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University of Groningen
Parenting and child psychosocial problemsSpijkers, Willem
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Parenting and child psychosocial problems: Effectiveness of
parenting support inPreventive Child Healthcare. University of
Groningen.
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Parenting and child psychosocial problemsEffectiveness of
parenting support in Preventive Child Healthcare
W. Spijkers
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Colofon
This study was conducted within the Research Institute SHARE of
the Graduate School of Medical Sciences, University Medical Center
Groningen, University of Groningen and under the auspices of the
research program Public Health Research (OHR). This study was
funded by Netherlands Organisation for Health Research and
Development (ZonMw).
No parts of this thesis may be reproduced of transmitted in any
forms or by any means, electronic of mechanical, including
photocopying, recording or any information storage and retrieval
system, without permission of the author.
Lay-out: Rozemarijn Klein Heerenbrink, persoonlijk
proefschrift.nl Cover design: W. Spijkers Printed by: Ipskamp
Drukkers
ISBN: 978-90-367-8130-5
ISBN (E-book): 978-90-367-8129-9
© 2015, W. Spijkers
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Parenting and child psychosocial problems
Effectiveness of parenting support in Preventive Child
Healthcare
Proefschrift
ter verkrijging van de graad van doctor aan deRijksuniversiteit
Groningen
op gezag van derector magnificus prof. dr. E. Sterken
en volgens besluit van het College voor Promoties.
De openbare verdediging zal plaatsvinden op
woensdag 7 oktober 2015 om 11.00 uur
door
Willem Spijkers
geboren op 30 december 1972te Hardenberg
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PromotorProf. dr. S.A. Reijneveld
CopromotorDr. D.E.M.C. Jansen
BeoordelingscommissieProf. dr. T.A. van Yperen Prof. dr. F.J.M.
Feron Prof. dr. P.F.M. Verhaak
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ParanimfenErnst de Klerk Aäron Gudema
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TablE of ConTEnTs
abbreviations 9
Chapter 1 Introduction 13
Chapter 2 The impact of area deprivation on parenting stress
European Journal of Public Health 2011;22(6):760-765
25
Chapter 3 Parental internalizing problems in a community sample:
association with child psychosocial problems The European Journal
of Public Health 2013;24(1):11-15
43
Chapter 4 Psychometric properties of the Depression, Anxiety and
Stress Scale (DASS-21) in a large non-clinical sample Submitted
57
Chapter 5 Effectiveness of a parenting programme in a public
health setting: a randomised controlled trial of the positive
parenting programme (Triple P) level 3 versus care as usual
provided by preventive child healthcare (PCH) (Design paper) BMC
Public Health 2010;10:131
69
Chapter 6 Effectiveness of Primary Care Triple P on child
psychosocial problems in preventive child healthcare: a randomized
controlled trial BMC Medicine 2013;11: 240
81
Chapter 7 General discussion 99
Summary (EN) 115
Samenvatting (NL) 121
Dankwoord 127
Curriculum Vitea 131
Research Institute for Health Research 135
appendix 1 Effects of Primary Care Triple P compared with UC
(Results based on imputed data)
141
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AbbreviAtions
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10
Abbreviations
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Abbreviations used in this thesis (alphabetic order)
ADHD Attention Deficit Hyperactivity Disorder
CFI Comparative Fit Index
CHP Child Health Professional
CI Confidence Intervals
CONSORT Consolidated Standards of Reporting Trials
DASS Depression Anxiety Stress Scale
ECBI Eyberg Child Behaviour Inventory
FCC Family Care Center
ICC Intra Class Correlation
ITT Intention To Treat
METc Medisch Ethische Toetsingscommissie [Medical Ethics
Committee]
MOR Median Odds Ratio
NTR Nederlands Trial Register [Dutch Trial Registration]
OR Odds Ratio
PCH Preventive Child Healthcare
PCTP Primary Care Triple P (level 3 of the Positive Parenting
Program)
PS Parenting Scale
PSBC Problem Setting and Behaviour Checklist
PSI Parenting Stress Index
RCT Randomized Controlled Trial
RMSEA Root Mean Square Error of Approximation
SD Standard Deviation
SDQ-TDS Strengths and Difficulties Questionnaire – Total
Difficulties Score
SE position Socioeconomic position
Triple P Positive Parenting Program
UC / CAU Usual Care / Care As Usual
Zon MW Zorgonderzoek Nederland [The Netherlands Organisation of
Health Research and Development]
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Chapter 1Introduction
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Introduction
1.1 objECTivE and ouTlinE of THE THEsis
The object of this thesis is to contribute to current knowledge
of the relationship between parenting and child psychosocial
problems. To this end we investigated the effectiveness of Primary
Care Triple P (PCTP), level 3 of the Positive Parenting Programme,
in Preventive Child Healthcare (PCH). We also conducted research
among children aged 9-11 years after an initial screening of child
psychosocial problems. This introductory chapter focuses on the
interaction between child psychosocial problems and parenting and
further discusses the early detection and treatment of child
psychosocial problems in Preventive Child Healthcare (further:
PCH).
1.2 CHild PsyCHosoCial ProblEms
Child psychosocial problems comprise the behavioural, emotional
and social problems of children. The following case-vignette
provides an example of such problems:
Rosie is an eight-year-old girl who is doing quite well at
school, but she is sometimes hyperactive in class and tends not to
obey very well. At home, obedience is also a problem. Her parents
sometimes experience her behaviour as very hard to deal with.
Interaction of the parents with their child and disciplining
interventions seem to be counterproductive and sometimes even
worsen the problems. According to the parents, the interaction with
their child leaves a lot to be desired. They long for effective
support to handle the behaviour of their daughter. Rosie’s teacher
noticed that the child has tantrums but also acts withdrawn and
does not play much with other children. He advises Rosie and her
parents to contact a child health professional (CHP). Both Rosie’s
parents experience parenting stress and her mother feels sometimes
depressed because she thinks that she is failing to raise her
daughter properly.
This vignette describes a situation familiar to many parents of
young children. It obviously concerns a child with psychosocial
problems, and her parents experience difficulties in coping with
her difficult behaviour.
This thesis applies the definition of psychosocial problems
provided in the guideline for early detection by PCH in the
Netherlands.1,2 The definition comprises three elements:
1. Emotional problems (often referred to as internalizing
problems) such as anxiety, depressive feelings, withdrawn
behaviour, psychosomatic complaints);
2. Behavioural problems (often referred to as externalizing
problems) such as: hyperactivity, aggressive behaviour, and conduct
problems. This concerns problems that are visible to the
environment of the child;
3. Social problems; these are problems related to the ability of
the child to initiate and maintain social contacts and interactions
with others.
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This definition is used in several settings, including the PCH
local and National Monitor Youth Health in the Netherlands.3
Several population-based studies in the Netherlands show that
about 20%-28% of all children have been diagnosed with psychosocial
problems.3-5 A study in primary and secondary education showed that
13% of all pupils had internalizing problems, 11% had externalizing
problems and 3% had other problems, such as social problems. In
7.6% of all toddlers, CHPs identified one or more psychosocial
problems.52-55 Some different types of problems occur jointly.
