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This chapter responds to the first part of the committee’s charge—to identify core parenting knowledge, attitudes, and practices that are associated with positive parent-child interactions and the healthy development of children ages birth to 8. The chapter also describes findings from research regarding how core parenting knowledge, attitudes, and practices may differ by specific characteristics of children and parents, as well as by context.
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The chapter begins by defining desired outcomes for children that appear frequently in the research literature and inform efforts by agencies at the federal, state, and local levels to promote child health and well-being. It then reviews the knowledge, attitudes, and practices identified in the literature as core—those most strongly associated with healthy child development—drawing primarily on correlational and experimental studies. This is followed by brief discussion of the family system as a key source of additional determinants of parenting. The chapter concludes with a summary. The core knowledge, attitudes, and practices identified in this chapter serve as a foundation, along with contextual factors that affect parenting, for the committee’s review of the effectiveness of strategies for strengthening parenting capacity in subsequent chapters of this report.To determine the salient features of core parenting knowledge, attitudes, and practices, the committee first identified desired outcomes for children.
Identifying these outcomes grounds the discussion of core parenting knowledge, attitudes, and practices and helps researchers, practitioners. And policy makers establish priorities for investment, develop policies that provide optimal conditions for success, advocate for the adoption and implementation of appropriate evidence-based interventions, and utilize data to assess and improve the effectiveness of specific policies and programs.Child outcomes are interconnected within and across diverse domains of development. They result from and are enhanced by early positive and supportive interactions with parents and other caregivers. These early interactions can have a long-lasting ripple effect on development across the life course, whereby the function of one domain of development influences another domain over time.
In the words of, “effectiveness in one domain of competence in one period of life becomes the scaffold on which later competence in newly emerging domains develops. Competence begets competence.” From the literature, the committee identified the following four outcomes as fundamental to children’s well-being.
While the committee focused on young children (ages 0-8), these outcomes are important for children of all ages. Physical Health and SafetyChildren need to be cared for in a way that promotes their ability to thrive and ensures their survival and protection from injury and physical and sexual maltreatment. While such safety needs are important for all children, they are especially critical for young children, who typically lack the individual resources required to avoid dangers. Rather, young children rely on parents and other primary caregivers, inside and outside the home, to act on their behalf to protect their safety and healthy development. At the most basic level, children must receive the care, as reflected in a number of emotional and physiological protections, necessary to meet normative standards for growth and physical development, such as guidelines for healthy weight and receipt of recommended vaccinations. Physical health and safety are fundamental for achieving all of the other outcomes described below. Emotional and Behavioral CompetenceChildren need care that promotes positive emotional health and well-being and that supports their overall mental health, including a positive sense of self, as well as the ability to cope with stressful situations, temper emotional arousal, overcome fears, and accept disappointments and frustrations.
Parents and other caregivers are essential resources for children in managing emotional arousal, coping, and managing behavior. In this role by providing positive affirmations, conveying love and respect and engendering a sense of security. Provision of support by parents helps minimize the risk of internalizing behaviors, such as those associated with anxiety and depression, which can impair children’s adjustment and ability to function well at home, at school, and in the community.
Such symptoms as extreme fearfulness, helplessness, hopelessness, apathy, depression, and withdrawal are indicators of emotional difficulty that have been observed among very young children who experience inadequate parental care. Social CompetenceChildren who possess basic social competence are able to develop and maintain positive relationships with peers and adults. Social competence, which is intertwined with other areas of development (e.g., cognitive, physical, emotional, and linguistic), also may include children’s ability to get along with and respect others, such as those of a different race or ethnicity, religion, sexual orientation, or economic background. Basic social skills include a range of prosocial behaviors, such as empathy and concern for the feelings of others, cooperation, sharing, and perspective taking, all of which are positively associated with children’s success both in school and in nonacademic settings and can be fostered by parents and other caregivers (; ). These skills are associated with children’s future success across a wide range of contexts in adulthood (e.g., school, work, family life) (; ). Cognitive CompetenceCognitive competence encompasses the skills and capacities needed at each age and stage of development to succeed in school and in the world at large. Children’s cognitive competence is defined by skills in language and communication, as well as reading, writing, mathematics, and problem solving.
Children benefit from stimulating, challenging, and supportive environments in which to develop these skills, which serve as a foundation for healthy self-regulatory practices and modes of persistence required for academic success.The child outcomes described above provide the context for considering the range of parenting knowledge, attitudes, and practices and identifying those that research supports as core. As noted in, the term.
“knowledge” for the purposes of this report refers to facts, information, and skills gained through experience or education and understanding of an issue or phenomenon. “Attitudes” refers to viewpoints, perspectives, reactions, or settled ways of thinking about aspects of parenting or child development, including parents’ roles and responsibilities. Attitudes may be related to cultural beliefs founded in common experience. And “practices” refers to parenting behaviors or approaches to childrearing that can shape how a child develops.
Generally speaking, knowledge relates to cognition, attitudes relate to motivation, and practices relate to ways of engaging or behavior, but all three may emanate from a common source.These three components are reciprocal and intertwined theoretically, empirically, and bidirectionally, informing one another. For example, practices are related to knowledge and attitudes, and often involve the application of knowledge. According to behavior modification theory (; ), a person’s attitude often determines whether he or she will use knowledge and transform it into practice. In short, if one does not believe in or value knowledge, one is less likely to act upon it. What parents learn through the practice of parenting can also be a source of knowledge and can shape parents’ attitudes. Parenting attitudes are influenced as well by parenting self-efficacy, which has been broadly defined as the level of parents’ self-belief about their ability to succeed in the parenting role.Parenting knowledge, attitudes, and practices are shaped not only by each other but also by a number of contextual factors, including children’s characteristics (e.g., gender, temperament); parents’ own experiences (e.g., those from their own childhood) and circumstances; expectations learned from others, such as family, friends, and other social networks; and cultural systems. Of particular relevance to this study, the contextual factors that influence parenting knowledge, attitudes, and practices also include the supports available within the larger community and provided by institutions, as well as by policies that affect the nature and availability of supportive services.In response to the study charge ( in ), this chapter presents the evidence on core parenting knowledge, attitudes, and practices separately.
