Diagnostic challenges

October 2013

Professional

A is for aphorism

‘Give me a child until they are seven and I will show you the man’

Volume 42, No.10, October 2013 Pages 744-745

Rae Thomas

Georga Cooke

This aphorism is true for some, but not most. Child development is about both continuity and change. Experiences in early childhood shape cognitions and new experiences are integrated into familiar models of relationships.1 For example, children who have experienced rejection from parents will often assume rejection from others, not initiate positive contacts, isolate themselves, and consequently experience rejection from peers.2 But they may also experience a caring and supportive teacher who assists them in making lifelong friends who change their perceptions and expectations. So, early experience matters and early family life plays an important role in child development outcomes.3–5

For this aphorism to be true, early behavioural problems must be linked to enduring and stable patterns of maladaptation. Children with externalising behaviours both at school and at home are at greater risk for substance abuse, arrest and risky sexual behaviour in mid-adolescence than children with these behavioural problems in only one setting.6 One study found that 60–80% of children with clinical levels of child behavioural problems in early childhood show continued social and academic problems later in childhood.7 Conversely, this means that 20–40% of these children improve by late childhood. Again, the evidence talks about risks, rather than the certainties that this aphorism would suggest.

While early behavioural problems do not guarantee problems in later life, many parents are confused about how to ‘parent’. What is ‘the right way’? Indeed, behavioural problems in early childhood represent the greatest proportion of referrals to paediatricians8 and child psychologists.9 Therefore, the other question that this aphorism raises is: Does intervening early in the course of these problems alter child development outcomes? Is parenting ‘learn-able’?

Of all the modifiable variables, parenting has the most potential to impact a child’s development before the age of 7 years. For example, even decades later, a young child with a warm, involved, responsive parent is likely to parent their own child similarly10 and, further, parents good at responding to a child’s distress help a child regulate negative affect.11 At 7 years old, this could be seen in how a child manages their disappointment after receiving an unfortunate gift from Grandma – smiling sweetly and saying thank you – or crying. On the other hand, the absence of positive parent–child interactions has been shown to be associated with increased child behavioural problems.12 As well as externalising problems, maternal hostility and physical discipline have been associated with child-internalising symptoms (eg. some anxiety and feelings of hopelessness).13 But, even in the case of physical discipline, warm and responsive parenting can buffer these negative outcomes.13

A majority of parents with children with behavioural problems benefit from attending a parenting course, whether it reaffirms their current behaviour management strategies, enables them to normalise their experiences with other parents, or learn new and effective skills.  However, parenting interventions provided early in the course of behavioural problems generally have better outcomes than those provided later.14,15 It may be easier to change one or two years of maladaptive behaviour than eight or nine. But evidence for universal parenting interventions (parenting courses provided to parents whose children do not have behavioural problems) is equivocal.16

To intervene early in child behavioural problems, evidence-based intervention programs known collectively as Parent Management Training (PMT) have been shown to be effective in both the research and ‘real-world’ settings.17 Three of the most widely researched evidence-based PMT interventions available in Australia are Triple P (Positive Parenting Program; www.triplep.net/glo-en/home), the Incredible Years (IY; www.incredibleyears.com/) and Parent–Child Interaction Therapy (PCIT; www.pcit.org/). Each has evidence for reducing child behavioural problems in the short-term for children between the ages of 4 and 6 years.

Most children survive childhood and enter adulthood without marked psychological disorders or criminal histories. But history and prior experience remain important in their continued development: ‘Experience creates the child, but, at the same time, the child creates experience, through seeking, reacting to, and interpreting the world in individual ways.’2 If the aphorism held true for all, then there would be no point in psychological interventions after the age of 7 years. Indeed, the whole principle of lifelong learning, which is so central to our professional identities, would be a waste of effort. Fortunately we strive to be serene enough to accept the inevitable, courageous enough to act on changeable circumstance and now, thanks to evidence-based practice, we are wise enough to know we can.

General information about the availability of local parenting courses can be found at www.parentingrc.org.au and http://raisingchildren.net.au/

Competing interests: None.
Provenance and peer review: Commissioned; not peer reviewed.

References

  1. Bowlby J. Attachment and loss: Vol II. Separation. New York: Basic Books; 1973.
  2. Sroufe LA, Egeland B, Carlson EA, Collins WA. The development of the person: The Minnesota study of risk and adaptation from birth to adulthood. New York: The Guilford Press; 2005.
  3. Belsky J, Jaffe SR. The multiple determinants of parenting. In: Cicchetti D, Cohen DJ, editors. Developmental psychopathology, 2nd edn. Volume 3. Risk, disorder, and adaptation. Hoboken, NJ: John Wiley & Sons Inc; 2006, p. 38–85.
  4. Hoeve M, Blokland A, Dubas JS, Loeber R, Gerris JR, van der Laan PH. Trajectories of delinquency and parenting styles. J Abnorm Child Psychol 2008;36:223–35.
  5. Mäntymaa M, Puura K, Luoma I, Latva R, Salmelin RK, Tamminen T. Predicting internalizing and externalizing problems at five years by child and parental factors in infancy and toddlerhood. Child Psychiatry Hum Dev 2012;43:53–70.
  6. Dishion TJ. Cross-setting consistency in early adolescent psychopathology: Deviant friendships and problem behavior sequelae. J Pers 2000;68:1109–26.
  7. Masten AS, Roisman GI, Long JD, et al. Developmental cascades: Linking academic achievement and externalizing and internalizing symptoms over 20 years. Dev Psychol 2005;41:733–46.
  8. Hiscock H, Roberts G, Efron D, et al. Children attending a paediatricians study: A national prospective audit of outpatient practice from the Australian paediatric research network. Med J Aust 2011;194:392–97.
  9. Dishion TJ, Patterson GR. The development and ecology of antisocial behavior in children and adolescents. In: Cicchetti D, Cohen DJ, editors. Developmental psychopathology 2nd edn, Volume 3. Risk, disorder, and adaptation. Hoboken, NJ: John Wiley & Sons Inc; 2006, p. 503–41.
  10. Kovan MN, Chung AL, Sroufe LA. The intergenerational continuity of observed parenting: A prospective, longitudinal study. Dev Psychol 2009;45:1205–13.
  11. Davidov M, Grusec JE. Untangling the links of parental responsiveness to distress and warmth to child outcomes. Child Dev 2006;77:44–58.
  12. Pettit GS, Bates JE. Family interaction patterns and children’s behavior problems from infancy to 4 years. Dev Psychol 1989;25:413–20.
  13. McKee L, Roland E, Coffelt N, et al. Harsh discipline and child problem behaviors: The roles of positive parenting and gender. J Fam Violence 2007;22: 187–96.
  14. Barlow J, Smailagic N, Ferriter M, Bennett C, Jones H. Group-based parent-training programmes for improving emotional and behavioural adjustment in children from birth to three years old. Cochrane Database Syst Rev 2010;3:CD003680.
  15. Woolfenden S, Williams KJ, Peat J. Family and parenting interventions in children and adolescents with conduct disorder and delinquency aged 10–17. Cochrane Database Syst Rev 2001;2:CD003015.
  16. Malti T, Ribeaud D, Eisner MP. The effectiveness of two universal preventive interventions in reducing children’s externalizing behavior: A cluster randomized controlled trial. J Clin Child Adolesc Psychol 2011;40:677–92.
  17. Michelson D, Davenport C, Dretzke J, Barlow J, Day C. Do evidence-based interventions work when tested in the “real world?” A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior. Clin Child Fam Psychol Rev 2013;16:18–34.

Correspondence afp@racgp.org.au

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