Studies on trends in the prevalence of psychosocial problems are
not consistent in their findings. According to a study of American
4- to 15-year olds by Kelleher et al.8, in the period from 1979 to
1996 clinician-identified psychosocial problems increased from 6.8%
to 18.7%. Similar distinct trends could not, however, be found in
the Netherlands. In the Netherlands, Tick et al.9,10 found evidence
only for some small changes in self-reported child psychosocial
problems. Decreases were noted for boys, mostly concerning their
behavioural problems. Some increases were found for girls,
especially in emotional and behavioural problems. Epidemiological
studies in the province of Groningen (part of our study area)
showed no consistent increase over the last eight years.11
The prevalence and nature of psychosocial problems differ among
specific groups of children, as mentioned above between boys and
girls.12,13 Whereas externalizing problems are more prevalent among
boys, internalizing problems are more common in girls. However, in
young children differences between boys and girls are smaller.2
There are, moreover, a few groups with more than a normal risk of
developing psychosocial problems. These include preterm born
children14, immigrants15 children from non-industrialized
countries, and children with low socio-economic status.16 Moreover,
child psychosocial problems also occur more frequently in deprived
areas, and research has shown that the environment in which
children grow up affects their mental state.17,18
Consequences of early psychosocial problemsChild psychosocial
problems can seriously interfere with the normal psychological
development of children. Changes in psychosocial problems over time
appeared to have most negatively affected the functioning of young
adolescent girls.9,10 Many authors emphasize that child
psychosocial problems may be an important precursor of negative
psychological consequences in adolescence and maturity. For
example, childhood conduct problems are associated with a wide
range of adverse psychosocial outcomes (e.g. crime, substance use,
mental health, sexual- and partner relationships) even after
controlling for confounding factors. Anxiety and depressive
symptoms in adulthood are often preceded by emotional problems in
youth. Research has shown that many adult delinquents exhibited
intemperate and aggressive behaviour in their youth. Furthermore,
child psychosocial problems are the major cause of long-term work
disability in young adults and of future societal costs.19-21
In their daily practice, Child Health Professionals (CHPs) often
encounter parents who seek parenting support for their children
with mild psychosocial problems. In the past, raising children
seemed to be a collective activity conducted in their primary
social environment, involving
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Introduction
family, other relatives, and also neighbours. Parents sought
advice and support within their social network.22 Nowadays, raising
children has become more and more individualized and takes place
within the context of the closed family. As a result, when things
go wrong parents tend to lean more and more on professional care
instead of their social network.23,24 In this respect, the burden
of responsibility for raising children has shifted from the
community to the parents alone.
1.3 ParEnTing and CHild PsyCHosoCial ProblEms
Problems in effective parenting have become an increasing public
health problem, also reflected in public policy.1 Research suggests
that different parenting styles and parenting practices have an
important impact on child development and that child psychosocial
problems and parenting stress are mutually linked.25-27 Parents of
children with behaviour problems experience highly elevated levels
of child-rearing stress which may make it more difficult for them
to respond to their children in positive, consistent, and
supportive ways.28 This can lead to a vicious circle in which
parents and their children have a perpetual negative effect on each
other.
Ineffective and inconsistent parenting styles, such as
over-reactivity, verbosity, and laxness may contribute to and
maintain child psychosocial problems.21 Over-reactivity refers to
an authoritarian parenting style, which includes threats and
physical punishment. Dishion and Patterson29 reviewed extensive
literature supporting theories that harsh and coercive discipline
is associated with antisocial behaviour in adolescents. Verbosity
describes the approach of parents who tend to give lengthy verbal
reprimands rather than taking direct action.30 Hakman indicated an
association between rates of child compliance and levels of
maternal verbosity; high levels of verbosity resulted in more
noncompliance in children than did low levels of verbosity.31
Laxness describes the approach of parents who are permissive and
inconsistent in providing discipline. Research has shown a
relationship between permissive parenting, characterized by lack of
consistency and ineffective setting of limits, and oppositional
behaviour and conduct disorders.30 It is clear that parents are
very important intermediates in the treatment of child psychosocial
problems.
The child problem behaviours associated with the above-mentioned
over-reactivity, verbosity and laxness have inspired many
interventionists to develop methods or programs for parenting
support. Moreover, several studies have emphasized that parenting
stress may lead to parental depression. Early detection and
treatment of child psychosocial problems therefore seem to benefit
both children and their parents. This reinforces the need for
greater investment in early detection and treatment of child
psychosocial problems.32
1.4 Early dETECTion and TrEaTmEnT of CHild PsyCHosoCial
ProblEms
Early treatment of child psychosocial problems is important for
prevention of further aggravation of the problems.26,33 Early
detection means as soon as the problems emerge. It also means
early
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in the life of the child and, most importantly, early in the
developmental process of the problem itself.
As mentioned before, research has shown that early recognition
of emotional and behavioural problems in children, if followed by
adequate treatment, significantly improves their prognoses. Care
for children with psychosocial problems has in recent decades
become increasingly professionalized. In the Netherlands care is
provided by healthcare organisations such as organisations for
youth and parenting, and child and adolescent mental health care
(Jeugd GGZ).34 These organisations play a role as soon as the
problems have become clinically manifested.
Systematic screening of psychosocial problems in all children
belongs to the domain of PCH. CHPs, i.e. doctors and nurses,
working in preventive child healthcare offer the entire Dutch
population routine well-child care, including the early detection
and treatment of psychosocial problems.35,36 PCH would therefore
seem to be the obvious organisation for the early detection of
psychosocial problems among preschool children, comparable to
community pediatrics in the USA. Following through on early
detection, PCH can also play an important role in treatment at the
onset of mild psychosocial problems in children.
Preventive Child HealthcarePCH is a health service available at
no cost to all Dutch parents and their child(ren) aged 0 to 19
years. PCH comprises regular activities offered to all children
conform a uniform and protocolled routine arranged at a national
level and established by law.37 Each municipality is responsible
for the execution of PCH activities. In the Netherlands, PCH is
part of the Municipal Health Service (Gemeenschappelijke
GezondheidsDienst; GGD).
PCH was established in the past century. Initially, it was
established mainly to offer physical healthcare for every child
(focused on poverty, (mal)nutrition and arrears in growth, domestic
hygienic circumstances, infectious diseases, et cetera). Nowadays
the focus has shifted towards overfeeding, new infectious diseases
and lifestyle. There is also more attention to the child’s
psychosocial problems and problems within his family, neighbourhood
and school environment. The aim of PCH is to promote, protect and
safeguard children’s physical, mental, social, and cognitive health
and development.38 PCH provides information for parents and
children about a healthy development. It detects (imminent)
problems and risks and offers support to the child and caregivers
or refers them to more specialized care.
PCH organisations in the Netherlands have the duty to detect
children with psychosocial problems and, if necessary, to assure
that these children and their parents receive adequate support,
treatment or care. In the last version of the so-called Basic Task
Package (BasisTakenPakket Jeugdgzondheidszorg 0-19 jaar (BTP/JGZ)
of PCH in the Netherlands, screening on psychosocial problems
already had become one of the most important issues.37 This Basic
Task Package was evaluated in 2013.38 The evaluation commission
concluded that maintenance of most of the described activities was
legitimate. The commission also emphasized that early detection and
prevention of child psychosocial problems (including bullying)
should be part of the primary tasks of PCH.
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Introduction
In conclusion, in the field of healthcare for children, PCH has
a unique position in the early detection and treatment of child
psychosocial problems (i.e. primary and secondary prevention),
including short interventions for children with subclinical level
problems. This offers an ideal setting to provide parenting support
following an evidence-based method of early detection of
psychosocial problems in children. To reach this goal there is a
need for standardized parenting support interventions that are
short and that suit the competences of professionals in PCH. As
yet, such interventions are not available.
identification of psychosocial problems: the strengths and
difficulties Questionnaire (sdQ)For the identification of child
psychosocial problems, PCH uses the Strengths and Difficulties
Questionnaire. Accurate screening of psychosocial problems is
necessary in order to intervene as early as possible. In the
prevention of child psychosocial problems, the Strengths and
Difficulties Questionnaire (SDQ) plays an important role in
present-day PCH. This questionnaire is a brief behavioural
screening questionnaire for children aged 3-16 years. 39-41 The SDQ
is available in several versions to meet the needs of researchers,
clinicians and educationalists. All versions include questions
about 25 attributes, some positive and others negative. These 25
items are divided among 5 scales:
1) Emotional symptoms (5 items); 2) Conduct problems (5 items);
3) Hyperactivity/inattention (5 items); 4) Peer relationship
problems (5 items); 5) Pro-social behaviour (5 items).