However, it should be noted that in the research literature, the distinctions among these concepts, especially knowledge and attitudes, are not well-delineated and that the applications of these concepts to parenting often are equally informed by professional wisdom and historical observation. Parenting KnowledgeParenting is multidimensional. To respond to the varied needs of their children, parents must develop both depth and breadth of knowledge, rang. Ing from being aware of developmental milestones and norms that help in keeping children safe and healthy to understanding the role of professionals (e.g., educators, child care workers, health care providers, social workers) and social systems (e.g., institutions, laws, policies) that interact with families and support parenting. This section describes these areas of knowledge, as well as others, identified by the available empirical evidence as supporting core parenting practices and child outcomes. It is worth noting that the research base regarding the association between parental knowledge and child outcomes is much smaller than that on parenting practices and child outcomes.
Where data exist, they are based largely on correlational rather than experimental studies. Knowledge of Child Development Parent VoicesSome parents recognized the need for education related to providing care for young children.“I am a new parent and even though I have a bachelor’s degree from India, I do not have a particular education in child care. Just because I have a degree, it does not mean it is a degree on how to take care of a child.”—Father from Omaha, NebraskaThe importance of parents’ knowledge of child development is a primary theme of many efforts to support parenting. Evidence-based recommendations issued by the, the, and the emphasize the need for policy and program initiatives to promote parenting knowledge. As they suggest, to optimize children’s development, parents need a basic understanding of infant and child developmental milestones and norms and the types of parenting practices that promote children’s achievement of these milestones (;, p. 1187;;;;;; ).A robust body of correlational research demonstrates tremendous variation in parents’ knowledge about childrearing. Several of these studies suggest that parents with higher levels of education tend to know more about child developmental milestones and processes (.
), as well as effective parenting strategies. This greater knowledge may reflect differential access to accurate information, differences in parents’ trust in the information or information source, and parents’ comfort with their own abilities, among other factors.
For example, research shows that parents who do not teach math in the home tend to have less knowledge about elementary math, doubt their competence, or value math less than other skills (;; ). However, parents’ knowledge and willingness to increase their knowledge may change; thus, they can acquire developmental knowledge that can help them employ effective parenting practices. Parent VoicesSome parents recognized the need for comprehensive parenting education.“I always prefer education for the parents, from the beginning to the end. From pregnancy, some don’t know when to go to the doctor, and after birth, when to go to the hospital or the doctor. So we need education from the beginning to the end.”—Mother from Omaha, NebraskaThe focus on parental knowledge as a point of intervention is important because parents’ knowledge of child development is related to their practices and behaviors.
For example, mothers who have a strong body of knowledge of child development have been found to interact with their children more positively compared with mothers with less knowledge (; ). Parents who understand child development also are less likely to have age-inappropriate expectations for their child, which affects the use of appropriate discipline and the nature and quality of parent-child interactions (; ).Support for the importance of parenting knowledge to parenting practices is found in multiple sources and is applicable to a range of cognitive and social-emotional behaviors and practices. Several correlational studies show that mothers with high knowledge of child development are more likely to provide books and learning materials tailored to children’s interests and age and engage in more reading, talking, and storytelling relative to mothers with less knowledge (;; ). Fathers’ understanding of their young children’s development in language and literacy is associated with being better pre. Pared to support their children. And parents who do not know that learning begins at birth are less likely to engage in practices that promote learning during infancy (e.g., reading to infants) or appreciate the importance of exposing infants and young children to hearing words and using language. For example, mothers who assume that very young children are not attentive have been found to be less likely to respond to their children’s attempts to engage and interact with them.Stronger evidence of the role of knowledge of child development in supporting parenting outcomes comes from intervention research.
Randomized controlled trial interventions have found that parents of young children showed increases in knowledge about children’s development and practices pertaining to early childhood care and feeding (; ).Some studies have found a direct association between parental knowledge and child outcomes, including reduced behavioral challenges and improvements on measures of cognitive and motor performance (;;; ). In an analysis of data from a prospective cohort study that controlled for potential confounders, children of mothers with greater knowledge of child development at 12 months were less likely to have behavior problems and scored higher on child IQ tests at 36 months relative to children of mothers with less developmental knowledge.
This and other observational studies also show that parental knowledge is associated with improved parenting and quality of the home environment, which, in turn, is associated with children’s outcomes (;; ), in addition to being contingent on parental attitudes and competence (;; ).Experimental studies of parent education interventions support these associational findings. In an experimental study of parent education for first-time fathers, fathers, along with home visitors, reviewed examples of parental sensitivity and responsiveness from videos of themselves playing with their children. These fathers showed a significant increase in parenting competence and skills in fostering their children’s cognitive growth as well as sensitivity to infant cues 2 months after the program, compared with fathers in the control group, who discussed age-appropriate toys with the home visitor. Another experimental study examined a 13-week population-level behavioral parenting program and found intervention effects on parenting knowledge for mothers and, among the highest-risk families, increased involvement in children’s early learning and improved behavior management. Lower rates of conduct problems for boys at high risk of problem behavior also were found. Knowledge of Parenting PracticesParents’ knowledge of how to meet their children’s basic physical (e.g., hunger) and emotional (e.g., wanting to be held or soothed) needs, as well as of how to read infants’ cues and signals, can improve the synchronicity between parent and child, ensuring proper child growth and development.
