The child outcomes described above provide the context for considering the range of parenting knowledge, attitudes, and practices and identifying those that research supports as core. As noted in Chapter 1, the term “knowledge” for the purposes of this report refers to facts, information, and skills gained through experience or education and understanding of an issue or phenomenon. “Attitudes” refers to viewpoints, perspectives, reactions, or settled ways of thinking about aspects of parenting or child development, including parents' roles and responsibilities. Attitudes may be related to cultural beliefs founded in common experience. And “practices” refers to parenting behaviors or approaches to childrearing that can shape how a child develops. Generally speaking, knowledge relates to cognition, attitudes relate to motivation, and practices relate to ways of engaging or behavior, but all three may emanate from a common source. These three components are reciprocal and intertwined theoretically, empirically, and bidirectionally, informing one another. For example, practices are related to knowledge and attitudes, and often involve the application of knowledge. According to behavior modification theory (Ajzen and Fishbein, 1980; Fishbein et al., 2001), a person's attitude often determines whether he or she will use knowledge and transform it into practice. In short, if one does not believe in or value knowledge, one is less likely to act upon it. What parents learn through the practice of parenting can also be a source of knowledge and can shape parents' attitudes. Parenting attitudes are influenced as well by parenting self-efficacy, which has been broadly defined as the level of parents' self-belief about their ability to succeed in the parenting role (Jones and Prinz, 2005). Parenting knowledge, attitudes, and practices are shaped not only by each other but also by a number of contextual factors, including children's characteristics (e.g., gender, temperament); parents' own experiences (e.g., those from their own childhood) and circumstances; expectations learned from others, such as family, friends, and other social networks; and cultural systems. Of particular relevance to this study, the contextual factors that influence parenting knowledge, attitudes, and practices also include the supports available within the larger community and provided by institutions, as well as by policies that affect the nature and availability of supportive services. In response to the study charge (Box 1-2 in Chapter 1), this chapter presents the evidence on core parenting knowledge, attitudes, and practices separately. However, it should be noted that in the research literature, the distinctions among these concepts, especially knowledge and attitudes, are not well-delineated and that the applications of these concepts to parenting often are equally informed by professional wisdom and historical observation. Parenting is multidimensional. To respond to the varied needs of their children, parents must develop both depth and breadth of knowledge, ranging from being aware of developmental milestones and norms that help in keeping children safe and healthy to understanding the role of professionals (e.g., educators, child care workers, health care providers, social workers) and social systems (e.g., institutions, laws, policies) that interact with families and support parenting. This section describes these areas of knowledge, as well as others, identified by the available empirical evidence as supporting core parenting practices and child outcomes. It is worth noting that the research base regarding the association between parental knowledge and child outcomes is much smaller than that on parenting practices and child outcomes (Winter et al., 2012). Where data exist, they are based largely on correlational rather than experimental studies. [Some parents recognized the need for education related to providing care for young children.] “I am a new parent and even though I have a bachelor's degree from India, I do not have a particular education in child care. Just because I have a degree, it does not mean it is a degree on how to take care of a child.”
The importance of parents' knowledge of child development is a primary theme of many efforts to support parenting. Evidence-based recommendations issued by the American Psychological Association Task Force on Evidence-Based Practice with Children and Adolescents (2008), the Centers for Disease Control and Prevention (CDC) (2015b), and the World Health Organization (WHO) (2009) emphasize the need for policy and program initiatives to promote parenting knowledge. As they suggest, to optimize children's development, parents need a basic understanding of infant and child developmental milestones and norms and the types of parenting practices that promote children's achievement of these milestones (Belcher et al., 2007; Benasich and Brooks-Gunn, 1996, p. 1187; Bond and Burns, 2006; Bornstein and Cote, 2004; Hess et al., 2004; Huang et al., 2005; Larsen and Juhasz, 1985; Mercy and Saul, 2009). A robust body of correlational research demonstrates tremendous variation in parents' knowledge about childrearing. Several of these studies suggest that parents with higher levels of education tend to know more about child developmental milestones and processes (Bornstein et al., 2010; Conrad et al., 1992; Hess et al., 2004; Huang et al., 2005), as well as