Validation research in the Netherlands42-44 showed that the SDQ
is a reliable and valid instrument for detecting psychosocial
problems in children aged 7-12 years old, also in community
samples. Implementation of the SDQ in PCH organisations was
recommended by their umbrella organisation of Municipal Health
Services (GGD Nederland). This resulted in a nearly universal use
of this questionnaire by PCH in the Netherlands.
1.5 inTErvEnTions and THEir EvidEnCE
Effective early detection is useless and even unethical if no
effective early treatment is available.45 Therefore, evidence-based
interventions targeting child psychosocial problems are needed.
During the last decades, a battery of interventions have emerged.
Examples of parenting interventions are: Video home training,
Incredible Years46,47, Families First, STEP, Parenting and more
(Opvoeden&zo), and Firm Parenthood (Stevig ouderschap). The
database from the Netherlands Youth Institute (NJI) contains
several interventions related to parenting practices and parenting
strategies. Regrettably, however, as yet only one program is
considered to be evidence-based, which is Incredible Years.47 Most
of the above mentioned parenting interventions are based on the
same principles such as: reinforcing positive behaviour and
negating negative
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problem behaviour. The Positive Parenting Program (Triple P)28
is one of those programs. Recently, studies in the Netherlands and
elsewhere on the evidence effectiveness of the more intensive
variants of Triple P have been criticised.48,49 We can conclude
that evidence on the effectiveness of PCTP is particularly scarce
and inconclusive, and is lacking for the Dutch setting.
The Positive Parenting Program (Triple P)This thesis describes a
study of the effects of Triple P level 3, also known as: Primary
Care Triple P (PCTP). Triple P is a multilevel system of family
intervention that provides five increasingly intense levels of
intervention.28,50 Level 1 refers to a media-based parent
information campaign that targets all parents wanting to improve
their parenting skills. Level 2 consists of a brief one- or
two-session primary healthcare intervention providing guidance to
parents of children with mild behaviour problems. Level 3 is one of
the levels with mediate intensity. It is a brief, narrow-focus
parent program aimed at parents with specific concerns about their
child’s behaviour or development. It combines advice, rehearsal and
self-evaluation to teach parents to manage discrete child problem
behaviour during four individual consultations of 20-30 minutes
with the parents and their child. 51 Level 4 is an intensive
eight-to-ten session individual or group parent-training program
for children with more serious behaviour problems. Level 5 offers
help to parents of children with very difficult child behaviour
problems and family dysfunction.28
Several studies showed that the Triple P interventions,
including level 3, seem promising when compared with a wait-list
control group receiving no help.52-55 In the Netherlands, a
quasi-experimental study on the effects of Triple P level 3 showed
significant decreases in the emotional and behavioural problems of
children as well as effects on parental satisfaction, parental
efficacy and overall parental sense of competence. A randomised
controlled trial investigating the effects of parenting support
with Triple P level 3 after an evidence-based, initial screening on
psychosocial problems in children has not previously been conducted
and long-term follow-up data are currently not available.
1.6 rEsEarCH QuEsTions and ouTlinE of THis THEsis
To contribute to the knowledge on the relationship between
parenting, the family and child environment, and child problem
behaviour and parenting we collected data on:
child psychosocial problems; parenting competences; parenting
stress; and depression, anxiety and stress symptoms among
parents.
Chapter 2 presents the design of an effectiveness study on
Primary Care Triple P. It describes extensively the theoretical
background of Triple P, the main reason for this research, the
research question, the methods, the analyses, and the outcome
measures. Chapter 3 assesses how living in a deprived area affects
parenting stress; the aim of this study was to examine the impact
of area deprivation and urbanisation. Chapter 4 describes the
relationship between parental depression, anxiety, and stress and
child psychosocial problems. The objective here was to examine
the
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Introduction
association between parental internalizing problems (symptoms of
depression, anxiety and stress) and child psychosocial problems in
a community sample, crude and adjusted for potential confounders
(such as child gender, parental educational level, ethnicity) and
whether parental concerns affect this association. Chapter 5
presents the results of a randomized controlled trial on parenting
support. The objective of this study was to assess the
effectiveness of Primary Care Triple P level 3 (PCTP) compared with
care as usual (CAU) for parents of children with mild psychosocial
problems after an initial, evidence-based screening in routine
Preventive Child Healthcare. Chapter 6 presents the results of an
evaluation of the psychometric characteristics of a scale measuring
symptoms of depression, anxiety and stress among adult subjects in
a non-clinical population. Chapter 7 provides a summary of Chapters
3, 4 and 5 and a general discussion of the main findings and their
implications. Moreover, it addresses the question of whether
Primary Care Triple P (level 3) is a suitable intervention to be
adopted by the Dutch Preventive Child Healthcare and discusses the
most important findings of the trial. It also reviews the
challenges and (dis) advantages of conducting RCTs in PCH.
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Adolesc Health. 2010;46(2):189-196.
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link with children’s conduct problems? J Abnorm Child Psychol.
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prospects. Am Psychol. 1979;34(10):844-850.
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25. Chang L, Schwartz D, Dodge KA, McBride-Chang C. Harsh
parenting in relation to child emotion regulation and aggression.
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26. Fite PJ, Colder CR, Lochman JE, Wells KC. The mutual
influence of parenting and boys’ externalizing behavior problems.
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2006;27(2):151-164.
27. Baker BL, McIntyre LL, Blacher J, Crnic K, Edelbrock C, Low
C. Pre-school children with and without developmental delay:
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28. Sanders MR, Markie-Dadds C, & Turner KMT. Theoretical,
scientific and clinical foundations of the triple P-positive
parenting program: A population approach to the promotion of
parenting competence. Parenting Research and Practice Monograph.
2010;1:1-21.
29. Dishion TJ, Patterson GR. The timing and severity of
antisocial behavior: Three hypotheses within an ecological
framework. In: D. M. Stoff, J. Breiling, J. D. Maser, eds. Hoboken,
NJ, US: John Wiley & Sons Inc; 1997:205-217.
30. Irvine AB, Biglan A, Smolkowski K, Ary DV. The value of the
parenting scale for measuring the discipline practices of parents
of middle school children. Behav Res Ther. 1999;37(2):127-142.
31. Hakman M, Sullivan M. The effect of task and maternal
verbosity on compliance in toddlers. Infant and Child Development.
2009;18(2):195-205.
32. Fergusson DM, John Horwood L, Ridder EM. Show me the child
at seven: The consequences of conduct problems in childhood for
psychosocial functioning in adulthood. Journal of Child Psychology
and Psychiatry. 2005;46(8):837-849.
33. Reijneveld SA, Vogels AG, Brugman E, van Ede J, Verhulst FC,
Verloove-Vanhorick SP. Early detection of psychosocial problems in
adolescents: How useful is the Dutch short indicative questionnaire
(KIVPA)? Eur J Public Health. 2003;13(2):152-159.
34. Reijneveld SA, Wiegersma PA, Ormel J, Verhulst FC,
Vollebergh WAM, Jansen DEMC. Adolescents’ use of care for
behavioral and emotional problems: Types, trends, and determinants.
PLoS ONE 9(4): e93526. doi:10.1371/journal.pone.0093526. .
35. Crone MR, Bekkema N, Wiefferink CH, Reijneveld SA.
Professional identification of psychosocial problems among children
from ethnic minority groups: Room for improvement. J Pediatr.
2010;156(2):277-284.
36. Jaspers M, de Meer G, Verhulst FC, Ormel J, Reijneveld SA.
Limited validity of parental recall on pregnancy, birth, and early
childhood at child age 10 years. J Clin Epidemiol.
