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Parenting and health: a call for action
SYMPOSIUM: SOCIAL PAEDIATRICS
Parenting and health: a call for action
find paediatricians asking for training on how they could support parenting in their day to day practice, or calling for support for parenting through social and political channels. There is a wealth of transdisciplinary evidence from psychology, neuroscience, the social sciences, and public health describing the impact of the relational environment in the home on child and adult health which may not be well known to paediatricians or other healthcare professionals. A recent RCPCH survey looking at poverty and child health highlighted parental mental illness and limitations on family time due to long working hours, alongside food insecurity, overcrowded and damp housing, homelessness, stress and worry linked to poverty as important concerns to paediatricians. All of these issues merit advocacy, and wider social and structural change, however tackling them is complex and requires cross-disciplinary effort. Parenting interventions are well evidenced and can mitigate some of the impact of poor parenting. This article aims to provide an outline of what is currently known about parenting and its importance for child and adult health and point to possible ways that healthcare professionals might intervene in the hope that individuals will feel more empowered to take action on this key determinant of health.
Neha Shah Sarah Stewart-Brown
Abstract Paediatricians and healthcare professionals working with children are well placed to observe parents and see a wide range of parenting from the exceptional to the abusive. Parenting has important short, medium and long term effects on child physical and mental health. Understanding these effects more fully helps paediatricians to comment on parenting, offer advice or refer to parenting programmes. This article outlines advances in neuroscience and attachment theory as well as contemporary issues that underpin the case for parenting intervention. It also discusses the rationale and evidence base for particular programmes, the UK policy context, and makes some suggestions on how paediatricians may wish to support better parenting.
Keywords advocacy; life parenting; physical health
course influences; mental health;
Neuroscience ‘Use it or lose it’ e early life matters Knowledge has been building over the last few decades regarding the plasticity of the infant brain and its great sensitivity to the environment, particularly the relational environment created by primary caregivers. Most cerebral neurons develop during pregnancy and the first two years of life. Simple neurological circuits supporting different skills develop and provide the scaffolding for more advanced circuits and dendritic connections over time. The process is one of ‘use it or lose it’; pathways that are frequently activated grow and those that are not wither. Also, ‘neurons which fire together wire together’ establishing links between feelings, settings and actions that do not involve higher brain circuits. This patterning, linked to emotional or relational experiences, sculpts the brain, determining dominant pathways and associations. Mirror neurons, which fire both when an action is performed and when an action is watched, provide insight into the mechanisms which could underpin the profound influence of the relational environment on learning. Neural plasticity continues throughout life but at a slower rate. There is a second spurt during adolescence and this period represents an opportunity to enable change in some of the pathways developed in infancy. Plasticity is fostered by intention, attention and compassionate awareness. These skills are recognised by the great spiritual traditions as fundamental for human development and are now widely taught in the Western world under the label of mindfulness. A significant body of neuroscience now attests to the capacity of mindfulness to enable neural plasticity. So whilst what happens in the home in childhood is profoundly influential for health and wellbeing throughout the life-course, it is still possible to reverse some of the damage at any stage of life.
Introduction A lack of knowledge is a barrier to positive action Healthcare professionals working with families see a wide range of parenting from the exceptional to the abusive. They commonly recognise the harms that accrue to child health and development from aspects of parenting like provision of unhealthy food, lack of exercise and lack of support for language development and education. Most offer advice and support with regard to the care of children and paediatricians, in particular, are required to investigate and report parenting that may be abusive or neglectful. Most paediatricians will also be aware of research relating childhood influences to health throughout the life course, which begins in utero. Many observational studies have shown that the lifestyles acquired in childhood and adolescence track through into adulthood and influence adult health and longevity. These may also impact on the health of the next generation as patterns of behaviour become trans-generationally ingrained. Some will consider it their responsibility to promote or advocate for improvement in social conditions, by drawing attention to the impact poverty and deprivation have on child health and development. They campaign for improvements in school meals, taxation on high sugar foods and beverages, opportunities for safe physical activity and protection from harmful substances like tobacco and illegal drugs. It is, however, rare to
Neha Shah BMBS (Hons) BMedSci Msc Public Health is Public Health Registrar at Warwick Medical School, University of Warwick, UK. Conflict of interest: none declared.
Stress response A nurturing relationship can mitigate the stress response A key biological system affected by the relational environment in early childhood is the hypothalamic-pituitary-axis (HPA).
Sarah Stewart-Brown BMBCh PhD FFPH FRCPCH is Professor of Public Health at Warwick Medical School, University of Warwick, UK. Conflict of interest: none declared.
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Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
SYMPOSIUM: SOCIAL PAEDIATRICS
development and the negative consequences of learned patterns of dysfunctional cognitions, emotional responses and behaviour that limit personal development and relationships throughout the life course. Because these behaviours are linked to the stress of attachment insecurity and exaggerated physiological responses to common stressors, these circumstances also influence physical health.
Secure, nurturing relationships enable the development of systems to regulate the HPA stress response from higher brain circuits. Lack of security embeds reactivity to stress and ultimately chronic activation of the HPA, leading to raised baseline cortisol and flattening of circadian rhythms; and chronic immune system activation leading to chronic inflammation and upregulation of acute immune responses that impair later resistance to chronic disease. In this way infant and fetal relational experiences also shape endocrine and immune systems influencing the biology of the child and adult’s response to stress and thus their physical and mental resilience. Stress also impacts on learning and memory. Cortisol is neurotoxic, particularly to the hippocampus, impairing cognitive functioning including working memory and the establishment of new memories. Children whose stress response is easily triggered and who lack the ability to self-regulate are disabled in the classroom, leading to educational underachievement with lifelong consequences for social mobility and earning. Seminal studies of resilient children e those who transcend emotionally and materially deprived circumstances e show that what makes this possible is a secure nurturing relationship with at least one adult, perhaps a teacher, social worker, older sibling, or grandparent.
ACEs Adverse experiences in childhood lead to physical and mental health problems in later life The long term impact of these early experiences is now being illustrated in epidemiological studies of Adverse Childhood Experiences (ACEs). The latter are retrospectively reported experiences of childhood psychological, physical or sexual abuse, violence against mother, or living with household members who were substance abusers, mentally ill or incarcerated. These have been shown to greatly increase adult risk of alcoholism, drug abuse, depression, and suicide attempts; smoking, numerous sexual partners, and sexually transmitted disease; physical inactivity and severe obesity. Experience of four or more of these risk factors doubles the risk of severe chronic disease aged 60 years with a graded relationship between number of risk factors and disease outcomes (observed in about 10% of the population). These findings have been consistently repeated in different settings. ACEs are usually but not necessarily attributable to parents or parenting. Even when not directly attributable they affect children because parents are not sufficiently sensitive or aware to be able to see their impact, or they are not able or willing to offer protection. Studies of ACEs have attracted great attention in highlighting the need for parenting support and proved important in persuading professionals and policy makers that action is necessary.