effective parenting strategies (Morawska et al., 2009). This greater knowledge may reflect differential access to accurate information, differences in parents' trust in the information or information source, and parents' comfort with their own abilities, among other factors. For example, research shows that parents who do not teach math in the home tend to have less knowledge about elementary math, doubt their competence, or value math less than other skills (Blevins-Knabe et al., 2000; Cannon and Ginsburg, 2008; Vukovic and Lesaux, 2013). However, parents' knowledge and willingness to increase their knowledge may change; thus, they can acquire developmental knowledge that can help them employ effective parenting practices. [Some parents recognized the need for comprehensive parenting education.] “I always prefer education for the parents, from the beginning to the end. From pregnancy, some don't know when to go to the doctor, and after birth, when to go to the hospital or the doctor. So we need education from the beginning to the end.”
The focus on parental knowledge as a point of intervention is important because parents' knowledge of child development is related to their practices and behaviors (Okagaki and Bingham, 2005). For example, mothers who have a strong body of knowledge of child development have been found to interact with their children more positively compared with mothers with less knowledge (Bornstein and Bradley, 2012; Huang et al., 2005). Parents who understand child development also are less likely to have age-inappropriate expectations for their child, which affects the use of appropriate discipline and the nature and quality of parent-child interactions (Goodnow, 1988; Huang et al., 2005). Support for the importance of parenting knowledge to parenting practices is found in multiple sources and is applicable to a range of cognitive and social-emotional behaviors and practices. Several correlational studies show that mothers with high knowledge of child development are more likely to provide books and learning materials tailored to children's interests and age and engage in more reading, talking, and storytelling relative to mothers with less knowledge (Curenton and Justice, 2004; Gardner-Neblett et al., 2012; Grusec, 2011). Fathers' understanding of their young children's development in language and literacy is associated with being better prepared to support their children (Cabrera et al., 2014). And parents who do not know that learning begins at birth are less likely to engage in practices that promote learning during infancy (e.g., reading to infants) or appreciate the importance of exposing infants and young children to hearing words and using language. For example, mothers who assume that very young children are not attentive have been found to be less likely to respond to their children's attempts to engage and interact with them (Putnam et al., 2002). Stronger evidence of the role of knowledge of child development in supporting parenting outcomes comes from intervention research. Randomized controlled trial interventions have found that parents of young children showed increases in knowledge about children's development and practices pertaining to early childhood care and feeding (Alkon et al., 2014; Yousafzai et al., 2015). Some studies have found a direct association between parental knowledge and child outcomes, including reduced behavioral challenges and improvements on measures of cognitive and motor performance (Benasich and Brooks-Gunn, 1996; Dichtelmiller et al., 1992; Hunt and Paraskevopoulos, 1980; Rowe et al., 2015). In an analysis of data from a prospective cohort study that controlled for potential confounders, children of mothers with greater knowledge of child development at 12 months were less likely to have behavior problems and scored higher on child IQ tests at 36 months relative to children of mothers with less developmental knowledge (Benasich and Brooks-Gunn, 1996). This and other observational studies also show that parental knowledge is associated with improved parenting and quality of the home environment, which, in turn, is associated with children's outcomes (Benasich and Brooks-Gunn, 1996; Parks and Smeriglio, 1986; Winter et al., 2012), in addition to being contingent on parental attitudes and competence (Conrad et al., 1992; Hess et al., 2004; Murphy et al., 2015). Experimental studies of parent education interventions support these associational findings. In an experimental study of parent education for first-time fathers, fathers, along with home visitors, reviewed examples of parental sensitivity and responsiveness from videos of themselves playing with their children (Magill-Evans et al., 2007). These fathers showed a significant increase in parenting competence and skills in fostering their children's cognitive growth as well as sensitivity to infant cues 2 months after the program, compared with fathers in the control group, who discussed age-appropriate toys with the home visitor (Magill-Evans et al., 2007). Another experimental study examined a 13-week population-level behavioral parenting program and found intervention effects on parenting knowledge for mothers and, among the highest-risk families, increased involvement in children's early learning and improved behavior management practices. Lower rates of conduct problems for boys at high risk of problem behavior also were found (Dawson-McClure et al., 