2010;63(1878-5921; 0895-4356; 2):185-191.
37. VWS. Basistakenpakket jeugdgezondheidszorg [basic task
package preventive child healthcare]. Ministry of Health, Welfare
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38. De Winter M, van Yperen T, van Zeben-van der Aa T, et al.
Een stevig fundament. evaluatie van het basistakenpakket
jeugdgezondheidszorg. [A solid foundation. evaluation of the basic
task package preventive child healthcare]. Groningen. 2013.
39. Goodman R. The strengths and difficulties questionnaire: A
research note. J Child Psychol Psychiatry. 1997;38(0021-9630;
5):581-586.
40. Goodman R. Psychometric properties of the strengths and
difficulties questionnaire. J Am Acad Child Adolesc Psychiatry.
2001;40(11):1337-1345.
41. SDQinfo.com Web site. http://www.sdqinfo.com/.
42. Crone MR, Vogels AG, Hoekstra F, Treffers PD, Reijneveld SA.
A comparison of four scoring methods based on the parent-rated
strengths and difficulties questionnaire as used in the Dutch
preventive child health care system. BMC Public Health.
2008;8(1471-2458):106.
43. Vogels AG, Crone MR, Hoekstra F, Reijneveld SA. Comparing
three short questionnaires to detect psychosocial dysfunction among
primary school children: A randomized method. BMC Public Health.
2009;9:489.
44. Muris P, Meesters C, van den BF. The strengths and
difficulties questionnaire (SDQ) - further evidence for its
reliability and validity in a community sample of Dutch children
and adolescents. Eur Child Adolesc Psychiatry. 2003;12(1):1-8.
45. Wilson JMG, Junger, G. Principles and practice of screening
for disease. Public health papers. 1968; No. 34.
46. Reid M, Webster-Stratton C, Hammond M. Follow-up of children
who received the incredible years intervention for
oppositional-defiant disorder: Maintenance and prediction of 2-year
outcome. Behav Therapy. 2003;34(4):471-491.
47. Webster-Stratton C RM. The incredible years parents,
teachers, and children training series: A multifaceted treatment
approach for young children with conduct problems. In: Kazdin AE
WJ, ed. Evidence-based psychotherapies for children and
adolescents. New York: Guilford Press; 2003:224-240.
48. Coyne J, Kwakkenbos L. Triple P-positive parenting programs:
The folly of basing social policy on underpowered flawed studies.
BMC Medicine. 2013;11:11.
49. McConnell D, Breitkreuz R, Savage A. Independent evaluation
of the triple P positive parenting program in family support
service settings. Child & Family Social Work.
2012;17(1):43-54.
50. Sanders MR. Triple P - positive parenting program: Towards
an empirically validated multilevel parenting and family support
strategy for the prevention of behavior and emotional problems in
children. Clin Child Fam Psychol Rev. 1999;2(1096-4037;
2):71-90.
51. Turner KMT, Sanders MR, Markie-Dadds C. Practitioner’s
manual for primary care triple P. Vol Reprinted version 2003.
Australian Academic Press, Brisbane; 1999.
52. De Graaf I, Speetjens P, Smit F, de Wolff M, Tavecchio L.
Effectiveness of the triple P positive parenting program on
parenting: A meta-analysis. Fam Relat. 2008;57:553-566.
53. De Graaf IM. Helping families change. the adoption of the
triple P - positive parenting program in the Netherlands. Trimbos
Institute, University of Amsterdam; Amsterdam; 2008.
54. Leung C, Sanders MR, Leung S, Mak R, Lau J. An outcome
evaluation of the implementation of the triple P-positive parenting
program in hong kong. Fam Proc. 2003;42:531-544.
55. Leung C, Fan A, Sanders MR. The effectiveness of a group
triple P with chinese parents who have a child with developmental
disabilities: A randomized controlled trial. Res Dev Disabil.
2013;34(3):976-984.
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Chapter 2The impact of area deprivation
on parenting stress
Willem SpijkersDaniëlle E.M.C. Jansen
Sijmen A.Reijneveld
European Journal of Public Health 2011;22(6):760-765.
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The impact of area deprivation on parenting stress
absTraCT
backgroundArea deprivation negatively affects health and
lifestyles, among which child behaviours. The latter may aggravate
the effects of area deprivation on parental health due to higher
rates of parenting stress. However, evidence on the influence of
the living environment on parenting stress is mostly lacking. The
aim of this study was to examine the impact of area deprivation and
urbanization on the occurrence of parenting stress.
methodsA cross-sectional multilevel study was conducted using
both neighbourhood- and individual-level data. Living areas were
categorised into tertiles of deprivation. Data on parenting stress
(Parenting Stress Index), child psychosocial problems (Strengths
and Difficulties Questionnaire) and family background were
collected among 9453 parents prior to a routine health examination
of their child (response: 65%).
resultsIn the deprived areas parents reported parenting stress
more often compared to the least deprived tertile (OR=1.23; 95 %
CI=1.04-1.46). Adjusted for child problem behaviour the association
decreases (OR=1.11; 95 % CI=0.92-1.34). A small clustering of
parenting stress by area was found which increased when child and
family characteristics were taken into account.
ConclusionParents from deprived areas were most likely to report
parenting stress. Differences by area deprivation were partially
accounted for by child problem behaviour and parental concerns
about the behavioural and emotional problems of the child. This
shows a rather large potential to improve both parental and child
health by targeted parenting support in deprived areas.
Key wordsParenting, poverty areas, urbanization, social behavior
disorders, multilevel analysis
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baCKground
Parenting stress is more likely to occur in deprived families.1
It has been linked to socioeconomic issues, family dysfunction and
lack of social support.2 Many parents encounter problems in rearing
their children. National population-based studies have revealed
that 36% to 58% of parents have concerns about parenting, child
behaviour or the development of their children in the previous
year. Parenthood was experienced as more difficult than expected by
48% of parents and 11% felt they were not up to parenting. As a
consequence, 60% of the parents with parenting concerns obtain
professional advice or help.3,4. High parenting stress negatively
influences child behaviour problems over time, while high child
behaviour problems increase parenting stress. Increased parenting
stress is particularly associated with externalising behaviour
problems in children.5,6
Child behavioural problems occur more frequently among young
adolescents in deprived areas than in favourable areas.7-10
According to a review on the influence of the neighbourhood context
on child and adolescent health, neighbourhood socioeconomic
characteristics explained 11% of the variation in child behavioural
problems.11 Area deprivation is considered to be an important
factor in explaining differences in population health and
lifestyles.12 It is associated with neighbourhood stressors such as
crime, housing density, poor housing quality, antisocial behaviour
due to alcohol and drug misuse, green area quality, and social
participation.13,14 Neighbourhood structural characteristics (e.g.
poverty and instability) could have a negative impact on collective
efficacy. Less social cohesion and informal social control may
result in less means to cope with parenting stress within families.
Moreover, the availability of social and material collective
resources (e.g. health services and amenities, and social support)
may protect against and solve parenting stress. The latter may be
available to a lesser degree in deprived areas. 15 Therefore,
consistent with child problem behaviour, parenting stress is also
likely to occur more often in deprived areas.
To date, no research has been conducted on whether area
deprivation has an independent effect on parenting stress over and
above the effect of individual-level variables. Earlier research
mainly focused on the effects of area deprivation on health and
lifestyle outcomes in urbanised areas. The impact of area
deprivation in urbanised area might be differ between rural and
urban regions, e.g. in urban areas the high population density may
aggravate the accumulation of problems, whereas this would be less
the case in rural areas.16,17 However, research has demonstrated
that the relationship between child behavioural problems and area
deprivation do not differ in mixed urban and rural areas.10 Whether
urbanization modifies the effect of area deprivation on parenting
stress remains unknown.