Attachment security Secure attachments promote resilience Aligning with the neuroscience are numerous observational studies reported over the last century relating to attachment (the bond between child and caregiver) security. Based on observation of patterns of infant behaviour when separated and reunited with their caregiver (the ‘strange situation’ test), research has shown secure attachment promotes positive emotional and social development, with children being better able to cope with stress, having a higher perception of self-worth and being able to adjust better to adversity and change. The sensitive, attuned and caring parenting that enables attachment security, also enables infants to feel safe and develop the capacity to trust others. It enables the infant to develop self-regulation so that stressors can be experienced without prolonged biological consequences, building resilience. Parenting that is out of tune with infant needs, neglectful or abusive is stressful and this disrupts the neurochemistry and architecture of the developing brain, nervous system and the HPA. Insecure childhood attachment relationships predict depression, anxiety, self-harm and suicidal tendencies, anorexia, Post-Traumatic Stress Disorder and other mental health problems in adolescence and adulthood.
Reducing inequalities Parenting has a social gradient Reducing inequalities has been high on the public health and political agenda in recent years, and it is well established that early child development and health outcomes follow a socioeconomic gradient. Analysis from the UK Millennium Cohort Study indicates that the income gap for child socioemotional difficulties was largely explained by the psychosocial environment including home learning and family routines. Whilst these aspects of parenting show a social gradient they operate to some extent across the whole social spectrum. So tackling them would serve to reduce social inequalities and improve whole population health.
Complex PTSD Chronic trauma has long term effects Observation in psychotherapeutic settings has enabled the phenomenon of Complex PTSD to be recognised and studied. This is the legacy of the patterns of key relationships on emotional, mental and social functioning from childhood. Patterns may, for example, reflect development in a family which was safe as long as the child learnt to fit in which the needs of others and gave up trying to get their own met. Such adults often have problems displaying anger. Other families can feel safe as long as vulnerability is not expressed, particularly among boys. Child brain plasticity enables both positive
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Perinatal influences Early events are critical and maternal mental health has important consequences Postnatal mental illness is well recognised as a profound interrupter of the relational environment that supports attachment security and enables infants to thrive. Maternal psychosis is the severe but rare manifestation, but most of the long term costs associated with postnatal depression are attributable to the much commoner (estimates vary from 10 to 20% of births) less severe problems. Programmes to identify and offer support to women
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
SYMPOSIUM: SOCIAL PAEDIATRICS
conspiracy of silence can prevail to the detriment of the children. The status of parental mental illness as a profound disruptor of normal biology and development is emphasised today because it is one of the ACEs. Programmes to support the clinical conversation around children and enable better support for children have been developed. It is to be hoped that the ACEs agenda brings these to the attention of mental health services.
with postnatal depression are well established in Western healthcare services. Recently studies have investigated the antenatal period and it is becoming clear that maternal anxiety and depression during pregnancy is as common and impactful as postnatal depression. Prospective studies now show antenatal influences linked to reduced fetal growth and low birthweight, higher levels of anxiety, depression and behavioural problems in children, slow cognitive development, reduced educational attainment, and increased risk of developing autism and schizophrenia. Pregnancy specific anxiety has been shown to have a linear relationship with timing of delivery and predicts preterm birth with clear implications for paediatric workload. Maternal anxiety impacts the maternalefetaleplacental systems, which can programme the fetus’s HPA, upregulating stress responses from before birth. Chronic stressors during pregnancy such as unemployment, discrimination and racism are also associated with low birthweight. Vulnerabilities that predate pregnancy, particularly those developed in early childhood, may interact with these social conditions to increase levels of pregnancy anxiety.
Fathers The roles and responses of fathers are different but their parenting is no less important Most of the literature on parenting focuses on mothers, but in the last decade clear evidence has emerged that the mental and emotional health of fathers, from the antenatal period on, is probably as important as that of mothers. Their mental health has a profound impact on that of their partners or spouses so has secondary as well as primary influence. Depressed fathers are less likely to be involved in caregiving and less supportive of the mother. Father’s involvement can increase breastfeeding rates, engagement with education and pro-social behaviour. Fathers tend to have more play time with children and more intense interactions which are thought to help develop exploration and independence, whereas mothers offer safety. Mother’s amygdalae representing emotional involvement light up on functional MRI when watching their children, whereas father’s brains show activity in the superior temporal sulcus associated with mentalisation, the ability to keep someone else or yourself in mind and make sense of them. Children with special needs have better treatment adherence and outcomes when the father is involved in caregiving. Interestingly, fatherhood can be beneficial to the father themselves by acting as an impetus for fathers to improve their own health and wellbeing by improving diet, exercise and reducing risky behaviours. Social norms have limited the involvement of fathers in the past and currently, complex family situations may result in less time, opportunity and motivation for fathers to actively parent. Father’s involvement tends to drop significantly in context of relationship breakdown with the mother. There have been calls for interventions to support ongoing involvement of fathers, however work can also be done in small scale clinical settings. Although much has been done to enable fathers to feel important during labour and delivery, services may still marginalise fathers by focussing on mothers. One review has recommended active acknowledgement and appreciation for the father’s attendance at healthcare consultations; polite exploration of the father’s relationship and role in caregiving for the child; emphasizing the importance of the father as a role model for positive behaviour in the child; screening fathers for depression with tool such as the EPDS; encouraging fathers to have time alone with their infant to encourage confidence in caregiving; education of the father in matters such as breastfeeding so that they can support the mother; emphasizing father’s role in play and exercise; discussing adaptation to parenthood and impact upon family and relationship with both parents.