2015). Parents' knowledge of how to meet their children's basic physical (e.g., hunger) and emotional (e.g., wanting to be held or soothed) needs, as well as of how to read infants' cues and signals, can improve the synchronicity between parent and child, ensuring proper child growth and development. Specifically, parenting knowledge about proper nutrition, safe sleep environments, how to sooth a crying baby, and how to show love and affection is critical for young children's optimal development (Bowlby, 2008; Chung-Park, 2012; Regalado and Halfon, 2001; Zarnowiecki et al., 2011). For many parents, for example, infant crying is a great challenge during the first months of life. Parents who cannot calm their crying babies suffer from sleep deprivation, have self-doubt, may stop breastfeeding earlier, and may experience more conflict and discord with their partners and children (Boukydis and Lester, 1985; Karp, 2008). Correlational research indicates that improvement in parental knowledge about normal infant crying is associated with reductions in unnecessary medical emergency room visits for infants (Barr et al., 2015). That knowledge leads to changes in behavior is further supported in systematic reviews by Bryanton and colleagues (2013) of randomized controlled trials and Middlemiss and colleagues (2015) of studies with various design types, with both groups reporting that increases in mother's knowledge about infant behavior is associated with positive changes in the home environment, as well as improvements in infant sleep time. Specific knowledge about health and safety—including knowledge about how to access health care, protect children from physical harm (e.g., the importance of wearing a seat belt or a helmet), and promote good hygiene and nutrition—is a key parenting competency. Experimental studies show, for example, a positive link between parents' knowledge of nutrition and both children's intake of nutritious foods and reduced calorie and sodium intake (Campbell et al., 2013; Katz et al., 2011). In a randomized controlled trial, Campbell and colleagues (2013) found that children whose parents received knowledge, skills, and social support related to infant feeding, diet, physical activity, and television viewing consumed fewer sweet snacks and spent fewer minutes daily viewing television relative to children whose parents were in the control group (Campbell et al., 2013). Also associated with children's intake of nutritious foods is parents' modeling of good eating habits and nutritional practices (Mazarello Paes et al., 2015). In addition, although limited in scope, correlational evidence shows that parents with knowledge about immunization are more likely to understand its purpose and comply with the timetable for vaccinations (Smailbegovic et al., 2003); that parents with more knowledge about effective injury prevention practices are more likely to create safer home environments for their children and reduce unintentional injuries (Corrarino, 2013; Dowswell et al., 1996; Middlemiss et al., 2015; Morrongiello and Kiriakou, 2004); and that parents with knowledge about asthma are more likely to use an asthma management plan (Bryant-Stephens and Li, 2004; DeWalt et al., 2007; Harrington et al., 2015). Other studies have found that parents with more information about the purpose of vaccinations had greater knowledge of immunization than parents in the control group (Hofstetter et al., 2015; Jackson et al., 2011), and parents with more knowledge about sun safety provided sunscreen and protective clothing for their children, who presented with fewer sunburns (Crane et al., 2012). Still, knowledge alone may not be sufficient in some cases. For example, knowing about the importance of using car seats does not always translate into good car seat practices (Yanchar et al., 2012, 2015), and knowledge about the advantages of vaccines may not result in parents choosing to vaccinate their children. Some findings suggest that using multiple modes of delivery is important to advancing parents' knowledge. In an experimental study, for example, Dunn and colleagues (1998) found that parents who received educational information about child vaccinations via videotape as well as in written form showed greater gains in understanding about vaccinations than parents who received the information in written form alone. The evidence linking parental knowledge about the specific ways in which parents can help children develop cognitive and academic skills, including skills in math, is limited. However, the available correlational data show that parents who know about how children develop language are more likely to have children with emergent literacy skills (e.g., letter sound awareness) relative to parents who do not (Ladd et al., 2011). Several studies over the past 20 years have described parents' increasing knowledge and use of approaches for supporting children's literacy (Clark, 2007; National Research Council, 1998; Sénéchal and LeFevre, 2002). Much of this work has focused on book reading and parent-child engagement around reading (Hindman et al., 2008; Mol et al., 2008; Morrow et al., 1990). As early as the 1960s, Durkin (1966) and others referred to the important role of the home literacy environment and parents' beliefs about reading in children's early literacy development. Little is known about parents' knowledge of various supports—such as educators, social workers, health