The aim of this paper is to assess the impact of area
deprivation and urbanization on the occurrence of parenting stress.
Furthermore, the contribution of child and family factors to these
differences will be evaluated.
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The impact of area deprivation on parenting stress
mETHods
Procedure and sampleData were collected during the 2008–2009
school year within a preventive child healthcare (PCH) setting,
which is offered periodically and free of charge to all Dutch
children. Three PCH organisations covering three provinces in the
north of the Netherlands (i.e. Drenthe, Fryslân and Groningen)
participated in the study. The birth cohort size of primary school
children in the study area was 19,176. Although it is not
obligatory, more than 95% of the parents visit the well-child
clinics.
Along with the invitation for a routine health examination by
the PCH, a random sample of 14 648 parents of children aged 9-11
years received a screening questionnaire on parenting stress and
child psychosocial problems; in a next step, they were offered
parenting support in case of problems, as part of a randomised
controlled trial on its effectiveness.18 We obtained
cross-sectional data from 9453 parents (response: 65%). The
participating parents and children did not substantially differ
from the total population regarding family composition, work
situation of the parents, and child gender. However, immigrant
children were under-represented and highly educated parents were
over-represented in the sample.19 The study was approved by the
local Medical Ethical Committee.
measuresArea deprivation was measured by the national area
deprivation score per neighbourhood as published by the Dutch
Social and Cultural Planning Office10,20 This score was based on
unemployment, mean income and educational level per area. For the
current study, the 2006 values for the summary factor were used. To
assess the occurrence of parenting stress across the entire range
of area deprivation areas were categorized into tertiles of
deprivation: least deprived, medium deprived and most deprived
(Table 2). Urbanization was determined by the number of residential
addresses within 3.14 square kilometres (i.e. by drawing a circle
with a radius of one kilometre around each address). 21 Following
the guidelines of Statistics Netherlands, the threshold was set at
over 1000 being urban, with the rest rural. Parenting stress was
measured using a subscale of the Dutch Parenting Stress index
(PSI). 22 Eleven items on parenting-related depression and stress
(Cronbach’s α =.73) were scored on a six-point scale (1=totally
disagree, 2=disagree, 3=slightly disagree, 4=slightly agree,
5=agree, and 6=totally agree). A sum score (range 0–66) was
dichotomised at the 90th percentile.
Psychosocial problems in children were measured by the Strengths
and Difficulties Questionnaire (SDQ) 23 (Cronbach’s α =.82). This
version of the SDQ has been validated in the Netherlands 24,25 for
children aged 7 to 12. The questionnaire consists of 25 symptom
items describing positive and negative aspects of child behaviour
that can be allocated to 5 subscales of 5 items each: emotional
symptoms, conduct problems, hyperactivity-inattention, peer
problems, and pro-social behaviour. Each item has to be scored on a
3-point scale (0=‘not true’, 1=‘somewhat true’, and 2=‘certainly
true’). A total SDQ Total Difficulties Score (TDS) can be
calculated by aggregating the scores for the first four subscales
(range 0–40).
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Relevant child background characteristics concerned parental
concerns about child behavioural and emotional problems (yes/no),
psychosocial problems in at least one of the parents (yes/no), the
country of birth of the child (Dutch, Non-Dutch), parental
educational level (highest degree obtained by each parent),
employment (at least one of the parents working more than 12 hours
a week), financial situation (difficulties with managing income),
family composition (two or single parent family) and family size (5
members or more).
data analysesIn the analyses, we first assessed differences in
the occurrence of parenting stress by background. Multilevel
techniques, using ML Win 2.20, were applied to assess the degree of
clustering by area.26 The levels concerned were child and area. We
fitted these two-level models with a random intercept for each
neighbourhood to examine the associations between area deprivation
and parenting stress before and after adjusting for
individual-level child and family characteristics and
socio-demographic variables. To estimate the size of the area-level
clustering, the intraclass correlation (ICC) and the median odds
ratio (MOR) were computed. The MOR quantifies the variation between
clusters (the second-level variation) by comparing two persons from
two randomly chosen, different clusters. It shows the extent to
which the individual probability of having parenting stress is
determined by residential area. If the MOR is 1, there is no
area-level variation. A high MOR means considerable inter-cluster
variation.27
2
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The impact of area deprivation on parenting stress
rEsulTs
The data concerned 9453 children living in 735 areas. In
comparison with the mean socioeconomic (SE) position of the
Netherlands, the SE position of the study region was unfavourable.
Mean area deprivation in the study region was .37 (SD=.91) compared
with .00 (SD=1.00) for the Netherlands as a whole. Of the sample,
76.4% lived in rural areas, with the rest living in urbanised
areas. The questionnaire was completed by the child’s primary
caregiver or givers: 77.8% were mothers, 7.1% were fathers, and
13.8% of parents completed the questionnaire together. The
remaining caregivers (0.3%) were classified as ‘other relatives’ of
the child and 0.8% of the respondents did not specify their
relationship with the child. The mean age of the children concerned
was 10.13 (SD=.776), 50.2% were female, 10.2% of the children were
part of a single-parent family, 98.2% were born in the Netherlands,
and 90.9% of the children had both parents born in the Netherlands.
The distribution of most child and parent background
characteristics, including child psychosocial problems, was less
favourable in deprived areas (Table 1).
Table 1 | Distribution of various child background
characteristics by levels of area deprivation.
Most deprived Medium deprived Least deprived P-value
N % N % N %
All childrena 3185 33.7 3147 33.3 3121 33.0
Mean age (SD) 10.15 (0.81) 10.09 (0.77) 10.16 (0.75) .001b
Gender .021c
Male 1632 51.4 1505 47.9 1564 50.2
Female 1546 48.6 1636 52.1 1554 49.8
Family composition < 0.0001c
Two parents 2625 83.4 2706 86.5 2732 88.2
Single parent 396 12.6 314 10.0 247 8.0
Co parentsd 59 1.9 65 2.1 70 2.3
Two parents of the same sex 8 0.3 6 0.2 2 0.1
Other 59 1.9 36 1.2 45 1.5
Education level mother < 0.0001c
Low 1063 34.7 865 28.4 603 19.8
Medium 1408 45.9 1451 47.6 1360 44.6
High 595 19.4 735 24.1 1084 35.6
Education level father < 0.0001c
Low 1006 35.7 893 31.1 585 20.1
Medium 1180 41.9 1150 40.1 1104 38.0
High 630 22.4 824 28.7 1216 41.9
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Most deprived Medium deprived Least deprived P-value
N % N % N %
Parental employment < 0.0001c
At least one parent > 12 h/week 2626 95.8 2737 97.5 2805
98.2
No parent employed > 12 h/week 114 4.2 71 2.5 52 1.8
Ethnic background .172c
Dutch 3071 97.9 3070 98.4 3046 98.4
Non-Dutch 67 2.1 50 1.6 49 1.6
Child psychosocial problems < 0.0001c
No problems 2412 81.0 2466 83.8 2458 86.0
Sub clinical (SDQ ≥ 11 and
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The impact of area deprivation on parenting stress
All PSI(>p90) P-value
All childrena N n %
Co parents 187 18 9.6Two parents of the same sex 15 1 6.7Other
133 13 9.8
Education level mother 8817 < 0.0001b
Low 2411 321 13.3Medium 4063 484 11.9High 2343 168 7.2
Education level father 8260 < 0.0001b
Low 2353 296 12.6Medium 3323 376 11.3High 2585 213 8.2
Parental employment 8086 0.157b
At least one parent > 12 h/week 7871 825 10.5No parent
employed > 12 h/week 215 29 13.5
Ethnic background 8962 0.001b
Dutch 8810 973 11.0Non-Dutch 152 30 19.7
Area deprivation 9045 0.035b
Least deprived (< 0.065) 3022 301 10.0Medium deprived
(>0.065 – 0.075) 3004 346 11.5Most deprived (> 0.075) 3019
361 12.0
Urbanisation (number of inhabitants per km2) 8975 0.680b
Very urbanised (> 2.500) 432 51 11.8Urbanised (1.500 – 2.499)
554 52 9.4Mixed (1.000 - 1.499) 1122 130 11.6Rural (500 – 999) 2386
262 11.0Very rural (0 – 499) 4481 506 11.3
Child psychosocial problems 8425 < 0.0001b
No problems 7054 545 7.7Sub clinical (SDQ ≥ 11 and
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33
Multilevel logistic regression analyses revealed that the
prevalence rate of parenting stress increased by area deprivation
(Table 3). Parenting stress was reported statistically
significantly more often in the most deprived areas (Table 1).
