a wide range of health problems both in childhood and adulthood (see boxes 1 and 2). The quality of relationships parents make with their children predicts healthy eating,3 and the only programmes which have an (albeit modest) impact in reversing childhood obesity are programmes which offer development of parenting skills as well as lifestyle advice.4 5 Adverse parenting is also a risk factor for the adoption of smoking,6 alcohol and drug misuse,6 teenage pregnancy,6 and poor mental health in children,7 adolescents8 9 and adults.10 11 It is possible to show that adverse parenting and poor quality parent–child relationships are risk factors for poor health in general6 1214 and symptoms of poor physical health6 12 13 in childhood and adulthood, as well as cardiovascular disease,6 13 cancer,6 13 musculoskeletal problems,6 13 injury15 and mortality6 in later life. These risks are not restricted to families living in deprivation.13 Potential mechanisms are suggested by animal and human studies6 16 that examine the impact of parent–child relationships on the development of the areas of the brain which deal with emotional and social functioning and with the physiological response to stress. Healthy and unhealthy patterns of relating seem to be hardwired into the brain early in life, dictating subsequent resilience to stress and proving difficult, but not impossible, to moderate later on.

The aspects of parenting which are the focus of health related studies overlap with those relevant to behaviour problems but are subtly different. They derive from attachment theory as much as from social learning theory. They cover containment, and sensitivity and attunement to babies’ needs,8 9 aspects of the parent–child relationship including warmth,17 affection/rejection,10 hostility and conflict management,12 17 problem solving,6 13 discipline and behaviour management,13 17 monitoring and supervision in adolescence, and appropriate boundaries and control at all ages. Aspects of parenting with an adverse effect on health are surprisingly common in all social groups.12 The content of parenting programmes which could maximise health is therefore somewhat different from that of those which aim to improve behaviour. They focus on the quality of the parent–child relationship. All the programmes which have been developed to enhance attachment in infancy have this focus, aiming to improve parents’ (usually mothers’) sensitivity and attunement to their infants’ needs, programmes like Watch, Wait and Wonder,18 Mellow Baby, PIPPIN19 and those based on video interaction.20

Box 1 Aspects of parenting which impact on health

In infancy

  • Sensitivity

  • Attunement

  • Containment

In preschool and primary school years

  • Behaviour management

  • Discipline strategies

  • Praise

In adolescence

  • Monitoring

  • Supervision

All ages

  • Warmth, affection, support

  • Lack of hostility or rejection

  • Conflict management

  • Problem solving

  • Appropriate levels of control

Box 2 Aspects of health on which parenting has an impact

Conduct disorder

Oppositional defiancy disorder

Emotional and social development

Peer relationships

Mental health

Healthy eating

Obesity

Smoking

Alcohol misuse

Drug misuse

Teenage pregnancy

Injury

Adulthood

Health in general

Symptoms of poor health

Mental health

Cardiovascular health

Musculoskeletal problems

Early programmes are usually offered to high risk parents on a one-to-one basis, often in the home. While the research that has been published is on the whole favourable,21 22 there is much less of it than there is of research on behavioural programmes, probably for two reasons: first, the programmes have been developed from a psychotherapeutic rather than psychology perspective and psychotherapists have in the past been reluctant to undertake randomised controlled trials; and second, much more money has been poured into crime prevention research than into research to promote health. What is widely accepted, however, is that these programmes only work in the context of a therapeutic relationship23 and it is also accepted that such relationships may be very difficult to establish with very high risk families. A key component of therapeutic relationships is trust and such families often carry an intense suspicion of the motives of public service providers. Establishing trust can be done but is a skilled and time-consuming job.

The Nurse Partnership Programme24 is one of the few programmes of this nature to have a solid RCT evidence base. It is holistic, covering a wide range of health topics such as contraception, breastfeeding and immunisation as well as attachment promotion. It is currently being piloted in 10 primary care trusts (PCTs) in England under the guise of the Reaching Out: health-led parenting demonstration projects. The evidence base to support very early parenting programmes like the Nurse Partnership Programme is growing. As well as parenting and other outcomes related to emotional and social development, they show impact on a wide range of outcomes of traditional interest to paediatricians such as immunisation and injury.25 26 Many of the UK developed parenting programmes for preschool and school age children27 28 have a relationship focus. These stand a greater chance of influencing the wide range of outcomes described above than do the strictly behaviour management programmes. They nearly all teach behaviour management skills, but aim primarily to enable parents to gain insight into their own and their children’s emotional worlds. They offer the potential of improving relationships between adults as well as between parents and children. Some relationship programmes, like the Family Links Nurturing Programme,27 are now recommended for use in children’s centres, but as the evidence base to support these programmes remains poor, they are vulnerable to cuts. Many of the current parenting support initiatives described above specifically exclude these programmes in favour of those focusing on behaviour management alone.

What might paediatricians want to do about all this? The first step is to inform themselves, and because the evidence base for the relationship programmes does not all come neatly packaged in Cochrane Systematic Reviews or NICE guidelines, this may take time. It will involve reading, and also finding out what programmes are available locally, who has been trained to run them, whether they run them well and what the track record of the programmes is. Some Masters courses in Paediatrics and Child Health (eg, at Warwick and Leeds Universities) now have modules which cover parenting. A very good way of developing insight into what these programmes can offer is to get involved in one as a participant and observe the impact it has on family life at first hand.

The next step is to support research into these programmes so an evidence base can develop. RCTs of relationship type programmes are badly needed but also research to investigate what promotes uptake and reduces drop out. What are the optimum approaches to the training and selection of practitioners? What levels of practitioner supervision are appropriate? What are the most cost effective ways of providing this? Some of this research will be undertaken by the new National Academy for Parenting Practitioners which will have a significant research brief. However, left to its own devices the latter may focus on crime prevention and behaviour management and exclude the goal of promoting health and well-being. In the meanwhile, there is a need for advocacy: the role that parenting plays in promoting children’s health and well-being is not widely understood nor is the particular contribution of relationship programmes, and this is something paediatricians have the power to explain, to the parents whose children they look after and to the medical directorates and trusts for whom they work.

Although the Parenting Academy is an exciting step forward and should speed up the process, the time frame for change in parenting is likely to be long, so patience will be needed. Parenting support is currently patchy. Even in local Sure Start programmes, provision of parenting support was remarkably low.29

Developing a workforce that can help parents learn new skills and approaches will also take time, as will identifying the funding to provide good quality support. Managing the cultural change to ensure that all parents know that there might be useful things to learn about parenting, that there are now supportive, well qualified people to teach them and interesting non-stigmatising programmes to help them learn will also take time.

The recent UNICEF report30 which identified UK children’s well-being as amongst the worst in Europe, provides something of a wake-up call to those concerned with services to children. Support for parenting has a very important role to play in promoting children’s well-being, alongside initiatives to reduce social inequalities and improve schools. However, a great opportunity will be lost if parenting support is restricted to the thoroughly evidence based behaviour management programmes. Because problems with parenting are fairly ubiquitous in UK society, the opportunity will also be lost if parenting support is restricted to children living in social deprivation. On the other hand, support for parenting is currently on a roll with cross-government backing and significant financial investment of the sort which is unlikely to change with a change in administration. The potential for improving children’s well-being and having a notable impact on public health is great, so there is all to play for among paediatricians who want to support this agenda.

REFERENCES

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Footnotes

  • Competing interests: Professor Stewart-Brown undertakes research on parenting and parenting programmes and is in receipt of grants from government bodies and charities to undertake such research. She is Vice Chairman of the Board of Trustees of the charity Parenting UK and a Trustee of the National Academy for Parenting Practitioners.

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