care providers, and extended family—and the relationship between their conceptions of the roles of these supports and their use of them. To take an example, parents' knowledge about child care and their school decision-making processes are informed in a variety of ways through these different supports. In their literature review of child care decision making, Forry and colleagues (2013) found that many low-income parents learn about their child care options through their social networks rather than through professionals or referral agencies. While many parents say they highly value quality, their choices also may reflect a range of other factors that are valued. Parents tend to make child care decisions based on structural (teacher education and training) and process (activities, parent-provider communication) features, although their choices also vary by family income, education, and work schedules. Sosinsky and Kim (2013), for example, found that higher maternal education and income and being white were associated with the likelihood of parents choosing higher-quality child care programs that were associated with better child outcomes. Based on a survey of parents of children in a large public school system, Goldring and Phillips (2008) found that parents' involvement, not satisfaction with their child's school, was associated with school decision making. It should be noted that while parents may know what constitutes high-quality child care and education, structural (availability of quality programs and schools), individual (work, income, belief), and child (temperament, age) factors also influence these decision-making processes (Meyers and Jordan, 2006; Shlay, 2010). Taking another example, limited studies have looked at parental awareness of services for children with special needs. A study that utilized a survey and qualitative interviews with parents of children with autism indicated that parents' autism spectrum disorder service knowledge partially mediates the relationship between socioeconomic status and use of services for their children (Pickard and Ingersoll, 2015). Although considerable discussion has focused on attitudes and beliefs broadly, less research attention has been paid to the effects of parenting attitudes on parents' interactions with young children or on parenting practices. Few causal analyses are available to test whether parenting attitudes actually affect parenting practices, positive parent-child interaction, and child development. Even less research exists on fathers' attitudes about parenting. Given this limited evidence base, the committee drew primarily on correlational and qualitative studies in examining parenting attitudes. Parents' attitudes toward parenting are a product of their knowledge of parenting and the values and goals (or expectations) they have for their children's development, which in turn are informed by cultural, social, and societal images, as well as parents' experiences and their overall values and goals (Cabrera et al., 2000; Cheah and Chirkov, 2008; Iruka et al., 2015; Okagaki and Bingham, 2005; Rogoff, 2003; Rosenthal and Roer-Strier, 2006; Whiting and Whiting, 1975). People in the United States hold several universal, or near universal, beliefs about the types of parental behaviors that promote or impair child development. For example, there is general agreement that striking a child in a manner that can cause severe injury, engaging in sexual activity with a child, and failing to provide adequate food for and supervision of young children (such as leaving toddlers unattended) pose threats to children's health and safety and are unacceptable. At the same time, some studies identify differences in parents' goals for child development, which may influence attitudes regarding the roles of parents and have implications for efforts to promote particular parenting practices. While there is variability within demographic groups in parenting attitudes and practices, some research shows differences in attitudes and practices among subpopulations. For example, qualitative research provides some evidence of variation by culture in parents' goals for their children's socialization. In one interview study, mothers who were first-generation immigrants to the United States from Central America emphasized long-term socialization goals related to proper demeanor for their children, while European American mothers emphasized self-maximization (Leyendecker et al., 2002). In another interview study, Anglo American mothers stressed the importance of their young children developing a balance between autonomy and relatedness, whereas Puerto Rican mothers focused on appropriate levels of relatedness, including courtesy and respectful attentiveness (Harwood et al., 1997). Other ethnographic and qualitative research shows that parents from different cultural groups select cultural values and norms from their country of origin as well as from their host country, and that their goal is for their children to adapt and succeed in the United States (Rogoff, 2003). Similarly, whereas the larger U.S. society has historically viewed individual freedom as an important value, some communities place more emphasis on interdependence (Elmore and Gaylord-Harden, 2013; Sarche and Spicer, 2008). The importance of intergenerational connections (e.g., extended family members serving as primary caregivers for young children) also varies among and within cultural communities (Bertera and Crewe, 2013; Mutchler et al., 2007). The values and traditions of cultural communities may be expressed as differences in parents' views regarding gender roles, in parents' goals for children, and in their attitudes related to childrearing. [One parent described differences between men and women in parenting roles.] “Mothers play the main role as parents in [certain cultures]. Culturally men aren't that involved. The dad is the outer worker; the mother is the inner worker. If you are talking about the mom, they are the ones who care about the kids. They aren't typically working outside the home. But now, in the United States, the mothers are working outside the home.”