After adjustment for child psychosocial problems (SDQ), the
relationship between parenting stress and area deprivation lost its
statistical significance. The impact of area deprivation on
parenting stress further decreased after adjustment for parental
concerns about child behavioural and emotional problems. Adjustment
for other individual-level factors of importance, i.e. psychosocial
problems of the parents, large family size, low educational level
of the mother, and child immigrant, showed no further decrease of
the impact of area deprivation on parenting stress. .
MOR indices showed a relatively small clustering by area, but
the MOR increased when factors at the individual level,
particularly child problem behaviour, were added. Urbanization did
not modify the effect of area deprivation on changes in parenting
stress. Thus, the impact of area deprivation on parenting stress
did not vary between urban and rural areas.
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The impact of area deprivation on parenting stress
Table 3 | Occurrence of parenting stress: Odds ratios (OR) and
95% confidence intervals (CI) derived using multilevel logistic
regression
Empty model Area deprivation (AD) Background (BG) AD+BG
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Area deprivation *
Least deprived 1.00 ref 1.00 ref
Medium deprived 1.18 1.00 - 1.40 1.08 0.87 -1.33
Most deprived 1.23 1.04 - 1.46 0.99 0.81 -1.23
Score on the SDQ **
Normal 1.00 ref 1.00 ref
Sub clinical 2.02 1.55 - 2.63 2.02 1.55 - 2.63
Clinical 3.48 2.78 - 4.36 3.49 2.79 - 4.37
Concerns about child behavioural problems (yes vs. no)
2.38** 1.97 - 2.80 2.40** 1.97 - 2.93
Concerns about child emotional problems (yes vs. no)
1.41** 1.16 – 1.73 1.42** 1.16 - 1.73
Psychological problems parent
2.41** 1.98 – 2.93 2.40** 1.67 - 3.44
Large family size (> 5 persons)
1.20* 1.02-1.42 1.20* 1.02 - 1.41
Education level mother *
Low 1.00 ref 1.00 ref
Medium 0.96 0.80 - 1.16 0.96 0.80 - 1.16
High 0.57** 0.45 - 0.72 0.57** 0.45 - 0.72
Child immigrant 2.04* 1.23 - 3.39 2.05* 1.23 - 3.39
Urbanization 1.07 0.87 - 1.30 1.06 0.86 - 1.29
Area level variance (SE) 0.031 (0.030) 0.024 (0.029) 0.050
(0.044) 0.048 (0.043)
MOR 1.182 1.160 1.238 1.231
ICC 0.009 0.007 0.015 0.014
a Parental concerns about child behavioural problems and child
emotional problemsSDQ, Strengths and Difficulties Questionnaire;
Ref, reference category; SE, standard error; MOR, median odds
ratio; ICC, intraclass correlation coefficient.* p
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35
disCussion
This study showed that parents in deprived areas more frequently
have parenting stress than parents in more favourable areas.
Urbanization had no effects on the relationship between area
deprivation and parenting stress. Parenting stress in the medium
and most deprived areas differed from the least deprived areas.
Furthermore, there was some clustering of parenting stress by area
though not statistically significant. This might suggest that the
context of these areas contributes to parenting stress.
Area-clustering increased when child and family characteristics
were taken into account, but changes is in the MOR were small and
likely to be due to chance variation. The prevalence of both
parenting stress and child psychosocial problems is higher in
deprived areas. Child problem behaviour and parenting stress were
associated and parents of children with an SDQ score in the
clinical range were most likely to report parenting stress. Child
problem behaviour and parental concerns about their behavioural and
emotional problems explained a substantial part of the differences
due to area deprivation on parenting stress.
This study is among the first to examine whether area
deprivation affects the occurrence of parenting stress. The results
of this study are in line with other studies of the significance of
area deprivation on, for instance, child behavioural problems7-9
and health risk behaviour in general14,28,29. In the present study,
child psychosocial problems accounted for variance in parenting
stress more than neighbourhood-level factors did. This supports the
hypothesis that parenting stress is mainly caused by child problem
behaviour.5,30 The importance of information on parental concerns
about child behavioural and emotional problems has been emphasized
before in earlier research31,32. Agreeing with a study on the
impact of area deprivation on behavioural problems of adolescents
in the north of the Netherlands10, this study found no differential
effect of the level of area deprivation due to urbanization. This
indicates that the effects of area deprivation impact on urban and
rural areas, but this does not exclude the possibility that the
routes to these effects differ by degree of urbanization. For
instance, in urbanised areas a high density of problems could
amplify these effects, whereas decreasing population sizes could
play the same role in rural areas. Apparently, this requires
additional study. The study region did not include the four largest
Dutch agglomerations. This may have affected our findings since the
scale and nature of area deprivation in big agglomerations may
differ from that in provincial towns. However, earlier research
showed that differences by area deprivation in prevalence rates of
child psychosocial problems did not vary between urban and rural
areas.9,10
Interestingly, adjustment for individual-level factors, in
particular child problem behaviour, did increase area clustering,
while the association between area deprivation and parenting stress
diminished. This suggests that variation by to area deprivation is
largely explained by individual child characteristics. Area effects
are not necessarily due to the characteristics of an area but may
be connected to the people with similar health and lifestyles
actually living in these areas (social selection).33
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The impact of area deprivation on parenting stress
Area deprivation was associated with parenting stress but the
association of area deprivation with child psychosocial problems
was stronger (Table 3).A possible interpretation is that
neighbourhood-level factors in deprived areas buffer the effect of
child problems on the parenting experience. At the community level,
social support and social cohesion could result in a lower
likelihood of disorder in an area.34 Since these mechanisms are
mostly associated with affluent areas, this is unlikely.
A lack of institutional resources owing to geographic variations
in the availability of institutional resources, e.g. (mental)
health services, may contribute to area differences in health and
lifestyle.16 However, in the Netherlands, well-child care clinics
are freely accessible to all parents and children, which could
affect the experienced levels of parenting stress. Within this
setting, increasing attention is paid to parenting problems and
parenting support particularly targets groups with low
socioeconomic status.35 Further exploration of buffering mechanisms
in relation to parenting stress in deprived areas is needed.
People living in deprived areas have to cope with a variety of
everyday concerns, such as limited means and more negative life
events (e.g. unemployment, divorce, isolation).36 Parenting stress
could be a minor concern but also an additional cause of shame. In
addition, norms and collective efficacy in child rearing or
managing child problem behaviour could be insufficient in deprived
areas (e.g. a lack of social control and disapproval of antisocial
behaviour).16 Parents living in these areas may feel that their
situation does not deviate from the norm because neighbours
encounter similar parenting problems. Thus, parents in deprived
areas may experience relatively less stress given a certain level
of child problems since these problems do not seem to exceed the
problems that their neighbours face with their children (i.e. the
area norm regarding child psychosocial problems). This process
similar then resembles that of not feeling poor when everyone is
poor, i.e. people assessing their relative deprivation. Moreover,
norms regarding parenting stress and child problem behaviour in
deprived areas could be different from scientific or professional
standards. Future research is required to explore parental norms
regarding child rearing and managing child problem behaviour in
deprived areas.
study strengths and limitationsThis study’s large sample size
and high response rate were important strengths. Comparison of the
demographic characteristics of the participating parents and
children with normative population data showed no significant
differences for child and parent factors.