Specifically, parenting knowledge about proper nutrition, safe sleep environments, how to sooth a crying baby, and how to show love and affection is critical for young children’s optimal development (;;; ).For many parents, for example, infant crying is a great challenge during the first months of life. Parents who cannot calm their crying babies suffer from sleep deprivation, have self-doubt, may stop breastfeeding earlier, and may experience more conflict and discord with their partners and children (; ).
Correlational research indicates that improvement in parental knowledge about normal infant crying is associated with reductions in unnecessary medical emergency room visits for infants. ); that parents with more knowledge about effective injury prevention practices are more likely to create safer home environments for their children and reduce unintentional injuries (;;; ); and that parents with knowledge about asthma are more likely to use an asthma management plan (;; ). Other studies have found that parents with more information about the purpose of vaccinations had greater knowledge of immunization than parents in the control group (; ), and parents with more knowledge about sun safety provided sunscreen and protective clothing for their children, who presented with fewer sunburns.Still, knowledge alone may not be sufficient in some cases. For example, knowing about the importance of using car seats does not always translate into good car seat practices (, ), and knowledge about the advantages of vaccines may not result in parents choosing to vaccinate their children. Some findings suggest that using multiple modes of delivery is important to advancing parents’ knowledge. In an experimental study, for example, found that parents who received educational information about child vaccinations via videotape as well as in written form showed greater gains in understanding about vaccinations than parents who received the information in written form alone.The evidence linking parental knowledge about the specific ways in which parents can help children develop cognitive and academic skills, including skills in math, is limited.
However, the available correlational data show that parents who know about how children develop language are more likely to have children with emergent literacy skills (e.g., letter sound awareness) relative to parents who do not. Several studies over the past 20 years have described parents’ increasing knowledge and use of approaches for supporting children’s literacy (;; ). Much of this work has focused on book reading and parent-child engagement around reading (;; ). As early as the 1960s, and others referred to the important role of the home literacy environment and parents’ beliefs about reading in children’s early literacy development. Knowledge of Supports, Services, and SystemsLittle is known about parents’ knowledge of various supports—such as educators, social workers, health care providers, and extended family—and the relationship between their conceptions of the roles of these supports and their use of them.
To take an example, parents’ knowledge about child care and their school decision-making processes are informed in a variety of ways through these different supports. In their literature review of child care decision making, found that many low-income parents learn about their child care options through their social networks rather than through professionals or referral agencies.
While many parents say they highly value quality, their choices also may reflect a range of other factors that are valued. Parents tend to make child care decisions based on structural (teacher education and training) and process (activities, parent-provider communication) features, although their choices also vary by family income, education, and work schedules., for example, found that higher maternal education and income and being white were associated with the likelihood of parents choosing higher-quality child care programs that were associated with better child outcomes. Based on a survey of parents of children in a large public school system, found that parents’ involvement, not satisfaction with their child’s school, was associated with school decision making. It should be noted that while parents may know what constitutes high-quality child care and education, structural (availability of quality programs and schools), individual (work, income, belief), and child (temperament, age) factors also influence these decision-making processes (; ).Taking another example, limited studies have looked at parental awareness of services for children with special needs. A study that utilized a survey and qualitative interviews with parents of children with autism indicated that parents’ autism spectrum disorder service knowledge partially mediates the relationship between socioeconomic status and use of services for their children. Parenting AttitudesAlthough considerable discussion has focused on attitudes and beliefs broadly, less research attention has been paid to the effects of parenting attitudes on parents’ interactions with young children or on parenting practices. Few causal analyses are available to test whether parenting attitudes actually affect parenting practices, positive parent-child interaction, and child development.
Even less research exists on fathers’ attitudes about parenting. Given this limited evidence base, the committee drew primarily on correlational and qualitative studies in examining parenting attitudes.Parents’ attitudes toward parenting are a product of their knowledge of parenting and the values and goals (or expectations) they have for their children’s development, which in turn are informed by cultural, social, and societal images, as well as parents’ experiences and their overall. Values and goals (;;;;;; ). People in the United States hold several universal, or near universal, beliefs about the types of parental behaviors that promote or impair child development.
For example, there is general agreement that striking a child in a manner that can cause severe injury, engaging in sexual activity with a child, and failing to provide adequate food for and supervision of young children (such as leaving toddlers unattended) pose threats to children’s health and safety and are unacceptable. At the same time, some studies identify differences in parents’ goals for child development, which may influence attitudes regarding the roles of parents and have implications for efforts to promote particular parenting practices.While there is variability within demographic groups in parenting attitudes and practices, some research shows differences in attitudes and practices among subpopulations. For example, qualitative research provides some evidence of variation by culture in parents’ goals for their children’s socialization.
In one interview study, mothers who were first-generation immigrants to the United States from Central America emphasized long-term socialization goals related to proper demeanor for their children, while European American mothers emphasized self-maximization. In another interview study, Anglo American mothers stressed the importance of their young children developing a balance between autonomy and relatedness, whereas Puerto Rican mothers focused on appropriate levels of relatedness, including courtesy and respectful attentiveness. Other ethnographic and qualitative research shows that parents from different cultural groups select cultural values and norms from their country of origin as well as from their host country, and that their goal is for their children to adapt and succeed in the United States.Similarly, whereas the larger U.S. Society has historically viewed individual freedom as an important value, some communities place more emphasis on interdependence (; ).