Although slowly changing, attitudes about the roles of men and women in the raising of young children often differ between men and women and among various communities in the United States. Longitudinal research on mothers' attitudes toward fathers' involvement in childrearing has made reference to the “gatekeeping” role of mothers of children with nonresidential fathers (Fagan and Barnett, 2003; Schoppe-Sullivan et al., 2008). Research has shown that fathers of young children participate in child caregiving activities in increasing numbers (Cabrera et al., 2011), but has not examined the specific attitudes that fathers bring to particular parenting behaviors across the life span. Parents' values and goals related to childrearing, both overall and for specific demographic groups, also may shift from one generation to the next in the United States based on changing norms and viewpoints within social networks and cultural communities, as well as parents' knowledge of and access to new research and information provided by educators, health care providers, and others who work with families. Relatively little research has been conducted on parents' attitudes toward specific parenting-related practices. Much of the extant research focuses on practices related to promoting children's physical health and safety. Studies of varying designs indicate that parental attitudes and beliefs about the need for and safety of vaccination influence vaccination practices (Mergler et al., 2013; Salathé and Bonhoeffer, 2008; Vannice et al., 2011; Yaqub et al., 2014). Maternal attitudes and beliefs about breastfeeding (e.g., views about breastfeeding in public, the belief that it will be uncomfortable) are associated with initiation and continuation of breastfeeding and appear to factor into differences in breastfeeding rates and practices observed across cultural and other demographic groups in cross-sectional survey and qualitative research (Vaaler et al., 2010; Wojcicki et al., 2010). Other studies have found differences among parents (e.g., those living in rural versus urban areas) in attitudes about the importance of monitoring children's activities and whereabouts (Armistead et al., 2002; Jones et al., 2003) and parents' beliefs about young children's literacy development (Lynch et al., 2006). Parental involvement in children's education has been linked to academic readiness (Fan and Chen, 2001). However, parents differ in their attitudes about the role of parents in children's learning and education (Hammer et al., 2007). Some see parents as having a central role, while others view the school as the primary facilitator of children's education and see parents as having less of a role (Hammer et al., 2007). These attitudinal differences may be related to cultural expectations or parents' own education or comfort with teaching their children certain skills. Some parents, for example, may have lower involvement in their children's education because of insecurity about their own skills and past negative experiences in school (Lareau, 1989; Lawrence-Lightfoot, 2003). And as discussed above, some parents view math skills as less important for their children relative to other types of skills and therefore are less likely to teach them in the home. Parents within and across different communities vary in their opinions and practices with respect to the role and significance of discipline. Some of the parenting literature notes that some parents use control to discipline children, while others aim to correct but not to control children (Nieman and Shea, 2004). In a small cross-cultural ethnographic study, Mosier and Rogoff (2003) found that some parents regard rules and punishment as inappropriate for infants and toddlers. The approach valued by these parents to help children understand what is expected of them is to cooperate with them, perhaps distracting them but not forcing their compliance. In contrast, many middle-class U.S. parents display a preference for applying the same rules to infants and toddlers that older children are expected to follow, although with some lenience (Mosier and Rogoff, 2003). And ethnographic research provides some evidence of differences in African American and European American mothers' beliefs about spoiling and infant intentionality (whether infants can intentionally misbehave) related to the use of physical punishment with young children (Burchinal et al., 2010). Parents' attitudes not only toward parenting but also toward providers in societal agencies—such as educators, social service personnel, health care providers, and police—which can be shaped by a variety of factors, including discrimination, are important determinants of parents' access to and ability to