A limitation is that the data on differences between
neighbourhoods was limited to the deprivation score and the degree
of urbanization. We did not have information on neighbourhood
stressors, mediating factors, and norms and attitudes concerning
parenting and parenting stress.16,37,38 Future research should
include these factors since they might play an important buffering
role in the relationship between area deprivation and parenting
stress, possibly leading to an underestimation of the prevalence of
parenting stress. Furthermore, parent-reported child psychosocial
problems may be influenced by the emotional state of the parent.
Earlier research
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37
among distressed parents showed a discrepancy between the number
of parent-reported child psychosocial problems and the children’s
self-report.39 Multi-informant assessments of child psychosocial
problems (e.g. by CHP’s and teachers) in future research may
provide evidence on whether such information bias indeed
occurs.
study implicationsThis study reveals differences in the
occurrence of parenting stress by area deprivation irrespective of
the degree of urbanization. Child health professionals aiming at
the reduction of parenting stress should be sensitive to the
problems and concerns of the parents, as well as to child problem
behaviour in both urbanised and rural deprived areas. Screening for
child psychosocial problems is often a part of routine well-child
care clinics by child health professionals (CHPs). This offers an
ideal opportunity to verify the latent presence of related
parenting stress. To this end, reliable and valid instruments to
identify suspected parenting stress or the need for parenting
support are required, as well as evidence-based parenting support
interventions.
Prevention does not only concern child healthcare. Since
stress-buffering mechanisms are likely to manifest themselves at
the neighbourhood level, public policies concerned with the social
and physical environment of residents (e.g. social welfare, justice
and safety, infrastructure and the environment) can also play an
important role.40 Community-based interventions could be the most
efficient and should not only target individuals but also their
social context. A community approach requires accurate mapping and
knowledge of the characteristics of deprived areas. Properly
targeted interventions could contribute to reducing the burden of
disease due to parenting stress and related child psychosocial
problems. This study shows great potential to improve both parental
and child health in this way.
aCKnowlEdgEmEnTs
This project was carried out in close collaboration with PCH
organisations in the northern part of the Netherlands. We are
grateful to the PCH organisations, child health professionals, and
the parents who participated in this research and to everyone who
worked on this project and made it possible.
funding
This work was supported by The Netherlands Organisation for
Health Research and Development (ZonMw) [50-50110-96-412].
Conflicts of interests: None declared.
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38
The impact of area deprivation on parenting stress
KEyPoinTs
• Parenting stress occurs more frequently in deprived areas.
• Differences in rates of parenting stress by area deprivation
are partially accounted for by child problem behaviour and parental
concerns.
• The impact of area deprivation on parenting stress is similar
in urban and rural areas.
• Both parental and child health may be improved by parenting
support in deprived areas.
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39
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concerns about their child’s behavior. Clin Pediatr (Phila).
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32. Glascoe FP, Altemeier WA, MacLean WE. The importance of
parents’ concerns about their child’s devel-opment. Am J Dis Child.
1989;143(8):955-958.
33. Drukker M, Kaplan C, Feron F, van Os J. Children’s
health-related quality of life, neighbourhood so-cio-economic
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2003;57(5):825-841.
34. Stockdale SE, Wells KB, Tang L, Belin TR, Zhang L,
Sherbourne CD. The importance of social context: Neighborhood
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mental health disorders. Soc Sci Med. 2007;65(9):1867-1881.
35. Rots C. Rich evidence for poor families. exploring the
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37. Mair C, Diez Roux AV, Morenoff JD. Neighborhood stressors
and social support as predictors of depres-sive symptoms in the
chicago community adult health study. Health Place.
2010;16(5):811-819.
38. Drukker M, van Os J. Mediators of neighbourhood
socioeconomic deprivation and quality of life. Soc Psychiatry
Psychiatr Epidemiol. 2003;38(12):698-706.
39. Canning EH, Hanser SB, Shade KA, Boyce WT. Maternal distress
and discrepancy in reports of psychopa-thology in chronically ill
children. Psychosomatics. 1993;34(6):506-511.
40. Green J. Public health and health promotion. In: Scambler G,
ed. Sociology as applied to medicine. Sixth ed. London: Saunders,
Elsevier; 2008:283-295.
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Chapter 3Parental internalizing
problems in a community sample: association with child
psychosocial problems
Willem SpijkersDaniëlle E.M.C. Jansen
Sijmen A. Reijneveld
The European Journal of Public Health 2013;24(1):11-15
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Parental internalizing problems in a community sample:
association with child psychosocial problems
absTraCT
backgroundOffspring of depressed, anxious and stressed parents
are at increased risk of developing mental disorders. However, most
studies investigating this association concentrate on clinical
symptoms. The objective of this study is to examine the association
between parental internalizing problems (symptoms of depression,
anxiety and stress) and child psychosocial problems in a community
sample, crude and adjusted for potential confounders (such as child
gender, parental educational level, ethnicity) and whether parental
concerns affect this association.
study designPreceding a routine health examination,
cross-sectional data were obtained from a representative sample of
9453 parents of children aged 9–11 years (response 65%). Measures
of parental internalizing problems (Depression Anxiety Stress
Scale), child psychosocial problems (Strengths and Difficulties
Questionnaire – Total Difficulties Score), background
characteristics, and parental concerns were completed by the
parents.
resultsParental internalizing problems were associated with
child psychosocial problems in crude analysis and after adjustment
for child, parent, and family characteristics (β =.12, 95%
Confidence Interval (CI) = .10 – .14). Parental concerns about
their child’s emotional and behavioural problems were also strongly
associated with child psychosocial problems. After adjustment for
these parental concerns, the association of parental stress with
child psychosocial problems remained, while the association of
parental depression and anxiety symptoms with child psychosocial
problems lost statistical significance.
ConclusionsAs in clinical samples, parental internalizing
problems in a community sample are associated with child
psychosocial problems. Parental concerns on the child seem to
affect this association. Further research is needed on the
mechanisms affecting this association.
KeywordsSocial behaviour disorders, depression, anxiety, stress,
family health
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baCKground
Many clinical studies have shown that offspring of depressed,
anxious and stressed parents are at risk of a spectrum of
psychopathological disorders. Parental depression and stress are
not only associated with affective disorders and attention deficit
disorders, but also with substance abuse, poor social functioning
and school problems (e.g. attention problem, learning disabilities)
in children.3,4 Furthermore, these children are at increased risk
of neglect and abuse.5-7 Offspring of anxious parents are more
likely to have anxiety disorders.1,2 Depression and anxiety occur
most frequently from the ages of 25 to 44 years8,9, the stage of
life at which most adults become parents. It is therefore not
surprising that internalizing problems in parents are not uncommon.
Moreover, the levels of depression, anxiety and psychological
stress are higher among parents with children living at home than
in non-parents.10
Most research on the impact of parental mental health problems
on child psychosocial problems has been conducted in clinical
samples, particularly among parents with diagnosed mental
problems.1,3,4 However, depression and anxiety can be considered as
disorders that vary along a continuum of severity.11 It is not
known whether parental internalizing problems below the clinical
threshold are associated with child psychosocial problems. As such,
it may be useful to assess symptoms of depression, anxiety and
stress in non-clinical populations of parents.
Research using clinical samples suggests that several factors
affect the association between parental mental health problems and
child psychosocial problems, the most important being that parents
are overly concerned for their child.12 Parental concerns about the
behavioural and emotional problems of their child have been proven
to have a positive predictive power for child psychosocial
problems13,14, and anxious parents are more concerned about their
child’s wellbeing.15 Again, it is unknown whether this link holds
for sub-threshold parental problems in the community.