The importance of intergenerational connections (e.g., extended family members serving as primary caregivers for young children) also varies among and within cultural communities (; ). The values and traditions of cultural communities may be expressed as differences in parents’ views regarding gender roles, in parents’ goals for children, and in their attitudes related to childrearing. Children’s activities and whereabouts (; ) and parents’ beliefs about young children’s literacy development.Parental involvement in children’s education has been linked to academic readiness. However, parents differ in their attitudes about the role of parents in children’s learning and education. Some see parents as having a central role, while others view the school as the primary facilitator of children’s education and see parents as having less of a role. These attitudinal differences may be related to cultural expectations or parents’ own education or comfort with teaching their children certain skills.
Some parents, for example, may have lower involvement in their children’s education because of insecurity about their own skills and past negative experiences in school (; ). And as discussed above, some parents view math skills as less important for their children relative to other types of skills and therefore are less likely to teach them in the home.Parents within and across different communities vary in their opinions and practices with respect to the role and significance of discipline. Some of the parenting literature notes that some parents use control to discipline children, while others aim to correct but not to control children. In a small cross-cultural ethnographic study, found that some parents regard rules and punishment as inappropriate for infants and toddlers.
The approach valued by these parents to help children understand what is expected of them is to cooperate with them, perhaps distracting them but not forcing their compliance. In contrast, many middle-class U.S. Parents display a preference for applying the same rules to infants and toddlers that older children are expected to follow, although with some lenience. And ethnographic research provides some evidence of differences in African American and European American mothers’ beliefs about spoiling and infant intentionality (whether infants can intentionally misbehave) related to the use of physical punishment with young children.Parents’ attitudes not only toward parenting but also toward providers in societal agencies—such as educators, social service personnel, health care providers, and police—which can be shaped by a variety of factors, including discrimination, are important determinants of parents’ access to and ability to obtain support. Studies show a relationship between parents’ distrust of agencies and their likelihood of rejecting participation in an intervention. For example, in systematic reviews of studies of various types, parents who distrust the medical community and government health agencies are less likely to have their children vaccinated (; ). Racial and ethnic minority parents whose attitudes about appropriate remedies for young children vary from those of the West.
Ern medical establishment often distrust and avoid treatment by Western medical practitioners. While not specific to parents, studies using various methodologies show that individuals who have experienced racial and other forms of discrimination, both within and outside of health care settings, are less likely to utilize various health services or to engage in other health-promoting behaviors (;;; ). In a survey study, African American parents’ racism awareness was negatively associated with involvement in activities at their children’s school. Longitudinal studies, mostly involving families with older children, indicate that, like other sources of stress, parents’ experience of discrimination can have a detrimental effect on parenting and the quality of the parent-child relationship (; ).
Adverse outcomes for youth associated with their own experience of discrimination may be weakened by more nurturing/involved parenting (;; ).As noted earlier, attitudes are shaped in part by parenting self-efficacy—a parent’s perceived ability to influence the development of his or her child. Parenting self-efficacy has been found to influence parenting competence (including engagement in some parenting practices) as well as child functioning.
Studies show associations between maternal self-efficacy and children’s self-regulation, social, and cognitive skills (; ). Self-efficacy also may apply to parents’ confidence in their capacity to carry out specific parenting practices. For example, parents who reported a sense of efficacy in influencing their elementary school-age children’s school outcomes were more likely to help their children with school activities at home. A multimethod study of African American families found that maternal self-efficacy was related to children’s regulatory skills through its association with competence-promoting parenting practices, which included family routines, quality of mother-child interactions based on observer ratings, and teachers’ reports of mothers’ involvement with their children’s schools. Found in a longitudinal study that higher breastfeeding self-efficacy predicted exclusive breastfeeding at 6 months postpartum, as well as better emotional adjustment of mothers in the weeks after giving birth.
Parenting PracticesParenting practices have been studied extensively, with some research showing strong associations between certain practices and positive child outcomes. This section describes parenting practices that research indicates are central to helping children achieve basic outcomes in the areas discussed. At the beginning of the chapter: physical health and safety, emotional and behavioral competence, social competence, and cognitive competence. While these outcomes are used as a partial organizing framework for this section, several specific practices—contingent responsiveness of parents, organization of the home environment and the importance of routines, and behavioral discipline practices—that have been found to influence child well-being in more than one of these four outcome areas are discussed separately. Practices to Promote Physical Health and SafetyParents influence the health and safety of their children in many ways. However, the difficulty of using random assignment designs to examine parenting practices that promote children’s health and safety has resulted in a largely observational literature.
This section reviews the available evidence on a range of practices in which parents engage to ensure the health and safety of their children. It begins with breastfeeding—a subject about which there has historically been considerable discussion in light of generational shifts and commercial practices that have affected children in poor families.Breastfeeding Breastfeeding has myriad well-established short- and long-term benefits for both babies and mothers. Breast milk bolsters babies’ immunity to infectious disease, regulates healthy bacteria in the intestines, and overall is the best source of nutrients to help babies grow and develop.
Breastfeeding also supports bonding between mothers and their babies. According to a meta-analysis by the WHO , breastfeeding is associated with a small increase in performance on intelligence tests in children and adolescents, reduced risk for the development of type 2 diabetes and overweight/obesity later in life, and a potential decreased risk for the development of cardiovascular disease. Breastfeeding may benefit mothers’ health as well by lowering risk for postpartum depression, certain cancers, and chronic diseases such as diabetes. Current guidelines from the and the recommend mothers breastfeed exclusively until infants are 6 months old. Thereafter and until the child is either age 1 year or 2 years , it is recommended that children continue to be breastfed while slowly being introduced to other foods.According to 2011 data from the, about 80 percent of babies born in the United States are breastfed (including fed breast milk) for some duration, and about 50 percent and 27 percent are breastfed (to any extent with or without the addition of complementary liquids or solids) at.