obtain support. Studies show a relationship between parents' distrust of agencies and their likelihood of rejecting participation in an intervention. For example, in systematic reviews of studies of various types, parents who distrust the medical community and government health agencies are less likely to have their children vaccinated (Brown et al., 2010; Mills et al., 2005). Racial and ethnic minority parents whose attitudes about appropriate remedies for young children vary from those of the Western medical establishment often distrust and avoid treatment by Western medical practitioners (Hannan, 2015). While not specific to parents, studies using various methodologies show that individuals who have experienced racial and other forms of discrimination, both within and outside of health care settings, are less likely to utilize various health services or to engage in other health-promoting behaviors (Gonzales et al., 2013; Institute of Medicine, 2003; Pascoe and Smart Richman, 2009; Shavers et al., 2012). In a survey study, African American parents' racism awareness was negatively associated with involvement in activities at their children's school (McKay et al., 2003). Longitudinal studies, mostly involving families with older children, indicate that, like other sources of stress, parents' experience of discrimination can have a detrimental effect on parenting and the quality of the parent-child relationship (Murray et al., 2001; Sanders-Phillips et al., 2009). Adverse outcomes for youth associated with their own experience of discrimination may be weakened by more nurturing/involved parenting (Brody et al., 2006; Gibbons et al., 2010; Simons et al., 2006). As noted earlier, attitudes are shaped in part by parenting self-efficacy—a parent's perceived ability to influence the development of his or her child. Parenting self-efficacy has been found to influence parenting competence (including engagement in some parenting practices) as well as child functioning (Jones and Prinz, 2005). Studies show associations between maternal self-efficacy and children's self-regulation, social, and cognitive skills (Murry and Brody, 1999; Swick and Hassell, 1990). Self-efficacy also may apply to parents' confidence in their capacity to carry out specific parenting practices. For example, parents who reported a sense of efficacy in influencing their elementary school-age children's school outcomes were more likely to help their children with school activities at home (Anderson and Minke, 2007). A multimethod study of African American families found that maternal self-efficacy was related to children's regulatory skills through its association with competence-promoting parenting practices, which included family routines, quality of mother-child interactions based on observer ratings, and teachers' reports of mothers' involvement with their children's schools (Brody et al., 1999). Henshaw and colleagues (2015) found in a longitudinal study that higher breastfeeding self-efficacy predicted exclusive breastfeeding at 6 months postpartum, as well as better emotional adjustment of mothers in the weeks after giving birth. Parenting practices have been studied extensively, with some research showing strong associations between certain practices and positive child outcomes. This section describes parenting practices that research indicates are central to helping children achieve basic outcomes in the areas discussed at the beginning of the chapter: physical health and safety, emotional and behavioral competence, social competence, and cognitive competence. While these outcomes are used as a partial organizing framework for this section, several specific practices—contingent responsiveness of parents, organization of the home environment and the importance of routines, and behavioral discipline practices—that have been found to influence child well-being in more than one of these four outcome areas are discussed separately. Parents influence the health and safety of their children in many ways. However, the difficulty of using random assignment designs to examine parenting practices that promote children's health and safety has resulted in a largely observational literature. This section reviews the available evidence on a range of practices in which parents engage to ensure the health and safety of their children. It begins with breastfeeding—a subject about which there has historically been considerable discussion in light of generational shifts and commercial practices that have affected children in poor families. Breastfeeding Breastfeeding has myriad well-established short- and long-term benefits for both babies and mothers. Breast milk bolsters babies' immunity to infectious disease, regulates healthy bacteria in the intestines, and overall is the best source of nutrients to help babies grow and develop. Breastfeeding also supports bonding between mothers and their babies. According to a meta-analysis by the WHO (Horta and Victora, 2013), breastfeeding is associated with a small increase in performance on intelligence tests in children and adolescents, reduced risk for the development of type 2 diabetes and overweight/obesity later in life, and a potential decreased risk for the development of cardiovascular disease. Breastfeeding may benefit mothers' health as well by lowering risk for postpartum depression, certain cancers, and chronic diseases such as diabetes (U.S. Department of Health