Finally, various demographic and family characteristics have
been shown to affect both psychosocial problems in children and
parental internalizing problems. Therefore, these characteristics
may be confounders affecting the association. For example, risk of
psychosocial problems in children was higher for children who
recently experienced a negative life event, such as parental
unemployment or parental divorce or separation.16 Children growing
up in families at a socioeconomic disadvantage or in single-parent
families were also more likely to develop child psychosocial
problems.17 Marital problems, unemployment and a low socioeconomic
position also increased the chance of internalizing problems in
adults.18,19 Furthermore, higher rates of psychosocial problems
were found in boys20, among immigrant children and adults21-24, and
in children with a chronic illness.25,26 Compared with parents of
healthy children, parents of children with chronic illness scored
higher for internalizing problems.27
The aim of this study is to examine the association between
parental internalizing problems (depression, anxiety and stress)
and child psychosocial problems in a community sample, crude and
adjusted for background characteristics, and to assess to what
extent parental concerns affect this association.
3
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46
Parental internalizing problems in a community sample:
association with child psychosocial problems
mETHods
Procedure and sampleData were collected as part of the routine
preventive health assessments which all Dutch children periodically
undergo. Primary school children were screened for physical and
psychosocial problems. Along with an invitation for a preventive
health examination, all parents of children aged 9–11 years
received a questionnaire on symptoms of depression, anxiety and
stress and on the psychosocial problems of their children. There
were no exclusion criteria. Data were obtained from 9,453 parents
(response rate: 65%). Participating parents and children did not
substantially differ from the Dutch general population with regard
to family composition, work situation of the parents and child
gender. However, highly educated parents were over-represented and
immigrants were slightly under-represented in the sample.28 The
study was approved by the local Medical Ethical Committee.
measuresChild psychosocial problems were measured by the
Strengths and Difficulties Questionnaire Total Difficulties Score
(SDQ-TDS).29,30 This questionnaire has been validated in the
Netherlands31,32 for children aged 7–12 years. The SDQ consists of
25 symptom items describing positive and negative aspects of child
behaviour which are scored on a three-point scale (0 = ‘not true’,
1 = ‘somewhat true’ and 2 = ‘certainly true’). Scores can be
allocated to five subscales of five items each: emotional symptoms,
conduct problems, hyperactivity, inattention, peer problems and
pro-social behaviour. The SDQ Total Difficulties Score (SDQ-TDS,
range 0–40) is the sum of the scores on all subscales except the
pro-social behaviour subscale; its internal consistency in the
current study was good (Cronbach’s alpha .82).
Parental internalizing problems were measured by the 21-item
Depression Anxiety Stress Scale (DASS)11. The DASS-21 consists of
three subscales of seven items each: a depression scale, an anxiety
scale and a stress scale (Cronbach’s alphas were .83, .76 and .84,
respectively, and .90 for the total score). Participants reported
the extent to which they had experienced each symptom over the
previous week on a four-point Likert scale ranging from 0 (did not
apply to me at all) to 3 (applied to me very much, or most of the
time).
Parents provided information on relevant child background
characteristics, i.e., ethnicity (country of birth of the parents
and the child), parental educational level (highest degree obtained
by each parent) on an eight-point scale arranged in hierarchical
order from 0 (no education) to 7 (university). As the association
of parental educational level with child psychosocial problems was
rather linear, we used this a continuous variable with seven
levels. Parental employment status was measured for each parent and
categorized as employed (paid job for > 12 hours/week) or else
unemployed, voluntary work or paid job < 12 hours/week. The
family financial situation was assessed by the degree to which
parents were ‘able to make ends meet’ (0 = no difficulties, 1 = no
difficulties, but thrifty, 2 = moderate difficulties, 3 = severe
difficulties). Respondents were asked to report the family
composition (two- or single-parent family) and the current age of
both parents.
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47
Finally, parents indicated their concerns about their child’s
behavioural and emotional problems by selecting one of three
categories (0 = not at all, 1 = only a little, 2 = quite a
lot)13.
data analysesWe first assessed differences in child psychosocial
problems by background characteristics; differences were tested
using Student’s t-tests, and F-tests in an analysis of variance
(ANOVA). Next, we computed Pearson’s correlation coefficients
between parental Depression-, Anxiety-, and Stress and child
psychosocial problems. Subsequently, multiple linear regressions
were conducted to model this relationship. In a second model, we
adjusted for a broad range of background characteristics
traditionally considered to be relevant in predicting a high risk
of child psychosocial problems and parental internalizing problems.
In the third model, parental concerns about child emotional and
behavioural problems were added to the analyses. Additionally, the
DASS total scale was replaced by the DASS subscales. Data were
analysed using the Predictive Analytics SoftWare (PASW) Statistics,
version 18.0.3.
rEsulTs
Of the 9453 questionnaires, most were completed by mothers
(77.8%), 7.1% by fathers, 13.8% by both parents jointly and 1.1% by
other relatives or unknown. The mean age of the participating
parents was 42.10 (SD = 4.69) years. The mean age of the children
concerned was 10.13 (SD = 0.77) years. Further demographic
information is presented in Table 1. In general, boys had higher
mean psychosocial problem scores than girls. Children with less
favourable background characteristics had higher mean psychosocial
problem scores (Table 1).
Table 1 | Distribution of family, parent and child
characteristics and mean SDQ-TDSa
nb % mean sdQ-Tds
sdc p-valued
Gender child 8763 < .0001
Male 4325 49.4 6.7 5.4
Female 4438 51.6 6.6 4.8
Child immigrant 8689 < .05
Yes 153 1.8 7.2 5.6
No 8536 98.2 6.1 5.1
Education level mother 8518 < .0001
Low 2351 27.6 7.2 5.5
Medium 3912 45.9 6.0 5.0
High 2255 26.5 5.2 4.7
3
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48
Parental internalizing problems in a community sample:
association with child psychosocial problems
nb % mean sdQ-Tds
sdc p-valued
Education level father 7981 < .0001
Low 2313 29.0 7.0 5.4
Medium 3184 39.9 6.0 5.0
High 2484 31.1 5.2 4.7
Employment mother 8523 < .0001
Yes 6660 78.1 5.9 5.0
No 1863 21.9 6.9 5.7
Employment father 7943 < .0001
Yes 7496 94.4 5.9 5.0
No 447 5.6 7.4 6.1
Family financial situation (making ends meet) 8523 <
.0001
No difficulties 4474 52.5 5.4 4.7
No difficulties, but thrifty 3221 37.8 6.6 5.3
Moderate difficulties 683 8.0 8.3 5.8
Severe difficulties 145 1.7 8.9 5.7
Family composition 8706 < .0001
Two parents 7498 86.1 5.93 5.0
Single parent 883 10.1 7.78 5.7
Other 325 3.8 6.6 4.9
Chronic illness child 8628 < .001
Yes 827 9.6 9.5 6.9
No 7801 90.4 5.8 4.8
Recent divorce parents 8382 < .0001
Yes 228 2.7 8.4 5.9
No 8154 97.3 6.0 5.0
a SDQ-TDS = Strengths and Difficulties Questionnaire – Total
Difficulties Score b Totals differ due to missing data c SD =
Standard deviation d T-Tests and F-tests in analysis of variance
ANOVA regarding (mean) differences by SDQ-TDS
The univariate correlations between the scores on the DASS total
scale and the Depression-, Anxiety-, and Stress subscales and child
psychosocial problems (SDQ-TDS) were .27, .21, .19 and .27
respectively (all p < .001).
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Linear regression analysis showed that parental internalizing
problems were associated with psychosocial problems i