Growing up in Scotland: parenting and children's health

CHAPTER 6 SUMMARY AND CONCLUSIONS

This chapter summarises the main findings, discusses some of the limitations of the study and reflects on implications for policy and practice.

The main aim of this report was to investigate two research questions:

(1) Which aspects of day-to-day parenting are associated with children's health and health behaviours?

(2) Do variations in parenting account for social inequalities in child health outcomes?

The study examined six child health outcomes:

• general health
• limiting long-standing illness
• social, emotional and behavioural difficulties
• dental health
• short-term health problems in the last year
• accidents and injuries

and four child health behaviours:

• physical activity
• 'screen time': watching television or using computers and games consoles
• fruit and vegetable consumption
• snacking on crisps, sweets and sugary drinks.

With the exception of accidents and injuries, which used data from all five sweeps, these outcomes were based on information reported by mothers at the fifth interview in 2009/10 when the study children were almost 5 years old (58 months).

6.1 Associations between parenting and health and health behaviours

Parenting behaviours covered three main 'domains' identified in other research (Belsky
et al. 2007): connection, negativity and control. Connection included a measure of early mother-infant attachment, a later measure of the warmth of the mother-child relationship and activities undertaken together. Negativity covered a measure of conflict in the mother-child relationship and parent's use of smacking as a disciplinary tool. Control comprised parental supervision, rule setting and amount of household disorganisation or 'home chaos'. Some parenting measures were based on sweep 5 information (warmth and conflict, and home chaos). Other measures used information from earlier sweeps (mother-infant attachment used sweep 1 information, and supervision used sweep 4 information) while the remainder (joint activities and rule-setting) drew on information from more than one sweep. All parenting behaviours were reported by the mother at interview.

The report examined associations between these individual measures or 'dimensions' of parenting and health, as well as looking at associations between health outcomes and a composite measure or 'index' of parenting. This parenting index was similar to one devised for the evaluation of Sure Start (National Evaluation of Sure Start 2008), although GUS does not contain the observational measures used in the Sure Start evaluation. The parenting index combined scores across various dimensions. Parents who had high scores on warmth, number of joint activities, supervision and rule-setting, but low scores on conflict and 'home chaos', were considered to have the highest skill in this parenting index. The report used the index to divide parents into three equal groups of low, average and high parenting skills.

The analysis of associations between parenting and health outcomes controlled for other important family influences on poor health, including low income and maternal mental health that have been widely found in other research including other investigations using GUS data.

Low overall parenting skill, as measured by the parenting index, was associated with greater risk of several health outcomes including:

• poor general health;
• limiting long-term illness;
• social, emotional and behavioural difficulties; and
• poor dental health.

Low overall parenting skill was also associated with all four health behaviours - physical activity, screen time, fruit and vegetable consumption and snacking on crisps, sweets and sugary drinks.

The increased likelihood of social, emotional and behavioural difficulties for children whose mother had low parenting skills was particularly strong. There was evidence that average parenting skills were also disadvantageous compared to high skills for some of these outcomes. There were no associations between overall parenting skills and the number of health problems in the past year and accidents and injuries.

Overall, there were significant associations between all three domains of parenting and the outcomes studied. When the various dimensions of parenting were examined in detail, it appeared that both child health outcomes and health behaviours each had slightly different patterns of association with parenting behaviours. Low parental supervision was associated with behavioural difficulties, limiting long-term illness and poor general health. For child health behaviours, joint mother-child activities and parental rules appeared more important. Lower scores on each of these measures were associated with lower physical activity, lower fruit and vegetable consumption and unhealthy snacking.

6.2 Does parenting help to explain social inequalities in child health?

To explore the second research question, an index of family adversity combined eight different indicators of health risk including low income and maternal depression, using an approach that was similar to a US study (Larson et al. 2008). Higher family adversity index scores were associated with higher prevalence of poor child health and health behaviours, with two exceptions. In the case of limiting long-term illness, there was no clear increase in prevalence with higher family adversity score, although any score above zero was associated with a greater risk of limiting long-term illness compared to children with no family adversity.

There was no clear association of physical activity with the family adversity score. Another study using Growing Up in Scotland data did find a relationship between physical activity and social background (Marryat et al. 2009). However, the two studies have taken different approaches to measuring activity and social background. Here we have separated out sedentary behaviour - watching TV and playing on computers and games consoles - from active behaviours, and we have looked at associations with an overall measure of adversity rather than the relationship between activity and the individual components of this measure. Our study did find a strong association between screen time and social background.

There was also strong patterning of parenting behaviour according to family adversity score. Parents in families with higher adversity scores were less likely to have a warm relationship with their child, to share joint activities, to have low conflict and avoid smacking and to exercise control over their child's behaviour. Variations in parenting amongst families with different levels of adversity offered some explanation for part of the association found between family adversity and several health outcomes. However, there was a negligible effect of variation in parenting on associations between family adversity and accidents and injuries. Furthermore, after allowing for parenting, there was still an association between family adversity and other poorer health outcomes. This implies that parenting is likely to offer only a partial explanation for inequalities in child health that are linked to social background.

