Growing up in Scotland: parenting and children's health

EXECUTIVE SUMMARY

Introduction

The Scottish Government has placed the individual wellbeing of children and young people at the heart of its policy agenda on Getting it Right for Every Child, with a recognition of the important role of parents and other carers in providing "good basic care, stimulation and emotional warmth, guidance and boundaries, safety and stability".
It recognises that the challenges to successful parenting posed by family adversity may contribute to inequalities in health.

This report focuses on day-to-day parenting of young children in three 'domains': connection (love and togetherness), negativity (conflict and harsh discipline) and control (supervision, routine and regularity). The study uses data from the Growing Up in Scotland study ( GUS).

Two main questions were investigated:

• Which aspects of day-to-day parenting are likely to be important for children's health and health behaviours?
• Do variations in parenting account for social inequalities in child health outcomes?

Health outcomes and health behaviours

The study examines 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).

Day-to-day parenting

Parenting behaviours covered three main domains: 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 the amount of household disorganisation or 'home chaos'.

All parenting behaviours were reported by the mother at interview. Mothers of the first birth cohort of GUS were surveyed every year from 2005/06, when their children were aged around 10 months old. Some parenting measures were drawn from sweeps 1 to 4; these measures therefore pre-dated most of the health information. In order to obtain a fuller picture of parenting this report also uses parenting measures collected at sweep 5.

In addition to individual measures or 'dimensions' of parenting, a composite measure or 'index' of parenting skills was devised. This index combined scores across various dimensions. Parents who had high scores on warmth, number of joint parent-child activities, supervision and rule-setting, but low scores on conflict and 'home chaos', were considered to be highly skilled on this parenting index. The report used the index to divide parents into three equal groups, with low, average and high parenting skills.

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

The analysis of associations between parenting and each health outcome or health behaviour controlled for other important family characteristics known to influence poor health, including poverty and maternal mental health.

Low overall parenting skills as measured by the parenting index were associated with greater risk of a number of poorer health outcomes and health behaviours amongst children. In particular:

• health outcomes (see above)
  • the odds of children who experienced low parenting skills having social, emotional or behavioural difficulties were more than eleven times higher than for children experiencing high parenting skills
  • the odds of children with low-skilled parents experiencing poor health were two to four times higher than for children with high-skilled parents
• health behaviours (see above)
  • the odds of children with low-skilled parents displaying unhealthy behaviour were 1.5 times higher than for children with high-skilled parents.

After allowing for other family influences on health, there were no associations between overall parenting skills and the number of health problems in the past year, and accidents and injuries over the first five years.

All three domains of parenting (connection, negativity and control) were related to one or more health outcomes and health behaviours. This suggests that a wide range of different parenting skills are important for health, although the following aspects of parenting appeared particularly relevant for specific outcomes:

• High levels of parent-child conflict were strongly associated with social, emotional and behavioural difficulties.
• Low parental supervision was associated with poor general health, limiting long-term illness and social, emotional and behavioural difficulties. The odds of children in the low supervision group having poor health were around twice as high as those for the high supervision group.
• Joint mother-child activities and parental rules appeared important for health behaviours. The odds of children who took part in few activities or had few rules showing unhealthy behaviours were between 1.5 and 2.6 times higher than those for children with a high number of joint activities or many rules.

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

It is known that child health and health behaviours vary according to socio-economic characteristics, with more disadvantaged groups experiencing poorer health. This report explored whether parenting behaviours also varied according to family circumstances, and if so whether differences in parenting offer an explanation for social inequalities in health.

A measure of social inequality was devised using an index of 'family adversity'. This combined eight different indicators of social inequality from maternal, family and area characteristics including poverty and maternal depression.

The findings showed that, in general, the higher the family adversity index score, the higher the prevalence of poor child health and health behaviours. There were two exceptions to this picture. In the case of limiting long-term illness, any family adversity was associated with a greater risk of illness but there was no clear increase in prevalence with higher family adversity. Physical activity showed no clear association with family adversity.

There was a strong patterning of parenting according to family adversity. Parents in families with higher adversity scores were less likely to have a warm relationship with their child, less likely to share joint activities, less likely to exercise control over their child's behaviour and less likely to have low levels of conflict.

In order to find out whether parenting skills explain some of the relationship between family adversity and health outcomes and behaviours, we examined whether the strength of association between adversity and health was reduced when parenting skills were taken into account. The results showed that:

• High parenting skill reduced the association between adversity and health by between 33% and 44% for poor general health, limiting long term illness, social, emotional and behavioural difficulties, and poor dental health.
• Parenting skill had a lesser effect on health problems (22%) and accidents and injuries (8%).
• Parenting skill accounted for between 32% and 54% of the association between adversity and screen time, fruit and vegetable consumption, snacking on crisps, sweets and sugary drinks.

Thus, not only is parenting skill itself related to child health and health behaviours, variations in parenting skill also explained some of the relationship between children's experience of family adversity and their health outcomes and health behaviours. Nevertheless, even after taking variations in parenting into account greater family adversity was still independently associated with poorer health outcomes for children.

Policy implications

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 mothers' reports of both parenting and children's health, which may have introduced an element of bias and overestimated the strength of associations.
• Several parenting behaviours were measured concurrently with health outcomes. This means that some of the associations found could be due to a child's health affecting parenting behaviour, rather than the other way round.
• Unmeasured factors may be responsible for many of the associations found, including genetic predispositions underlying both parenting behaviour and poor health.
• The study 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 these limitations, 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 better parenting, and measures could range from direct (e.g. parenting classes) to indirect
(e.g. alleviating aspects of family adversity that impede good parenting). In what follows, the term 'parenting programmes' is intended to cover a range of options. The findings suggest that:

• Parenting programmes supporting a broad range of skills are likely to achieve more wide-ranging health improvements than programmes with a narrower focus on only one or two dimensions of parenting.
• Parenting that encompasses many joint mother-child activities and has rules to guide a child's daily actvities may be optimal for good health behaviours.
• Parenting programmes may achieve the greatest health benefits for children with social, behavioural and emotional difficulties. Even if part of the association between parenting and behavioural/emotional difficulties is due to reverse causation, with children's difficulties leading to problems in parenting rather than the other way round, the findings underline the need to support parents of these children.
• Parenting programmes supporting general parenting skills may have less impact on health problems and on accidents and injuries. It is likely that other aspects of parenting, such as a good diet, a warm and safe living environment and ensuring that a child's immunisation record is complete, are more closely related to these health outcomes than the general parenting skills examined in this report.

The health benefits of better parenting appear greatest for those families that experience the highest levels of family adversity, so that policies which improve parenting may contribute to a reduction in health inequalities. The strong patterning of parenting according to family adversity in itself suggests that parents in more disadvantaged 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.

However, the findings suggest that the role of parenting in reducing health inequalities may be greater for some health outcomes and behaviours than others. Overall, programmes to improve parenting skills are likely to form only a partial solution to the reduction of social inequalities in health.