Parenting in later childhood and adolescence Nurture, praise and positive discipline play an important role Parenting is well recognised as a determinant of behaviour problems, conduct disorder and risky lifestyles in adolescents. The triad of harsh and inconsistent discipline, lack of positive attention and inadequate nurture have been well documented as a cause, and multiple parenting programmes have been developed and tested which help parents interrupt these patterns. Most are offered on a group basis for parents with children aged 3e10 years, with fewer available for adolescents. The principles of positive attention and appreciation, consistent boundaries and age appropriate positive discipline are well established and promulgated to parents and the public through television programmes, books, websites and social networks. These principles are applicable to all families but the programmes tend to be provided for families in which behaviour problems have started to emerge. Long term follow up studies of children with behaviour problems document poor health and social outcomes, but links to the HPA and neuroscience underpinnings are not so evident in the literature. Parental mental illness Impact upon the child is often forgotten Focus on postnatal depression in mothers can interfere with appreciation of the negative impact of parental mental illness e both mothers’ and fathers’ e at all stages of childhood and adolescence: the latter has a much greater impact. 10e20% of adults have symptoms of psychiatric disorder at any one time and the prevalence is highest in the age bracket of parents e 30 e40 years. Mental illness disrupts parentechild relationships. It incapacitates adults and interferes with normal caring behaviours. Children may become carers for mentally ill parents with profound consequences for learning and development. It may seem appropriate to provide or signpost to parenting services through adult psychiatric settings, however discussion about children is often absent from psychiatric consultation, or touched on only from an instrumental perspective. Parents with mental illness may fear they might be deemed not fit to parent and psychiatrists may feel ill-equipped to advise and help. A
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Intervention research One size does not fit all but a range of solutions are available A great range of programmes to support parenting has grown up over the last four decades and many of these have been
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
SYMPOSIUM: SOCIAL PAEDIATRICS
background and lack positive peer or partner support. Risky sexual behaviours commonly co-occur with substance abuse, and adolescent mothers are more likely to experience school failure. Teen parents are still developing themselves and will have to look after their own growth and that of their child. This impacts on the adolescent’s ability to nurture and it is thus unsurprising that children of teen parents are more likely to be of low birthweight, die in the perinatal period, experience developmental and behavioural problems, alongside increased risk of substance abuse, early sexual activity and parenthood. Depression is also more common in teen parents, and safeguarding is a key concern here in relation to domestic and child abuse. The Family Nurse Partnership is the best known example of a parenting support intervention for teen parents. It employs nurses trained in relational support, interpersonal therapy and motivational interviewing to encourage positive relational and behaviour change. The US research on this programme was very positive but the results of the UK trial illustrate many principles of importance relating to research on parenting (see below). The Building Blocks RCT published in 2015 examined outcomes up to 24 months after birth. Mothers fed back positively regarding the engagement with the programme which was implemented well, but key outcomes of pre-natal tobacco use, birth weight, subsequent pregnancy by 24 months, A&E attendances and hospital admissions in first two years of life were not impacted.
investigated in clinical trials. Many systematic reviews have been undertaken and now there are many reviews of reviews. There is no doubt that parenting programmes can be effective in helping parents change their parenting, however many families with chaotic lifestyles will need more than a 10 week programme to bring about fundamental change. To impact parenting in these families a re-sculpting of the adverse neural pathways developed during that parent’s childhood is needed. This requires an element of re-parenting through the establishment of a relationship with an adult who is trustworthy and nurturing. Long term, one to one support with a highly skilled professional or multisystem family therapy involving all members may be necessary. Programmes offered to parents of infants are usually offered on a one to one, home visiting basis which may be provided alongside day care for the infant. Group based programmes are more common for parents of older children and a wide range of programmes have been developed and researched, of which Incredible Years and Triple P are perhaps the best known. School based programmes Successful programmes have been provided in schools. For example, the Families and Schools Together (FAST) is an 8 week school based programme where parents of reception class children are invited to attend with children. The programme aims to strengthen social networks between parents and build a supportive community; empower parents to be the primary teachers and caregivers for their children and strengthen relationships between school and parents.
Parenting programmes to support lifestyle change Parenting programmes have been developed to support lifestylerelated outcomes and injury prevention. Some trials have shown small but important impacts on childhood obesity predictors like in TV viewing, or fat/sugar/energy intake, but several of these programmes have delivered disappointing results. Programmes for parents to reduce tobacco, alcohol and drug misuse in under 18s have also shown limited effects but with fairly consistent reductions seen across tobacco alcohol and drug use when programmes are offered at the time of transition from primary to secondary school.
Parents with substance misuse There are specific programmes for parents with substance misuse problems, a high risk but hard to reach and influence group. These parents may have issues with emotion and impulse control and may find it more difficult to organise themselves and provide physical and emotional care for their children. Parents under Pressure is an example of such programmes. It is an intensive, home-based intervention incorporating techniques such as mindfulness to assist parents in affect regulation, with the aim that they learn these skills for themselves and provide them for their child. There are 12 modules delivered across 12 weeks and ongoing case management of real life problems.
Research on parenting programmes Parenting programmes are inherently difficult to trial. They depend on many factors which do not feature in trials of clinical or hospital based interventions. Parents need to engage with the programme without interruption by life events that impact on families in difficult circumstances, facilitators need a high level of skill e often acquired over years of practice and thus not trainable in the context of a trial; the subtle outcomes of attachment security are difficult to measure and long term outcomes too expensive; and local services and communities need to be supportive of the intervention. Because of this well respected programmes, valued by parents and facilitators, can deliver negative outcomes when trialled in RCTs. Realist evaluation can provide more reliable indicators of value in public health interventions like these. Programmes are easier to trial in clinical settings with high risk or indicated populations. The evidence base for these programmes is therefore stronger than that for universal programmes. This can be a barrier to provision of universal parenting support which could tackle the health impact of parenting across the social spectrum.
Interventions for postnatal depression Postnatal depression interventions are offered on a one to one basis in the home and involve counselling, emotional support and sometimes cognitive behavioural principles. Primary prevention programmes have not been shown to work but secondary prevention for at risk mothers is helpful. This includes education and interpersonal therapy delivered to those at risk due to social circumstances; and parenteinfant interaction support, peer support, person centred approaches and interpersonal psychotherapy delivered to those at high risk. Qualitative work indicates women value partner’s involvement and seeing the same healthcare worker in interventions. Interventions for teen parents Teen parents often have particular vulnerabilities and are less likely to have a warm and connected relationship with their own parents, more likely to come from a disruptive family
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Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
SYMPOSIUM: SOCIAL PAEDIATRICS
schools. NICE launched a technology appraisal guideline promoting the use of parenting programmes for the management of children with conduct disorders, providing the seal of approval from the NHS and Department of Health. Later the CANParent trial offering parenting support on a universal basis was offered through the Department for Education, with a view to normalising parenting education. The Troubled Families Programme (2012) championed multiagency working for families with multiple public sector service needs, employing family intervention workers to develop relationships and liaise between families and agencies. The Think Family approach similarly aimed to strengthen links between adult and children’s services working around the family. Like Sure Start, evaluation of these programmes failed to provide the unequivocal support that enabled them to survive the recent cuts in services and become more effective. Scotland’s policy and provision relating to parenting is now stronger than provision in England and there the centrality of parenting is more widely accepted in policy circles. Wales too is making progress on parenting support. But there is a long way to go before the appropriate level of support is available.