and Human Services, 2011). Current guidelines from the American Academy of Pediatrics (2012) and the WHO (2011) recommend mothers breastfeed exclusively until infants are 6 months old. Thereafter and until the child is either age 1 year (American Academy of Pediatrics, 2012) or 2 years (World Health Organization, 2011), it is recommended that children continue to be breastfed while slowly being introduced to other foods. According to 2011 data from the CDC (2015a), about 80 percent of babies born in the United States are breastfed (including fed breast milk) for some duration, and about 50 percent and 27 percent are breastfed (to any extent with or without the addition of complementary liquids or solids) at 6 and 12 months, respectively. Forty percent and 19 percent are exclusively breastfed through 3 and 6 months, respectively. Mothers in the United States often cite a number of reasons for not initiating or continuing breastfeeding, including lack of knowledge about how to breastfeed, difficulty or pain during breastfeeding, embarrassment, perceived inconvenience, and return to work (Hurley et al., 2008; Ogbuanu et al., 2009; U.S. Department of Health and Human Services, 2011). Low-income women with less education are less likely than women of higher socioeconomic status to breastfeed (Heck et al., 2006). Some research with immigrant mothers shows that rates of breastfeeding decrease with each generation in the United States, possibly because of differences in acceptance of bottle feeding here as compared with other countries (e.g., Sussner et al., 2008). Nutrition and physical activity Parents play an important role in shaping their young children's nutrition and physical activity levels (Institute of Medicine, 2011; Sussner et al., 2006). Among toddlers and preschool-age children, parents' feeding practices are associated with their children's ability to regulate food intake, which can affect weight status (Faith et al., 2004; Farrow et al., 2015). Parents' modeling of healthful eating habits for their children and offering of healthful foods, particularly during toddlerhood, when children are often reluctant to try new foods, may result in children being more apt to like and eat such foods (Hill, 2002; Natale et al., 2014; Sussner et al., 2006). The extant observational research generally shows that children's dietary intake (particularly fruit and vegetable consumption) is associated with food options available in the home and at school, and that parents are important role models for their children's dietary behaviors (Cullen et al., 2003; Pearson et al., 2009; Wolnicka et al., 2015). Conversely, the presence of less nutritious food and beverage items in the home may increase children's risk of becoming overweight. For example, Dennison and colleagues (1997) and Welsh and colleagues (2005) found positive associations between overweight in children and their consumption of sugar-sweetened beverages. On the other hand, there are some indications that overly strict diets may increase children's preferences for high-fat, energy-dense foods, perhaps causing an imbalance in children's self-regulation of hunger and satiety and increasing the risk that they will become overweight (Birch and Fisher, 1998; Farrow et al., 2015). A few cross-sectional and longitudinal studies, coupled with conventional wisdom, suggest that eating dinner together as a family is associated with increased consumption of fruits, vegetables, and whole grains and reduced consumption of fats and soda (Gillman et al., 2000), as well as with reduced risk for overweight and obesity (Gable et al., 2007; Taveras et al., 2005). However, these studies involved primarily older children and adolescents. Physical activity is a complement to good nutrition. Even in young children, physical activity is essential for proper energy balance and prevention of childhood obesity (Institute of Medicine, 2011; Kohl and Hobbs, 1998). It also supports normal physical growth. Parents may encourage activity in young children through play (e.g., free play with toys or playing on a playground) or age-appropriate sports. Children who spend more time outdoors may be more active (e.g., Institute of Medicine, 2011; Sallis et al., 1993) and also have more opportunity to explore their community and interact with other children. For many parents living in high-crime neighborhoods, however, most of whom are racial and ethnic minorities, the importance of safety overrides the significance of physical activity. In some neighborhoods, safety issues and lack of access to parks and other places for safe recreation make it difficult for families to spend time outdoors, leading parents to keep their children at home (Dias and Whitaker, 2013; Gable et al., 2007; Powell et al., 2003). Although more of the research on screen time and sedentary behavior has focused on adolescents than on young children, several cross-sectional and longitudinal studies on younger children show an association between television viewing and overweight and inactivity (Ariza et al., 2004; Carson et al., 2016; Dennison et al., 2002; DuRant et al., 1994; Gable et al., 2007; Tremblay et al., 2011). An analysis of data on 8,000 children participating in a longitudinal cohort study showed that those who watched more television during kindergarten and first grade were significantly more likely to be clinically overweight by the spring semester of third grade (Gable et