Supporting parents is seen mainly within UK practice as the role of specific community workers, such as health visitors, school nurses and social workers. The families that are known to these services have often experienced long-term difficulties and been in contact with many other health professionals before intervention starts. There is an ever-increasing need for parenting interventions to support children and families across all settings. The year-on-year rise in children and young people with poor mental health, and those who demonstrate dysfunctional behaviours and crime, evidence the need for early help by all professionals in contact with families. Nurses and healthcare practitioners across all areas of practice are able to contribute to the welfare of children, families and society by having increased awareness of who can provide support and how. Recognising early signs of negative parenting practices, offering guidance and referring for early help with parenting interventions may help address the difficulties within some families at the outset, and establish a culture of making every contact count.
Why a nurse's role?
Although it is recognised that community healthcare practitioners are often the professionals who are at the forefront of community interventions that support parenting, all healthcare workers will at some time in their careers come into contact with children and families. In order to develop systems that encourage better outcomes for all and provide early intervention, all professionals should be equipped with skills that can share positive parenting to families at every contact—whether this be a brief intervention, such as asking how parents manage, or a targeted support programme. Nurses should be able to observe the interaction of parents and children, assess the quality of this relationship and ascertain whether the child and parent appear to function together or independent from each other (Park et al, 2016).
Research into child behaviours has long focused on approaches to parenting and how the patterns formed from infancy shape the future of a child's brain development, creating pathways that will be embedded through childhood and adult life (Bowlby, 1988; Shapiro and White, 2014, Shaffer et al, 2019). Parenting is not simple, it is a social activity without which children would be unable to form secure attachments, develop stable emotions and be able to function well as a child and adult (Barrett, 2006). Bowlby (1988) identified that without sufficient attachment from parents, children were less likely to be socially compliant and more prone to a life of negative behaviours.
Ziv et al (2004) expressed that if parenting was suboptimal, with unclear boundaries and guidance, and home life did not provide positive meaningful interactions, children would replicate these experiences outside the home and be unable to conform to societal expectations. Parents are key to meeting a child's needs in every aspect of childhood, infancy through to adulthood (Thompson, 2000). Parents and caregivers are essential in meeting basic needs of food and shelter. Parents are also crucial to the child's need for warmth, comfort, reassurance, advice, friendship, practical and material support.
Parenting styles and strategies vary tremendously across different ethnic, cultural and environmental backgrounds. There is no universal approach to parenting that would be accepted across all domains. However, it is well established how parenting affects children's development and offers lifelong skills and practices that not only influence a child's life, but also how they function in society and how they will themselves parent (Dwivedi, 1997; Crittenden, 2004; Barrett, 2006; Shapiro and White, 2014). Parenting is a complex, often challenging, process that requires education, patience, dedication and commitment in order to produce children who are emotionally, physically and psychologically stable; children who are able to adapt to a changing society and feel confident in their ability, whatever they choose to do.
The need for strong and positive attachments, love and boundaries has been explored in children across all age spectrums. It has been recognised that from conception to adulthood, parents and caregivers are the single most influential and important element to producing secure and emotionally stable young people, with skills that they develop in their transition into adulthood (Klein et al, 2016; Schweizer et al, 2018; Shaffer et al, 2019).
The parent–child relationship
When the quality of the child–parent relationship is affected, children have difficulties forming positive connections, often seeking reassurance and guidance from external sources. This can result in disruptive and challenging patterns of behaviour. Professionals who come into contact with children and families need to be able to recognise when positive and negative behaviours are evident. A nurse has responsibilities in providing holistic care (Nursing and Midwifery Council, 2018), which includes emotional wellbeing. Children's experience of parenting affects all areas of their cognitive and psychological development (Park et al, 2016).
Table 1 identifies key non-verbal and verbal cues of positive parenting. Although not exhaustive, these characteristics should be part of the normal relaxed interaction in the parent–child dyad.
| Parent | Child |
|---|---|
| Lots of eye contact with child | Eye contact with parent |
| Touches, strokes and hugs child | Seeks comfort |
| Observing/watching | Stays close to parent |
| Listens to child |
Talks to parent |
| Concerned over child's welfare |
Notices parents' movements and interactions |
| Notices if child is hungry/thirsty and seeks to resolve this | Does not need to repeatedly ask for food or drink |
| Gives praise and reassurance | Smiles and accepts praise |
Source: Crittenden, 2004; Barrett, 2006
Table 2 outlines some interactions that should raise professional curiosity and elicit a need for further assessment. Although this is not a comprehensive list, consideration is required for intervention when more than one trait is evident. Each behaviour can rarely be considered a concern independently of other factors, however, the presence of such characteristics should encourage health professionals to be alert to the quality of parent–child interaction in that environment and instigate professional curiosity to seek further information or refer to another childcare professional (Neville et al, 1995; Dwivedi, 1997; Davis and Lebloch, 2013). Although it is clear within safeguarding policy (Department for Education (DfE), 2018) that safeguarding referrals do not require parental consent because the safety of a child is paramount, this would always be good practice. In all referrals for early help and parenting support parents or caregivers must be informed and in agreement.