Policy on parenting in the UK A lack of clear evidence and austerity have impacted upon funding for parenting programmes If policy makers understood the research on parenting summarised above and accepted its implications, support for parenting would feature in every government policy including health and social services, education, criminal justice and the economy. If children grew up with resilience and adaptability from supportive relational environments, the population could be healthier, able to survive, even flourish in the face of adversity and adapt successfully to new demands such as the changing face of work, major population migrations and climate change. There is a tension between employment and parenting agendas, with competing policy initiatives for provision of more day care so parents can go out to work. The evidence on the impact of day care in the first year of life was sufficiently negative for the government to legislate to extend maternity leave and enable paternity leave, thus supporting parenting. Financial and housing support for families in need enables parents who would otherwise have to go out to work to stay at home to look after their children. High quality childcare and children’s centres can lead to improved child outcomes and reduce socioeconomic inequalities in the context of poor parenting, as children from less advantaged backgrounds benefit more than those from more advantaged backgrounds.
The paediatrician’s role So what can paediatricians do about parenting? Few have time to take on new challenges and few are directly involved in policymaking. The role of hospital based paediatricians is likely to be different from those working in community settings.
Sure Start Policy makers have made intermittent strides towards better parenting policy. Sure Start (1998) was introduced as a national strategy for promoting the development of children under four and their families in areas of high need with aim of reducing youth crime, teenage pregnancy, family breakdown and poverty. This radical initiative offered a community based programme of support including outreach and health visiting, play, learning and childcare provision, parenting support, healthcare advice and support for those with special needs. In 2003 the initiative was extended from central to local government and from targeted to universal provision. Emphasis differed from one area to another and only some Sure Start Children’s Centres made parenting support central to their offer, focussing instead on childcare, preschool education and boosting parental employment. Evaluation of major policy initiatives with diverse approaches to provision is difficult and not always reliable. The Sure Start evaluation gave disappointing results with evidence suggesting small benefits to development, behaviour and parenting, but also indicating that programmes did not benefit the most disadvantaged families. There is no doubt the programme needed further development and refinement, but it was an important start. Acceptance of the need for this type of provision coupled with the negative evaluation was not strong enough to weather recent economic austerity.
Community settings It is valuable for paediatricians to be aware of the long-term implications of parenting and to recognise sub-optimal parenting. Commenting on positive parenting (positive praise, consistency and age-appropriate positive disciplinary methods alongside attuning to the child’s physical and emotional needs) is always going to be valuable and less challenging than commenting on the negative. It is important to take care with advice; criticism and judgement is not likely to yield dividends. Nonetheless failing to notice or comment enables parents who are getting it wrong for their children to persuade themselves all is well. It is important to be clear with parents that behaviour problems are a family issue and scapegoating the child who is acting out is not helpful. Such advice may be better received from someone who has an established relationship with the family and/or personal experience of parenting. Trainees who lack these opportunities may wish to ask other members of the team to perform this role until they are in a better position to do so themselves. Provision of parenting programmes is often by NGOs or charities which come and go, and quality of provision may vary. This can make it difficult to keep abreast of where to refer to locally. Umbrella NGOs like Parenting UK (http://www. parentinguk.org) can help signpost provision. They also contribute to the wealth of internet based ways of supporting parents like Parent Channel TV. Social networks like NetMums can provide valuable peer support and may provide platforms for advocacy, opening up the discussion, and reducing stigma. There are also often local parent groups for children with disabilities. Clinical commissioning groups and local authorities will hold information about locally commissioned services for parents and families. Clinics can ensure that they display leaflets about local
Other English parenting policy Every Child Matters (2004) was an English policy in which recommendations were made for universal parenting support and parenting commissioners in every local authority. In the Parenting Early Intervention Programme (2006) local authorities were funded to provide evidence based parenting programmes through
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Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
SYMPOSIUM: SOCIAL PAEDIATRICS
and internet provision for parents as well as sign post books and other resources.
Key points Hospital settings Acute care for sick children is not likely to be an appropriate setting for a conversation about parenting, but many families are under the long term care of hospitals and the quality of parenting is likely to influence usage. It is valuable for paediatricians to notice and comment on positive parenting and notice and look for opportunities to comment supportively on the negative, with the same caveats as within community settings. Paediatric outpatients can be a place where support for parenting is advertised.
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Policy making Improving child health is a central plank of the Royal College of Paediatrics and Child health, including advocating for better child health, challenging positively, sharing best practice, working proactively. However, there is little in the College’s State of Child Health 2017 report to suggest the knowledge and research on which this article is based is recognised and acted upon by paediatricians. At local levels paediatricians may be in a position to influence provision, managing child health services or contributing to Health and Wellbeing Boards or Clinical Commissioning Groups. Paediatricians are regarded as expert in the needs of children and their opinions matter. The presence of a paediatric voice in policy making is influential and there is much scope both locally and nationally for them to advocate for parenting support. A
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FURTHER READING Begley Sharon. Train your mind, change your brain: how a new science reveals our extraordinary potential to transform ourselves. Penguin Random House Books, 2007. Bhugra D, Bhui K, Wong S, Gilman S, eds. Oxford textbook of public mental health. OUP, 2018. Blair M, Stewart-Brown S, Waterstone A, Crowther R. Child public health and population paediatrics. OUP, 2015. Gerhardt S. Why love matters: how affection shapes a baby’s brain. 2nd Edn. Routledge, 2014. € pfert M, Webster J, Seema MV, eds. Parental psychiatric disorder: Go distressed parents and their families. Cambridge: CUP, 2004.
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Neurological development is profoundly influenced by relational processes, especially that of primary caregivers. Children exhibit much greater neuronal plasticity than adults. Emotional and relational experiences in infancy and early years shape social, emotional and cognitive development and these affect lifelong physical and mental health. The stress response is a key pathway in these developmental processes. There is further opportunity to influence these pathways in adolescence, but increasingly less as people age. The role of fathers has been hitherto underplayed but there is growing evidence that they have a unique and important role to play in child upbringing. Mental health of both mothers and fathers from pregnancy throughout childhood can have long term impacts on child outcomes. There is good evidence for the effectiveness of parenting programmes in improving child development, physical and mental health and addressing these issues may go some way to reducing social inequalities. Vulnerable parents, teenagers’ parents and those with mental health or substance abuse problems, may need intensive tailored intervention. Parenting provision is vulnerable to fluctuations in the social and political environment; Austerity policy has resulted in the closure of many Children’s Centres and provision of parenting support has been greatly reduced.
Practice points for paediatricians C
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Paediatricians can influence parenting in clinical interactions by positively commenting on good parenting and opening discussions to raise awareness of the impacts of parenting. They can advertise and signpost local programmes and webbased resources. They should advocate at national and level for policy and resources that support parenting.
Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
Parenting and health: a call for action
find paediatricians asking for training on how they could support parenting in their day to day practice, or calling for support for parenting through social and political channels. There is a wealth of transdisciplinary evidence from psychology, neuroscience, the social sciences, and public health describing the impact of the relational environment in the home on child and adult health which may not be well known to paediatricians or other healthcare professionals. A recent RCPCH survey looking at poverty and child health highlighted parental mental illness and limitations on family time due to long working hours, alongside food insecurity, overcrowded and damp housing, homelessness, stress and worry linked to poverty as important concerns to paediatricians. All of these issues merit advocacy, and wider social and structural change, however tackling them is complex and requires cross-disciplinary effort. Parenting interventions are well evidenced and can mitigate some of the impact of poor parenting. This article aims to provide an outline of what is currently known about parenting and its importance for child and adult health and point to possible ways that healthcare professionals might intervene in the hope that individuals will feel more empowered to take action on this key determinant of health.
Neha Shah Sarah Stewart-Brown
Abstract Paediatricians and healthcare professionals working with children are well placed to observe parents and see a wide range of parenting from the exceptional to the abusive. Parenting has important short, medium and long term effects on child physical and mental health. Understanding these effects more fully helps paediatricians to comment on parenting, offer advice or refer to parenting programmes. This article outlines advances in neuroscience and attachment theory as well as contemporary issues that underpin the case for parenting intervention. It also discusses the rationale and evidence base for particular programmes, the UK policy context, and makes some suggestions on how paediatricians may wish to support better parenting.
Keywords advocacy; life parenting; physical health
course influences; mental health;
Neuroscience ‘Use it or lose it’ e early life matters Knowledge has been building over the last few decades regarding the plasticity of the infant brain and its great sensitivity to the environment, particularly the relational environment created by primary caregivers. Most cerebral neurons develop during pregnancy and the first two years of life. Simple neurological circuits supporting different skills develop and provide the scaffolding for more advanced circuits and dendritic connections over time. The process is one of ‘use it or lose it’; pathways that are frequently activated grow and those that are not wither. Also, ‘neurons which fire together wire together’ establishing links between feelings, settings and actions that do not involve higher brain circuits. This patterning, linked to emotional or relational experiences, sculpts the brain, determining dominant pathways and associations. Mirror neurons, which fire both when an action is performed and when an action is watched, provide insight into the mechanisms which could underpin the profound influence of the relational environment on learning. Neural plasticity continues throughout life but at a slower rate. There is a second spurt during adolescence and this period represents an opportunity to enable change in some of the pathways developed in infancy. Plasticity is fostered by intention, attention and compassionate awareness. These skills are recognised by the great spiritual traditions as fundamental for human development and are now widely taught in the Western world under the label of mindfulness. A significant body of neuroscience now attests to the capacity of mindfulness to enable neural plasticity. So whilst what happens in the home in childhood is profoundly influential for health and wellbeing throughout the life-course, it is still possible to reverse some of the damage at any stage of life.
Introduction A lack of knowledge is a barrier to positive action Healthcare professionals working with families see a wide range of parenting from the exceptional to the abusive. They commonly recognise the harms that accrue to child health and development from aspects of parenting like provision of unhealthy food, lack of exercise and lack of support for language development and education. Most offer advice and support with regard to the care of children and paediatricians, in particular, are required to investigate and report parenting that may be abusive or neglectful. Most paediatricians will also be aware of research relating childhood influences to health throughout the life course, which begins in utero. Many observational studies have shown that the lifestyles acquired in childhood and adolescence track through into adulthood and influence adult health and longevity. These may also impact on the health of the next generation as patterns of behaviour become trans-generationally ingrained. Some will consider it their responsibility to promote or advocate for improvement in social conditions, by drawing attention to the impact poverty and deprivation have on child health and development. They campaign for improvements in school meals, taxation on high sugar foods and beverages, opportunities for safe physical activity and protection from harmful substances like tobacco and illegal drugs. It is, however, rare to
Neha Shah BMBS (Hons) BMedSci Msc Public Health is Public Health Registrar at Warwick Medical School, University of Warwick, UK. Conflict of interest: none declared.
Stress response A nurturing relationship can mitigate the stress response A key biological system affected by the relational environment in early childhood is the hypothalamic-pituitary-axis (HPA).
Sarah Stewart-Brown BMBCh PhD FFPH FRCPCH is Professor of Public Health at Warwick Medical School, University of Warwick, UK. Conflict of interest: none declared.
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
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development and the negative consequences of learned patterns of dysfunctional cognitions, emotional responses and behaviour that limit personal development and relationships throughout the life course. Because these behaviours are linked to the stress of attachment insecurity and exaggerated physiological responses to common stressors, these circumstances also influence physical health.
Secure, nurturing relationships enable the development of systems to regulate the HPA stress response from higher brain circuits. Lack of security embeds reactivity to stress and ultimately chronic activation of the HPA, leading to raised baseline cortisol and flattening of circadian rhythms; and chronic immune system activation leading to chronic inflammation and upregulation of acute immune responses that impair later resistance to chronic disease. In this way infant and fetal relational experiences also shape endocrine and immune systems influencing the biology of the child and adult’s response to stress and thus their physical and mental resilience. Stress also impacts on learning and memory. Cortisol is neurotoxic, particularly to the hippocampus, impairing cognitive functioning including working memory and the establishment of new memories. Children whose stress response is easily triggered and who lack the ability to self-regulate are disabled in the classroom, leading to educational underachievement with lifelong consequences for social mobility and earning. Seminal studies of resilient children e those who transcend emotionally and materially deprived circumstances e show that what makes this possible is a secure nurturing relationship with at least one adult, perhaps a teacher, social worker, older sibling, or grandparent.
ACEs Adverse experiences in childhood lead to physical and mental health problems in later life The long term impact of these early experiences is now being illustrated in epidemiological studies of Adverse Childhood Experiences (ACEs). The latter are retrospectively reported experiences of childhood psychological, physical or sexual abuse, violence against mother, or living with household members who were substance abusers, mentally ill or incarcerated. These have been shown to greatly increase adult risk of alcoholism, drug abuse, depression, and suicide attempts; smoking, numerous sexual partners, and sexually transmitted disease; physical inactivity and severe obesity. Experience of four or more of these risk factors doubles the risk of severe chronic disease aged 60 years with a graded relationship between number of risk factors and disease outcomes (observed in about 10% of the population). These findings have been consistently repeated in different settings. ACEs are usually but not necessarily attributable to parents or parenting. Even when not directly attributable they affect children because parents are not sufficiently sensitive or aware to be able to see their impact, or they are not able or willing to offer protection. Studies of ACEs have attracted great attention in highlighting the need for parenting support and proved important in persuading professionals and policy makers that action is necessary.