6 and 12 months, respectively. Forty percent and 19 percent are exclusively breastfed through 3 and 6 months, respectively.Mothers in the United States often cite a number of reasons for not initiating or continuing breastfeeding, including lack of knowledge about how to breastfeed, difficulty or pain during breastfeeding, embarrassment, perceived inconvenience, and return to work (;; ). Low-income women with less education are less likely than women of higher socioeconomic status to breastfeed. Some research with immigrant mothers shows that rates of breastfeeding decrease with each generation in the United States, possibly because of differences in acceptance of bottle feeding here as compared with other countries (e.g., ).Nutrition and physical activity Parents play an important role in shaping their young children’s nutrition and physical activity levels (; ). Among toddlers and preschool-age children, parents’ feeding practices are associated with their children’s ability to regulate food intake, which can affect weight status (; ). Parents’ modeling of healthful eating habits for their children and offering of healthful foods, particularly during toddlerhood, when children are often reluctant to try new foods, may result in children being more apt to like and eat such foods (;; ).
The extant observational research generally shows that children’s dietary intake (particularly fruit and vegetable consumption) is associated with food options available in the home and at school, and that parents are important role models for their children’s dietary behaviors (;; ). Conversely, the presence of less nutritious food and beverage items in the home may increase children’s risk of becoming overweight. For example, and found positive associations between overweight in children and their consumption of sugar-sweetened beverages. On the other hand, there are some indications that overly strict diets may increase children’s preferences for high-fat, energy-dense foods, perhaps causing an imbalance in children’s self-regulation of hunger and satiety and increasing the risk that they will become overweight (; ).A few cross-sectional and longitudinal studies, coupled with conventional wisdom, suggest that eating dinner together as a family is associated with increased consumption of fruits, vegetables, and whole grains and reduced consumption of fats and soda , as well as with reduced risk for overweight and obesity (. However, these studies involved primarily older children and adolescents.Physical activity is a complement to good nutrition. Even in young children, physical activity is essential for proper energy balance and prevention of childhood obesity (; ).
It also supports normal physical growth. Parents may encourage activity in young children through play (e.g., free play with toys or playing on a playground) or age-appropriate sports. Children who spend more time outdoors may be more active (e.g.,; ) and also have more opportunity to explore their community and interact with other children.
For many parents living in high-crime neighborhoods, however, most of whom are racial and ethnic minorities, the importance of safety overrides the significance of physical activity. In some neighborhoods, safety issues and lack of access to parks and other places for safe recreation make it difficult for families to spend time outdoors, leading parents to keep their children at home (;; ).Although more of the research on screen time and sedentary behavior has focused on adolescents than on young children, several cross-sectional and longitudinal studies on younger children show an association between television viewing and overweight and inactivity (;;;;; ). An analysis of data on 8,000 children participating in a longitudinal cohort study showed that those who watched more television during kindergarten and first grade were significantly more likely to be clinically overweight by the spring semester of third grade.
Although television, computers, and other screen media often are used for educational purposes with young children, these findings suggest that balancing screen time with other activities may be one way parents can promote their children’s overall health. As with diet, children’s sedentary behavior can be influenced by parents’ own behaviors. For example, found an association between parents’ screen time and that of their children ages 6-12 in a cross-sectional study.Vaccination Parents protect their own and other children from potentially serious diseases by making sure they receive recommended vaccines. Among children born in a given year in the United States, childhood vaccination is estimated to prevent about 42,000 deaths and 20 million cases of disease. In 2013, 82 percent of children ages 19-35 months received combined-series vaccines (for diphtheria, tetanus, and pertussis DTP; polio; measles, mumps, and rubella MMR; and Haemophilus influenzae type b Hib), up from 69 percent in 1994. Vaccination rates are lower among low-income children.
71 percent of children ages 19-35 months living below the poverty level received the combined-series vaccines listed above in 2014. Although much of the media coverage on this subject has focused on middle-income parents averse to having their children vaccinated, it is in fact poverty that is thought to account for much of the disparity in vaccination rates by race and ethnicity. As discussed earlier in this chapter, parental practices around vaccination may be influenced by parents’ knowledge and interpretation of information on and their attitudes about vaccination.Preconception and prenatal care The steps women take with their health care providers before becoming pregnant can promote healthy pregnancy and birth outcomes for both mothers and babies.
These include initiating certain supplements (e.g., folic acid, which reduces the risk of birth defects), quitting smoking, attaining healthy weight for women who are obese, and treating preexisting physical and mental health conditions (;; ).During pregnancy, receipt of recommended prenatal care can help parents reduce the risk of pregnancy complications and poor birth outcomes by promoting healthy behaviors (e.g., smoking cessation, adequate rest and nutrition), as well as identifying and managing any complications that do arise. Prior to the birth of a child, health care providers also can educate parents on the importance of breastfeeding, infant injury and illness prevention, and other practices.Infants born to mothers who do not receive prenatal care or who do not receive it until late in their pregnancy are more likely than those born to mothers who receive such care early in pregnancy to be born premature and at a low birth weight and are more likely to die. Since the 1970s, there has been a decline in the number of women in the United States receiving late or no prenatal care, with the majority of pregnant women now receiving recommended prenatal care. Yet disparities among subgroups persist.
In 2014, American Indian and Alaska Native (11% of births), black (10% of births), and Hispanic (8% of births) women were more than twice as likely as white mothers (4% of births) to receive late or no prenatal care. The proportion of women receiving timely prenatal care increases with age: in 2014, 25 percent of births to females under age 15 and 10 percent of births to females ages 15-19 were to mothers receiving late or no prenatal care, compared with 7.8 percent for females ages 20-24 and 5.6 percent for those ages 25-29. Women whose pregnancies are unintended also are less likely to receive timely prenatal care.
