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Parenting and child psychosocial problemsSpijkers, Willem

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Parenting and child psychosocial problemsEffectiveness of parenting support in Preventive Child Healthcare

W. Spijkers


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


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


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


ParanimfenErnst de Klerk Aäron Gudema


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


AbbreviAtions


10

Abbreviations


11

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]


Chapter 1Introduction


14

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.


15

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

1


16

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


17

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.

1


18

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


19

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

1


20

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.


21

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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.

1


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.


26

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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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).


29

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

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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


31

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


32


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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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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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


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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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


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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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.


39

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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.

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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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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

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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

university of groningen parenting and child psychosocial … · 2016. 3. 9. ·...

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