Attachment security Secure attachments promote resilience Aligning with the neuroscience are numerous observational studies reported over the last century relating to attachment (the bond between child and caregiver) security. Based on observation of patterns of infant behaviour when separated and reunited with their caregiver (the ‘strange situation’ test), research has shown secure attachment promotes positive emotional and social development, with children being better able to cope with stress, having a higher perception of self-worth and being able to adjust better to adversity and change. The sensitive, attuned and caring parenting that enables attachment security, also enables infants to feel safe and develop the capacity to trust others. It enables the infant to develop self-regulation so that stressors can be experienced without prolonged biological consequences, building resilience. Parenting that is out of tune with infant needs, neglectful or abusive is stressful and this disrupts the neurochemistry and architecture of the developing brain, nervous system and the HPA. Insecure childhood attachment relationships predict depression, anxiety, self-harm and suicidal tendencies, anorexia, Post-Traumatic Stress Disorder and other mental health problems in adolescence and adulthood.
Reducing inequalities Parenting has a social gradient Reducing inequalities has been high on the public health and political agenda in recent years, and it is well established that early child development and health outcomes follow a socioeconomic gradient. Analysis from the UK Millennium Cohort Study indicates that the income gap for child socioemotional difficulties was largely explained by the psychosocial environment including home learning and family routines. Whilst these aspects of parenting show a social gradient they operate to some extent across the whole social spectrum. So tackling them would serve to reduce social inequalities and improve whole population health.
Complex PTSD Chronic trauma has long term effects Observation in psychotherapeutic settings has enabled the phenomenon of Complex PTSD to be recognised and studied. This is the legacy of the patterns of key relationships on emotional, mental and social functioning from childhood. Patterns may, for example, reflect development in a family which was safe as long as the child learnt to fit in which the needs of others and gave up trying to get their own met. Such adults often have problems displaying anger. Other families can feel safe as long as vulnerability is not expressed, particularly among boys. Child brain plasticity enables both positive
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Perinatal influences Early events are critical and maternal mental health has important consequences Postnatal mental illness is well recognised as a profound interrupter of the relational environment that supports attachment security and enables infants to thrive. Maternal psychosis is the severe but rare manifestation, but most of the long term costs associated with postnatal depression are attributable to the much commoner (estimates vary from 10 to 20% of births) less severe problems. Programmes to identify and offer support to women
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conspiracy of silence can prevail to the detriment of the children. The status of parental mental illness as a profound disruptor of normal biology and development is emphasised today because it is one of the ACEs. Programmes to support the clinical conversation around children and enable better support for children have been developed. It is to be hoped that the ACEs agenda brings these to the attention of mental health services.
with postnatal depression are well established in Western healthcare services. Recently studies have investigated the antenatal period and it is becoming clear that maternal anxiety and depression during pregnancy is as common and impactful as postnatal depression. Prospective studies now show antenatal influences linked to reduced fetal growth and low birthweight, higher levels of anxiety, depression and behavioural problems in children, slow cognitive development, reduced educational attainment, and increased risk of developing autism and schizophrenia. Pregnancy specific anxiety has been shown to have a linear relationship with timing of delivery and predicts preterm birth with clear implications for paediatric workload. Maternal anxiety impacts the maternalefetaleplacental systems, which can programme the fetus’s HPA, upregulating stress responses from before birth. Chronic stressors during pregnancy such as unemployment, discrimination and racism are also associated with low birthweight. Vulnerabilities that predate pregnancy, particularly those developed in early childhood, may interact with these social conditions to increase levels of pregnancy anxiety.
Fathers The roles and responses of fathers are different but their parenting is no less important Most of the literature on parenting focuses on mothers, but in the last decade clear evidence has emerged that the mental and emotional health of fathers, from the antenatal period on, is probably as important as that of mothers. Their mental health has a profound impact on that of their partners or spouses so has secondary as well as primary influence. Depressed fathers are less likely to be involved in caregiving and less supportive of the mother. Father’s involvement can increase breastfeeding rates, engagement with education and pro-social behaviour. Fathers tend to have more play time with children and more intense interactions which are thought to help develop exploration and independence, whereas mothers offer safety. Mother’s amygdalae representing emotional involvement light up on functional MRI when watching their children, whereas father’s brains show activity in the superior temporal sulcus associated with mentalisation, the ability to keep someone else or yourself in mind and make sense of them. Children with special needs have better treatment adherence and outcomes when the father is involved in caregiving. Interestingly, fatherhood can be beneficial to the father themselves by acting as an impetus for fathers to improve their own health and wellbeing by improving diet, exercise and reducing risky behaviours. Social norms have limited the involvement of fathers in the past and currently, complex family situations may result in less time, opportunity and motivation for fathers to actively parent. Father’s involvement tends to drop significantly in context of relationship breakdown with the mother. There have been calls for interventions to support ongoing involvement of fathers, however work can also be done in small scale clinical settings. Although much has been done to enable fathers to feel important during labour and delivery, services may still marginalise fathers by focussing on mothers. One review has recommended active acknowledgement and appreciation for the father’s attendance at healthcare consultations; polite exploration of the father’s relationship and role in caregiving for the child; emphasizing the importance of the father as a role model for positive behaviour in the child; screening fathers for depression with tool such as the EPDS; encouraging fathers to have time alone with their infant to encourage confidence in caregiving; education of the father in matters such as breastfeeding so that they can support the mother; emphasizing father’s role in play and exercise; discussing adaptation to parenthood and impact upon family and relationship with both parents.