Despite the importance of timely and quality prenatal care, moreover, many parents. Experience barriers to receiving such care, including poor access and rural residence, limited knowledge of its importance, and mental illness.Injury prevention Unintentional injuries are the leading cause of death among children ages 1-9 and a leading cause of disability for both younger and older children in the United States. In addition to motor vehicle-related injuries, children sustain unintentional injuries (due, for example, to suffocation, falls, poisoning, and drowning) in the home environment. About 1,700 children under age 9 in the United States die each year from injuries in the home.Parents can protect their children from injury through various measures, such as ensuring proper use of automobile passenger restraints, insisting that children wear helmets while bike riding and playing sports, and creating a safe home environment (e.g., keeping medicines and cleaning products out of children’s reach, installing safety gates to keep children from falling down stairs). Yet the limited available research on parents’ use of safety measures suggests there is room for improvement in some areas. For instance, appropriate use of child restraint systems is known to reduce the risk of child motor vehicle-related injuries and deaths (; ); nonetheless, data show that many children ride in automobiles without appropriate restraints (;; ). Likewise, using data from a national survey conducted during 2001-2003, show that less than one-half of children ages 5-14 always wore bicycle helmets while riding, and 29 percent never did so.
More recent data on parents’ home safety practices and on helmet usage among young children are lacking.Evidence that families’ home safety practices affect child safety comes from intervention research. A large meta-analysis of randomized and nonrandomized controlled trials of home safety education interventions for families showed that the education was generally effective in increasing the proportion of families that stored medicines and cleaning products out of reach and that had fitted stair gates, covers on unused electrical sockets, safe hot tap water temperatures, functional smoke alarms, and a fire escape system.
There was also some evidence for reduced injury rates among children. As discussed in, helping parents reduce hazards in the home is a component of some home visiting programs.Parents also protect their children’s safety by monitoring their whereabouts and activities to prevent them from both physical and psychological harm. The type of supervision may vary based on a child’s needs and age as well as parents’ values and economic circumstances. For all young children, monitoring for the purposes of preventing exposure to hazards is. An important practice. As children grow older, knowing their friends and where the children are when they are not at home or in school also becomes important. As noted previously, research suggests the importance of monitoring screen time to children’s well-being.
And monitoring of children’s Internet usage may prevent them from being exposed to online predators. Practices to Promote Emotional and Behavioral Competence and Social CompetenceFundamental to children’s positive development is the opportunity to grow up in an environment that responds to their emotional needs and that enables them to develop skills needed to cope with basic anxieties, fears, and environmental challenges. Parents’ ability to foster a sense of belonging and self-worth in their children is vital to the children’s early development. In much the same way, parents contribute to children’s emerging social competence by teaching them skills—such as self-control, cooperation, and taking the perspective of others—that prepare them to develop and maintain positive relationships with peers and adults. Parents can promote the learning and acquisition of social skills by establishing strong relationships with their children.
The importance of early parent-child interactions for children’s social competence is embedded in many theoretical frameworks, such as attachment , family system theories , and ecocultural theories. Parents socialize their children to adopt culturally appropriate values and behaviors that enable them to be socially competent and act as members of a social group.Research suggests that children who are socially competent are independent rather than suggestible, responsible rather than irresponsible, cooperative instead of resistive, purposeful rather than aimless, friendly rather than hostile, and self-controlled rather than impulsive. In short, the socially competent child exhibits social skills (e.g., has positive interactions with others, expresses emotions effectively), is able to establish peer relationships (e.g., being accepted by other children), and has certain individual attributes (e.g., shows capacity to empathize, has coping skills). Parents help children develop these social skills through parenting practices that include fostering and modeling positive relationships and providing enriching and stimulating experiences and opportunities for children to exercise these skills (.
In this paper studies are reviewed from the last decade on postpartum depression effects on early interactions, parenting, safety practices and on early interventions. The interaction disturbances of depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups and, include less sensitivity of the mothers and responsivity of the infants. Several caregiving activities also appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines and well-child visits, vaccinations and safety practices. These data highlight the need for universal screening of maternal and paternal depression during the postpartum period. Early interventions reviewed here include psychotherapy and interaction coaching for the mothers, and infant massage for their infants. The significance of continuing research on postpartum depression is highlighted by the increasing incidence of postpartum depression and some longitudinal studies that have reported long-term negative effects of postpartum depression on children's health and their social, emotional, cognitive and physical development.
Statistics from large sample studies have placed postpartum depression at about 20–40% in mothers and a somewhat lower percentage in fathers (; ). In these samples, similar rates of postpartum depression were noted for the mothers and fathers in families where the mother was experiencing postpartum depression symptoms.The long-term negative outcomes, including behavioral, emotional and health problems, have been frequently attributed to disturbed mother-infant interactions, although more recent data suggest that poor parenting and safety practices are also risk factors. This paper is a review of studies from the last decade on postpartum depression effects on early interactions, parenting and safety practices and on early interventions. Early InteractionsAs already mentioned, researchers have attributed the long-term effects of maternal depression including behavior problems, cognitive delays and physical health problems to disturbed early interactions. In a meta-analysis of studies on the early interactions of postpartum depressed mothers, the mothers who were depressed across their infants’ first 3 months of life were noted to be more irritable and hostile, to be less engaged, t o exhibit less emotion and warmth and to have lower rates of play with their 3-month-old infants.Most of the mother-infant interaction studies have focused on infants between three and six months because that seems to be the primary form of play for infants that age. Non-depressed parents are noted to engage in face-to-face interaction play behavior that features vocalizing, smiling, imitation and gameplaying.