It should be stressed that associations found between parenting and child health and health behaviours in this report are not in themselves evidence of causation. There are several limitations to the analysis that should be borne in mind when assessing any policy relevance.

The study relies on mother's own reports of both parenting and their child's health. While there is evidence that use of self-rated health measures is likely to be a reasonable measure of social inequalities found in direct measures of health (Subramanian and Ertel 2008; Subramanian and Ertel 2009), less is known about the validity of mother's reports of child health and self-reported parenting information. There may be bias, if for example a mother's report of parenting behaviour is influenced by social desirability, or if a mother's views of her relationship with her child and the child's health are influenced by the mother's own difficulties. Future use of observational data and linkage of GUS data to independent health service data may help overcome these issues.

In addition, many of the parenting behaviours were measured concurrently with health outcomes. It is possible that some of the associations found could be due in part to reverse causation: for example, social, emotional and behavioural difficulties or a long-standing health problem could lead to conflict in the mother-child relationship. It is also likely that there are unmeasured factors responsible for many of the associations found: in particular, it is impossible with this type of study to distinguish between genetic and environmental influences on health. Genetic predispositions could affect both a mother's parenting behaviour and the propensity of her child to suffer poor physical and mental health.

6.3 Implications for policy and practice

These limitations underline the necessity for more in-depth exploration of possible mechanisms underlying associations between parenting and health. This will be aided by longitudinal analysis of associations between parenting measures used in this study and child health outcomes added in future sweeps, including more objective measures such as BMI and hospital admissions.

Research on factors conducive to positive change in parenting behaviour, using parenting measures tracked at future sweeps of GUS would also be a useful addition to the evidence base for parenting policy. Existing research on the ALSPAC cohort suggests that improving parental support may be effective (Waylen and Stewart-Brown 2010), although there is a particular challenge in engaging with parents to deliver the appropriate support (Mabelis and Marryat, 2011). The list of parenting processes included here is not exhaustive, and future work could add parenting behaviour that is likely to be related closely to specific outcomes, such as parental modelling of health behaviours, as well as parents' confidence in their ability to look after their children well, something that has been highlighted as important in other research (Lexmond and Reeves 2009). The study also has a limited focus on mothers' parenting of children up to the age of 5, and more work is required to establish wider applicability to the role of fathers or non-biological parent figures, or to the parenting of older children.

Despite the limitations of the study that have been highlighted above, the findings suggest that policy measures to strengthen parenting skills may benefit child physical and mental health and child health behaviours. It is beyond the remit of this report to suggest mechanisms for delivering parental support, and measures could range from direct (e.g. parenting advice and classes) to indirect (alleviating aspects of family adversity that may impede good parenting). In what follows, the term 'parenting programmes' is intended to cover a range of policy options.

Since greater parental connection, lower negativity and more control each contained dimensions of parenting associated with several health benefits, parenting programmes that support a wide range of skills are likely to achieve more wide-ranging health improvements than programmes with a narrower focus on only one or two aspects of parenting. With regard to health behaviours, parenting that encompasses many joint mother-child activities and has rules to guide a child's daily actvities may be optimal. For health, a high degree of parental supervision appeared important although not predominantly so.

Many different aspects of parenting were associated with social, behavioural and emotional difficulties in children, so it is possible that parenting programmes would achieve the greatest health benefits here. Even if part of the association is due to reverse causation, with children's behaviour and emotional difficulties leading to difficulties in parenting, the findings underline the need to support parents of these children.

Other aspects of child health, such as health problems and accidents and injuries, appeared to be less strongly influenced by general parenting skills. Stronger associations with parenting may be found in future studies that are able to account for differences in the type or severity of health problems and injuries, or that examine their accumulation over a longer period. In addition, it is likely that other aspects of parenting such as ensuring that children's immunisation record is complete, a good diet and a warm and safe living environment are more closely related to these health outcomes than the general parenting skills examined in this report.

The strong patterning of parenting according to family adversity in itself suggests that parents in higher-risk groups may need additional help in addressing obstacles to more skilful parenting of their children. Families experiencing adversity may benefit from support in multiple areas of parenting to promote a higher degree of connection and control, and lower conflict with children. More skilful parenting is likely to have wider benefits on children's overall development apart from health.

Echoing other research pointing to multiple explanations for health inequalities in terms of stress, culture, knowledge and resources as well as parenting skills (Bradley and Corwyn 2002; Chen 2004; Conger and Donnellan 2007) the findings suggest that parenting is likely to be only part of the answer to removing social inequalities in health.