Parenting in later childhood and adolescence Nurture, praise and positive discipline play an important role Parenting is well recognised as a determinant of behaviour problems, conduct disorder and risky lifestyles in adolescents. The triad of harsh and inconsistent discipline, lack of positive attention and inadequate nurture have been well documented as a cause, and multiple parenting programmes have been developed and tested which help parents interrupt these patterns. Most are offered on a group basis for parents with children aged 3e10 years, with fewer available for adolescents. The principles of positive attention and appreciation, consistent boundaries and age appropriate positive discipline are well established and promulgated to parents and the public through television programmes, books, websites and social networks. These principles are applicable to all families but the programmes tend to be provided for families in which behaviour problems have started to emerge. Long term follow up studies of children with behaviour problems document poor health and social outcomes, but links to the HPA and neuroscience underpinnings are not so evident in the literature. Parental mental illness Impact upon the child is often forgotten Focus on postnatal depression in mothers can interfere with appreciation of the negative impact of parental mental illness e both mothers’ and fathers’ e at all stages of childhood and adolescence: the latter has a much greater impact. 10e20% of adults have symptoms of psychiatric disorder at any one time and the prevalence is highest in the age bracket of parents e 30 e40 years. Mental illness disrupts parentechild relationships. It incapacitates adults and interferes with normal caring behaviours. Children may become carers for mentally ill parents with profound consequences for learning and development. It may seem appropriate to provide or signpost to parenting services through adult psychiatric settings, however discussion about children is often absent from psychiatric consultation, or touched on only from an instrumental perspective. Parents with mental illness may fear they might be deemed not fit to parent and psychiatrists may feel ill-equipped to advise and help. A
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Intervention research One size does not fit all but a range of solutions are available A great range of programmes to support parenting has grown up over the last four decades and many of these have been
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
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background and lack positive peer or partner support. Risky sexual behaviours commonly co-occur with substance abuse, and adolescent mothers are more likely to experience school failure. Teen parents are still developing themselves and will have to look after their own growth and that of their child. This impacts on the adolescent’s ability to nurture and it is thus unsurprising that children of teen parents are more likely to be of low birthweight, die in the perinatal period, experience developmental and behavioural problems, alongside increased risk of substance abuse, early sexual activity and parenthood. Depression is also more common in teen parents, and safeguarding is a key concern here in relation to domestic and child abuse. The Family Nurse Partnership is the best known example of a parenting support intervention for teen parents. It employs nurses trained in relational support, interpersonal therapy and motivational interviewing to encourage positive relational and behaviour change. The US research on this programme was very positive but the results of the UK trial illustrate many principles of importance relating to research on parenting (see below). The Building Blocks RCT published in 2015 examined outcomes up to 24 months after birth. Mothers fed back positively regarding the engagement with the programme which was implemented well, but key outcomes of pre-natal tobacco use, birth weight, subsequent pregnancy by 24 months, A&E attendances and hospital admissions in first two years of life were not impacted.
investigated in clinical trials. Many systematic reviews have been undertaken and now there are many reviews of reviews. There is no doubt that parenting programmes can be effective in helping parents change their parenting, however many families with chaotic lifestyles will need more than a 10 week programme to bring about fundamental change. To impact parenting in these families a re-sculpting of the adverse neural pathways developed during that parent’s childhood is needed. This requires an element of re-parenting through the establishment of a relationship with an adult who is trustworthy and nurturing. Long term, one to one support with a highly skilled professional or multisystem family therapy involving all members may be necessary. Programmes offered to parents of infants are usually offered on a one to one, home visiting basis which may be provided alongside day care for the infant. Group based programmes are more common for parents of older children and a wide range of programmes have been developed and researched, of which Incredible Years and Triple P are perhaps the best known. School based programmes Successful programmes have been provided in schools. For example, the Families and Schools Together (FAST) is an 8 week school based programme where parents of reception class children are invited to attend with children. The programme aims to strengthen social networks between parents and build a supportive community; empower parents to be the primary teachers and caregivers for their children and strengthen relationships between school and parents.
Parenting programmes to support lifestyle change Parenting programmes have been developed to support lifestylerelated outcomes and injury prevention. Some trials have shown small but important impacts on childhood obesity predictors like in TV viewing, or fat/sugar/energy intake, but several of these programmes have delivered disappointing results. Programmes for parents to reduce tobacco, alcohol and drug misuse in under 18s have also shown limited effects but with fairly consistent reductions seen across tobacco alcohol and drug use when programmes are offered at the time of transition from primary to secondary school.
Parents with substance misuse There are specific programmes for parents with substance misuse problems, a high risk but hard to reach and influence group. These parents may have issues with emotion and impulse control and may find it more difficult to organise themselves and provide physical and emotional care for their children. Parents under Pressure is an example of such programmes. It is an intensive, home-based intervention incorporating techniques such as mindfulness to assist parents in affect regulation, with the aim that they learn these skills for themselves and provide them for their child. There are 12 modules delivered across 12 weeks and ongoing case management of real life problems.
Research on parenting programmes Parenting programmes are inherently difficult to trial. They depend on many factors which do not feature in trials of clinical or hospital based interventions. Parents need to engage with the programme without interruption by life events that impact on families in difficult circumstances, facilitators need a high level of skill e often acquired over years of practice and thus not trainable in the context of a trial; the subtle outcomes of attachment security are difficult to measure and long term outcomes too expensive; and local services and communities need to be supportive of the intervention. Because of this well respected programmes, valued by parents and facilitators, can deliver negative outcomes when trialled in RCTs. Realist evaluation can provide more reliable indicators of value in public health interventions like these. Programmes are easier to trial in clinical settings with high risk or indicated populations. The evidence base for these programmes is therefore stronger than that for universal programmes. This can be a barrier to provision of universal parenting support which could tackle the health impact of parenting across the social spectrum.
Interventions for postnatal depression Postnatal depression interventions are offered on a one to one basis in the home and involve counselling, emotional support and sometimes cognitive behavioural principles. Primary prevention programmes have not been shown to work but secondary prevention for at risk mothers is helpful. This includes education and interpersonal therapy delivered to those at risk due to social circumstances; and parenteinfant interaction support, peer support, person centred approaches and interpersonal psychotherapy delivered to those at high risk. Qualitative work indicates women value partner’s involvement and seeing the same healthcare worker in interventions. Interventions for teen parents Teen parents often have particular vulnerabilities and are less likely to have a warm and connected relationship with their own parents, more likely to come from a disruptive family
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
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schools. NICE launched a technology appraisal guideline promoting the use of parenting programmes for the management of children with conduct disorders, providing the seal of approval from the NHS and Department of Health. Later the CANParent trial offering parenting support on a universal basis was offered through the Department for Education, with a view to normalising parenting education. The Troubled Families Programme (2012) championed multiagency working for families with multiple public sector service needs, employing family intervention workers to develop relationships and liaise between families and agencies. The Think Family approach similarly aimed to strengthen links between adult and children’s services working around the family. Like Sure Start, evaluation of these programmes failed to provide the unequivocal support that enabled them to survive the recent cuts in services and become more effective. Scotland’s policy and provision relating to parenting is now stronger than provision in England and there the centrality of parenting is more widely accepted in policy circles. Wales too is making progress on parenting support. But there is a long way to go before the appropriate level of support is available.