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These interactions, in turn, are thought to be the 'playing field' for infants learning communication skills such as turntaking. Fewer of these behaviors have been noted in depressed mothers and their infants, which may contribute to their interaction disturbances. The interaction disturbances of depressed mothers and their infants appear to be universal across different cultures and socioeconomic status groups. For example, less vocal and visual communication and less smiling have been noted in depressed mother-infant interactions in Switzerland. Similarly, in England, depressed mothers are less sensitively attuned to their infants. These early interactions disturbances have also been noted, for example, in Arabic cultures and Turkey.Depressed mothers appear to have at least two different styles of interacting including an intrusive, controlling and over-stimulating style or a withdrawn, passive and under-stimulating style.
Postpartum depressed mothers in comparison with non-depressed mothers touch their infants less frequently and in a less affectionate manner and a more negative manner (e.g. Rough pulling, tickling and poking) (;). Infants of depressed mothers spend more time touching their own skin, which may compensate for their receiving less positive touch from their mothers (; ).Depressed mothers also differ on their vocal behavior, including the use of longer utterances, less repetition, more negative affect, fewer explanations, suggestions and questions and fewer references to their infants' behavior (; ).
Others have noted differences in the vocal timing of depressed mothers' responses to their 4-month-old infants' vocalizations. In this study, the duration of switching pauses in depressed mothers was longer, more variable and less predictable than the timing mechanism of the non-depressed mothers. The authors suggested that depression may play a role in reducing synchrony in depressed mothers' and infants' interactions, affecting the mother’s ability to coordinate her vocal behavior with her infant’s vocalizations and non-verbal behavior. Consistent with the observation that depressed mothers have less infant-directed speech is a finding that they do not show a shorter mean length of utterance for younger versus older babies, in contrast to non-depressed mothers.
It is not surprising, then, that the infants of depressed mothers later show less expressive language and perform more poorly on measures of cognitive-linguistic functioning.In a study on a very large sample (N=5,089) of both depressed mothers and fathers, depressive symptoms were also associated with less enrichment activity with the infant including less reading, singing songs, telling stories and playing games. Mothers who were depressed were less likely to tell stories and play peek-a-boo with their infants (according to their self-report), and depressed fathers were less likely to sing songs and play with their infants. However, in another study, paternal depression did not affect at least the fathers' frequency of interactions (Lyons-Ruth et al, 2002).Postpartum paternal depression has been noted to exacerbate maternal depression effects on later child behavior problems but only if the father has spent significant amounts of time caring for the child during infancy. In addition, being exposed to a non-depressed father did not buffer the effects of maternal depression, even if the father spent significant amounts of time with his infant.All of these interaction activities are important for later cognitive, social, emotional and physical development (; ).
Thus, the lesser amount of time spent by depressed parents in these activities does not augur well for their infants' later development. This may be particularly true for male infants inasmuch as they are noted to have even more difficult interactions with their depressed mothers. For example, in a recent study, male infants as compared to female infants were more vulnerable to high levels of maternal depressive symptoms, and high symptom mothers and their sons had more difficult interactions. BreastfeedingMost studies on parenting practices have reported reduced odds of continuing breastfeeding for mothers who are postpartum depressed (; ). In both of these studies, the mothers with high postpartum depression scores were significantly more likely to discontinue breastfeeding at 4 to 16 weeks postpartum and were giving the infant water, juice or cereal during that time (; ).
These undesirable feeding practices may have, in turn, led to the feeding difficulties noted in infants of depressed mothers (Righett-Veltema et al, 2002).In the study, the mothers also reported being unsatisfied with breastfeeding and having experienced significant breastfeeding problems and lower levels of breastfeeding self-efficacy. Similarly, in another study based on high Edinburgh depression scores, an inverse relationship was noted between depressive symptoms and breastfeeding at 6 weeks postpartum , although, the inverse relationship did not continue beyond 12 weeks.
In at least one study, however, depression was surprisingly not related to breastfeeding. Sleep problemsIn the same large sample study reporting undesirable practices and infant feeding problems, undesirable sleep practices and sleep problems were also noted. The sleep practices associated with maternal depression included placing the infant to sleep in the prone position instead of the recommended supine position.
In other samples, sleep problems included the infant sleeping in the parents' bed, being nursed to sleep, taking longer to fall asleep and waking more often and for longer periods. The same sleep problems were associated with high depression scores and tended to increase as depression scores increased.
In still another study on disturbed sleep patterns, mothers with major depressive symptoms at 4 and 8 weeks were more likely to report that their infant cried often, woke up 3 times or more between 10pm and 6am, and received less than 6 hours of sleep in a 24 hour period during the past week. The infants' sleep problems also did not allow the mothers to get a reasonable amount of sleep. Consistent with these findings, the mothers with high depression scores were more likely to report that they often felt tired.Similarly, in another study, problematic sleep patterns included 1) parental disagreement regarding managing the infants' sleep; 2) the infant sleeping in the parents' room; 3) the mothers nursing the infants to sleep at the beginning of the night; and 4) the infants waking 7 nights per week. In addition, the mothers who reported infant sleep problems had poor mental and physical health as compared to those not reporting sleep problems. HealthcareMaternal depressive symptoms have also been noted to affect children's receiving health care during infancy.
In a cohort study of data collected prospectively as part of the National Evaluation of Healthy Steps for Young Children, infants whose mothers had depressive symptoms at 2–4 months had increased use of acute care later in infancy including emergency department visits in the past year. The infants of depressed mothers also had received fewer preventive services including age-appropriate well-child visits at 12 months and up-to-date vaccinations at 24 months.
Safety PracticesSafety practices have also been affected by maternal depression symptoms. In a secondary analysis from the Health Steps National Evaluation, interviews given at the end of infancy provided information about safety practices including using an infant car seat, having electric outlet covers, having safety latches on cabinets and having lowered the temperature on the water heater. In this sample, the mothers with depressive symptoms at 2–4 months had a reduced odds of using car seats and lowering the water heater temperature. Mothers with concurrent depressive symptoms had a reduced odds of using electric outlet covers and using safety latches. In a similar large database in England, however , maternal depression did not appear to be related to safety practices including the safe storage of medicines, the use of smoke alarms and the safe storage of sharp objects. These discrepant findings may relate to cross-cultural differences or simply the assessment of different safety practices by the two studies.