| Parent | Child |
|---|---|
| Lack of awareness of child's safety/nriovements | Child running around unfamiliar area unsupervised |
| Not responding to child in appropriate tinne | Crying |
| Lack of empathy |
Apathy |
| Ignoring child |
Attention seeking |
| Not providing food/drinks | Hunger/thirst |
| Not providing physical and emotional comfort | No awareness of parent interaction |
| Laughing at child (rather than with) | Trying hard to seek parent's approval |
| Not considering child's welfare | Unkempt appearance |
| Happy to leave child supervised by strangers | Overfamiliar with strangers |
| Prioritising self or others (often partner) over child | Acceptance of poor situation |
Source: Crittenden, 2004; Barrett, 2006; Davis and Lebloch, 2013
Making a difference
Nurses in all areas should be able to recognise where parenting needs extra intervention or targeted support in order to reduce risk of harm, and a referral to other services may be beneficial. Box 1 identifies where health professionals can refer to for parenting support. There is widespread knowledge around the responsibility of everyone to protect children from harm (DfE, 2018), nursing practice in the UK provides mandatory training around procedures to safeguard children and adults. However, health professionals should also be able to recognise and educate families in parenting where harm may not be identified, but parenting techniques could be further developed into more sustained positive approaches. (Park et al, 2016; Shaffer et al, 2019).
Positive approaches
Parenting programmes have historically focused on boundaries and managing undesired behaviours (Eyberg et al, 2008). Over the past decade the knowledge and expectation around how children are parented has shifted from a behaviourist to a positive approach (Shaffer et al, 2019). Research has established that children respond in a meaningful and considered way to positive interactions and encouragement of perceived good behaviours rather than being continually chastised for undesirable actions (Wyatt Kaminski et al, 2008; Coatsworth et al, 2010; Kehoe et al, 2014; Shaffer and Obradović, 2017).
When supporting parents, professionals need to be skilled in assessing the thinking processes that occur within each parent. The patterns by which adults make meaning and organise thoughts are learnt in childhood. Crittenden (2004) discussed how the actions of parents and caregivers are derived from learnt behaviours and previous experiences within their own childhood—children recreate all actions of their parents in some manner. Transgenerational transmission of parenting strategies requires considered investigation; changing adults' perceptions of how to parent will often require a whole-family approach. Generating deeper understanding of child brain development and expected norms of behaviour can go some way to interrupting the cycle of negative or harmful approaches to parenting (Smith Slep and O'Leary, 1998; Crittenden, 2004).
Although it cannot be generalised that maltreated children will all go on to maltreat their own children, research has shown that parents who do maltreat their children have almost always been abused children themselves (Young et al, 1991).
There is a need to understand how parents operate within the parent–child dyad, how the relationship functions on all levels. The explicit knowledge of how parents interpret and respond to triggers created by their child can inform professional programmes and develop informative individualised strategies that are tailored to the parent's comprehension and ability.
A parent's notion of how they respond to their child is derived in understanding of the need. This will depend on their idea of priority and what they understand from the signal expressed by the child (Box 2).
Although many parent responses will occur without consideration and as a matter of instinct, some will be generated through transgenerational actions and learnt from experiences in their own childhood. Education around child development, from the antenatal period throughout childhood, may help elicit actions that are positive and responsive to each child's individual need. Professional awareness of how parents interpret and prioritise the signals from their child is crucial when attempting to optimise parenting practices.
Shaffer et al (2019) studied 34 caregivers of school-age children in a parent programme that was developed to educate parents towards increasing emotional connections with their children. The programme found that enhancing parents' ability to respond to their children's emotions assisted parents' coping skills, improved parent and child communication, and promoted a healthier relationship. Parents expressed the belief that building awareness of their child's emotional development allowed them to develop insight into the behaviours presented and encouraged an approach to parenting that was generated by knowledge, resulting in less parental stress and improved family dynamics.
Creating a positive culture that supports parents and children is at the forefront of government legislation (Leadsom et al, 2014). Providing early support within healthcare practice may help to reduce the burden that poor life experiences contribute towards physical and emotional wellbeing at individual and family level, the NHS, communities and wider society.
There is increasing concern about the exponential increase in poor mental health, delinquency, antisocial behaviour, crime and the detrimental effect this has on community safety, security and society as a whole (van Ijzendoorn et al, 1999; Fearon et al, 2010). With the increasing pressure put on frontline staff, it may be difficult to imagine where or how staff can spend time supporting parents at the outset. However, often families in need of intervention are seen by many professionals in areas such as schools, emergency departments and general practice, presenting with low-level issues that may be eradicated. Behaviour pathways can be altered with early identification and the instigation of supportive practices. It is accepted that currently there are limited empirically supported training programmes that exist to help clinicians teach positive parenting practices to parents (Shaffer et al, 2019).
Summary
Thinking processes are learnt in childhood and parenting differs widely in each family. Often these difference will not offer any detrimental effects to the child. Understanding of context and meaning is essential when supportive interventions would benefit child and family outcomes. Nurses in community and acute settings may be the first health professional who comes into contact with children and families. In times of stress it may be evident, from the quality of family interactions, how well a parent and child function as part of a family unit. Nurses who have skills to offer early support, guidance, refer or provide intervention could help alter the trajectory of family life, providing much needed help towards a brighter future for children, families and society as a whole.