Policy on parenting in the UK A lack of clear evidence and austerity have impacted upon funding for parenting programmes If policy makers understood the research on parenting summarised above and accepted its implications, support for parenting would feature in every government policy including health and social services, education, criminal justice and the economy. If children grew up with resilience and adaptability from supportive relational environments, the population could be healthier, able to survive, even flourish in the face of adversity and adapt successfully to new demands such as the changing face of work, major population migrations and climate change. There is a tension between employment and parenting agendas, with competing policy initiatives for provision of more day care so parents can go out to work. The evidence on the impact of day care in the first year of life was sufficiently negative for the government to legislate to extend maternity leave and enable paternity leave, thus supporting parenting. Financial and housing support for families in need enables parents who would otherwise have to go out to work to stay at home to look after their children. High quality childcare and children’s centres can lead to improved child outcomes and reduce socioeconomic inequalities in the context of poor parenting, as children from less advantaged backgrounds benefit more than those from more advantaged backgrounds.
The paediatrician’s role So what can paediatricians do about parenting? Few have time to take on new challenges and few are directly involved in policymaking. The role of hospital based paediatricians is likely to be different from those working in community settings.
Sure Start Policy makers have made intermittent strides towards better parenting policy. Sure Start (1998) was introduced as a national strategy for promoting the development of children under four and their families in areas of high need with aim of reducing youth crime, teenage pregnancy, family breakdown and poverty. This radical initiative offered a community based programme of support including outreach and health visiting, play, learning and childcare provision, parenting support, healthcare advice and support for those with special needs. In 2003 the initiative was extended from central to local government and from targeted to universal provision. Emphasis differed from one area to another and only some Sure Start Children’s Centres made parenting support central to their offer, focussing instead on childcare, preschool education and boosting parental employment. Evaluation of major policy initiatives with diverse approaches to provision is difficult and not always reliable. The Sure Start evaluation gave disappointing results with evidence suggesting small benefits to development, behaviour and parenting, but also indicating that programmes did not benefit the most disadvantaged families. There is no doubt the programme needed further development and refinement, but it was an important start. Acceptance of the need for this type of provision coupled with the negative evaluation was not strong enough to weather recent economic austerity.
Community settings It is valuable for paediatricians to be aware of the long-term implications of parenting and to recognise sub-optimal parenting. Commenting on positive parenting (positive praise, consistency and age-appropriate positive disciplinary methods alongside attuning to the child’s physical and emotional needs) is always going to be valuable and less challenging than commenting on the negative. It is important to take care with advice; criticism and judgement is not likely to yield dividends. Nonetheless failing to notice or comment enables parents who are getting it wrong for their children to persuade themselves all is well. It is important to be clear with parents that behaviour problems are a family issue and scapegoating the child who is acting out is not helpful. Such advice may be better received from someone who has an established relationship with the family and/or personal experience of parenting. Trainees who lack these opportunities may wish to ask other members of the team to perform this role until they are in a better position to do so themselves. Provision of parenting programmes is often by NGOs or charities which come and go, and quality of provision may vary. This can make it difficult to keep abreast of where to refer to locally. Umbrella NGOs like Parenting UK (http://www. parentinguk.org) can help signpost provision. They also contribute to the wealth of internet based ways of supporting parents like Parent Channel TV. Social networks like NetMums can provide valuable peer support and may provide platforms for advocacy, opening up the discussion, and reducing stigma. There are also often local parent groups for children with disabilities. Clinical commissioning groups and local authorities will hold information about locally commissioned services for parents and families. Clinics can ensure that they display leaflets about local
Other English parenting policy Every Child Matters (2004) was an English policy in which recommendations were made for universal parenting support and parenting commissioners in every local authority. In the Parenting Early Intervention Programme (2006) local authorities were funded to provide evidence based parenting programmes through
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Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002
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and internet provision for parents as well as sign post books and other resources.
Key points Hospital settings Acute care for sick children is not likely to be an appropriate setting for a conversation about parenting, but many families are under the long term care of hospitals and the quality of parenting is likely to influence usage. It is valuable for paediatricians to notice and comment on positive parenting and notice and look for opportunities to comment supportively on the negative, with the same caveats as within community settings. Paediatric outpatients can be a place where support for parenting is advertised.
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Policy making Improving child health is a central plank of the Royal College of Paediatrics and Child health, including advocating for better child health, challenging positively, sharing best practice, working proactively. However, there is little in the College’s State of Child Health 2017 report to suggest the knowledge and research on which this article is based is recognised and acted upon by paediatricians. At local levels paediatricians may be in a position to influence provision, managing child health services or contributing to Health and Wellbeing Boards or Clinical Commissioning Groups. Paediatricians are regarded as expert in the needs of children and their opinions matter. The presence of a paediatric voice in policy making is influential and there is much scope both locally and nationally for them to advocate for parenting support. A
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FURTHER READING Begley Sharon. Train your mind, change your brain: how a new science reveals our extraordinary potential to transform ourselves. Penguin Random House Books, 2007. Bhugra D, Bhui K, Wong S, Gilman S, eds. Oxford textbook of public mental health. OUP, 2018. Blair M, Stewart-Brown S, Waterstone A, Crowther R. Child public health and population paediatrics. OUP, 2015. Gerhardt S. Why love matters: how affection shapes a baby’s brain. 2nd Edn. Routledge, 2014. € pfert M, Webster J, Seema MV, eds. Parental psychiatric disorder: Go distressed parents and their families. Cambridge: CUP, 2004.
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Neurological development is profoundly influenced by relational processes, especially that of primary caregivers. Children exhibit much greater neuronal plasticity than adults. Emotional and relational experiences in infancy and early years shape social, emotional and cognitive development and these affect lifelong physical and mental health. The stress response is a key pathway in these developmental processes. There is further opportunity to influence these pathways in adolescence, but increasingly less as people age. The role of fathers has been hitherto underplayed but there is growing evidence that they have a unique and important role to play in child upbringing. Mental health of both mothers and fathers from pregnancy throughout childhood can have long term impacts on child outcomes. There is good evidence for the effectiveness of parenting programmes in improving child development, physical and mental health and addressing these issues may go some way to reducing social inequalities. Vulnerable parents, teenagers’ parents and those with mental health or substance abuse problems, may need intensive tailored intervention. Parenting provision is vulnerable to fluctuations in the social and political environment; Austerity policy has resulted in the closure of many Children’s Centres and provision of parenting support has been greatly reduced.
Practice points for paediatricians C
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Paediatricians can influence parenting in clinical interactions by positively commenting on good parenting and opening discussions to raise awareness of the impacts of parenting. They can advertise and signpost local programmes and webbased resources. They should advocate at national and level for policy and resources that support parenting.
Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shah N, Stewart-Brown S, Parenting and health: a call for action, Paediatrics and Child Health (2017), https:// doi.org/10.1016/j.paed.2017.12.002