Clinical ImplicationsThe findings from these studies on early interaction problems and inadequate caregiving and safety practices have important clinical implications for pediatric healthcare professionals. One of the implications is the need for universal screening of maternal and paternal depression by pediatricians during the postpartum period, inasmuch as pediatric professionals have frequent contact with families at that time.
Several pediatric organizations have suggested that pediatric professionals not only be involved in the universal screening but also in guidance and referrals for maternal depression treatment. The US Preventive Service Task Force has recommended 2-item screeners to be used by primary care professionals to detect depression symptoms. In a recent study, for example, a significant increase was noted in the detection of depression symptoms among mothers during the first postpartum year following the implementation of the universal postpartum depression screening during well-childcare visits. Secondly, pediatricians are being encouraged to provide anticipatory guidance to mothers with depression symptoms, including discussions of parenting practices such as continuing breastfeeding, playing, talking and providing routines and book-reading. The screening and interventions should also be directed at depressed fathers and partners of depressed mothers.
Behavioral InterventionsMost intervention programs for postpartum depressed mothers have focused on providing pharmaceuticals or psychotherapy for the mothers. Although the psychotherapy studies have suggested positive effects, the literature on antidepressants is mixed and generally suggests that antidepressants should not be used at least by breastfeeding mothers (see for a review).In a review on the different types of psychosocial and psychological interventions for postpartum depression, several databases were searched for these kinds of interventions. Basically this review suggested that women who received psychosocial interventions were equally likely to develop postpartum depression as those receiving standard care.
The only promising intervention in this review was intensive postpartum support by public health nurses or midwives. Identifying mothers at-risk assisted the prevention of postpartum depression, although, surprisingly, interventions with only a postnatal component appeared to be more beneficial than interventions that also incorporated a prenatal component. In addition, while individually-based interventions were more effective than those that were group-based, the women who received multiple-contact interventions were again, surprisingly, just as likely to experience postpartum depression as those who received a single-contact intervention.In a study on psychotherapy to help postpartum depressed mothers interact with their infants, the depressed women were randomly assigned to interpersonal psychotherapy or to a waitlist control group.
At 6 months, the depressed mothers were less responsive to their infants, they experienced more parenting stress, and they viewed their infants more negatively than non-depressed mothers did. The treatment only reduced parenting stress, although parenting stress was still higher in the depressed versus the non-depressed mothers. At an eighteen month follow-up, the depressed mothers who received interpersonal psychotherapy still rated their children lower on attachment security, higher on behavior problems and more negative on temperament than the children of non-depressed mothers. Thus, it would appear that treatment of the mothers' depression symptoms is not sufficient. Early interventions may need to also focus on mother-infant interactions.Interaction coaching has been developed to help mothers improve their interaction behaviors by providing them video feedback, by giving them instructional sets such as having them imitate their infants’ behavior and by using “bug-in-the-ear” second-by-second suggestions as the interactions occur (see for a review). These interventions have been effective with postpartum depressed mothers in several studies reviewed. A recent study by another group targeted mother-infant interactions to help parents understand and respond to their infants’ behaviors with the goal of increasing positive affect in the infants.
The intervention was carried out in 5 weekly group sessions beginning when the infant was 3 months of age. The dyads were videotaped during face-to-face interactions. Following the intervention, the infants showed more interest and joy expressions when interacting with their mothers. Even though the mothers' depression ratings did not change, the authors concluded that the intervention had helped the mothers focus on what they were doing with their infants rather than simply how they were feeling.Finally, teaching depressed mothers to massage their infants has resulted in less irritability and fewer sleep problems in the infants and better mother-infant interactions. The mothers’ depression has also been reduced by massaging their infants.
Methodological LimitationsMany of these studies have the limitation that they used self-report measures (the CES-D and the Edinburgh Depression Scales) to assess parental depression. Although these self-report measures are not typically used for clinical diagnoses, the self-report depression scales do reflect a range of depressive symptoms that are typically associated with the diagnosis of depression, and they are reliable measures. Further, they are cost-effective measures that could be used for universal screening to identify postpartum depressed mothers and fathers for early interventions.The measures used for assessing parent caregiving activities and safety practices were also completed by self-report. Although parent reports have been correlated with observational measures in some studies, the self-reports are typically completed by the mothers, not the fathers.
This may, in part, explain the data on paternal depression effects. More detailed parenting style and behavior observations may be needed and on both mothers and fathers in future studies.Finally, it is not clear how the data from these studies have been affected by confounding interventions such as the anticipatory guidance intervention designed by the American Academy of Pediatrics. Inasmuch as most parents are being seen by pediatricians, which would suggest that they are receiving some anticipatory guidance, this may be a confounding factor in the assessment of the parents' behaviors. SummaryThis paper reviewed studies from the last decade on postpartum depression effects on early interactions, parenting, and safety practices, and on early interventions. The interaction disturbances of depressed mothers and their infants appear to be universal across different cultures and socioeconomic status groups and include less sensitivity of the mothers and responsivity of the infants. Several caregiving activities also appear to be compromised by postpartum depression including feeding practices, most especially breastfeeding, sleep routines and well child visits, vaccinations and safety practices.
These data highlight the need for universal screening of maternal and paternal depression during the postpartum period. Early interventions reviewed here include psychotherapy and interaction coaching for the mothers and infant massage for their infants. Further observational research and studies on educational and therapeutic interventions are needed.