al., 2007). Although television, computers, and other screen media often are used for educational purposes with young children, these findings suggest that balancing screen time with other activities may be one way parents can promote their children's overall health. As with diet, children's sedentary behavior can be influenced by parents' own behaviors. For example, De Lepeleere and colleagues (2015) found an association between parents' screen time and that of their children ages 6-12 in a cross-sectional study. Vaccination Parents protect their own and other children from potentially serious diseases by making sure they receive recommended vaccines. Among children born in a given year in the United States, childhood vaccination is estimated to prevent about 42,000 deaths and 20 million cases of disease (Zhou et al., 2014). In 2013, 82 percent of children ages 19-35 months received combined-series vaccines (for diphtheria, tetanus, and pertussis [DTP]; polio; measles, mumps, and rubella [MMR]; and Haemophilus influenzae type b [Hib]), up from 69 percent in 1994 (Child Trends Databank, 2015b). Vaccination rates are lower among low-income children; 71 percent of children ages 19-35 months living below the poverty level received the combined-series vaccines listed above in 2014 (Child Trends Databank, 2015b). Although much of the media coverage on this subject has focused on middle-income parents averse to having their children vaccinated, it is in fact poverty that is thought to account for much of the disparity in vaccination rates by race and ethnicity (Hill et al., 2015). As discussed earlier in this chapter, parental practices around vaccination may be influenced by parents' knowledge and interpretation of information on and their attitudes about vaccination. Preconception and prenatal care The steps women take with their health care providers before becoming pregnant can promote healthy pregnancy and birth outcomes for both mothers and babies. These include initiating certain supplements (e.g., folic acid, which reduces the risk of birth defects), quitting smoking, attaining healthy weight for women who are obese, and treating preexisting physical and mental health conditions (Aune et al., 2014; Gold and Marcus, 2008; Institute of Medicine and National Research Council, 2009). During pregnancy, receipt of recommended prenatal care can help parents reduce the risk of pregnancy complications and poor birth outcomes by promoting healthy behaviors (e.g., smoking cessation, adequate rest and nutrition), as well as identifying and managing any complications that do arise. Prior to the birth of a child, health care providers also can educate parents on the importance of breastfeeding, infant injury and illness prevention, and other practices. Infants born to mothers who do not receive prenatal care or who do not receive it until late in their pregnancy are more likely than those born to mothers who receive such care early in pregnancy to be born premature and at a low birth weight and are more likely to die. Since the 1970s, there has been a decline in the number of women in the United States receiving late or no prenatal care, with the majority of pregnant women now receiving recommended prenatal care (Child Trends Databank, 2015a). Yet disparities among subgroups persist. In 2014, American Indian and Alaska Native (11% of births), black (10% of births), and Hispanic (8% of births) women were more than twice as likely as white mothers (4% of births) to receive late or no prenatal care (Child Trends Databank, 2015a). The proportion of women receiving timely prenatal care increases with age: in 2014, 25 percent of births to females under age 15 and 10 percent of births to females ages 15-19 were to mothers receiving late or no prenatal care, compared with 7.8 percent for females ages 20-24 and 5.6 percent for those ages 25-29 (Child Trends Databank, 2015a). Women whose pregnancies are unintended also are less likely to receive timely prenatal care. Despite the importance of timely and quality prenatal care, moreover, many parents experience barriers to receiving such care, including poor access and rural residence, limited knowledge of its importance, and mental illness (Heaman et al., 2014). Injury prevention Unintentional injuries are the leading cause of death among children ages 1-9 (Centers for Disease Control and Prevention, 2015c) and a leading cause of disability for both younger and older children in the United States. In addition to motor vehicle-related injuries, children sustain unintentional injuries (due, for example, to suffocation, falls, poisoning, and drowning) in the home environment. About 1,700 children under age 9 in the United States die each year from injuries in the home (Mack et al., 2013). Parents can protect their children from injury through various measures, such as ensuring proper use of automobile passenger restraints, insisting that children wear helmets while bike riding and playing sports, and creating a safe home environment (e.g., keeping medicines and cleaning products out of children's reach, installing safety gates to keep children from falling down stairs). Yet the limited available research on parents' use of safety measures suggests there is room for improvement in some areas. For instance, appropriate use of child restraint systems is known to reduce the risk of child motor vehicle-related injuries and deaths (Arbogast et al., 2009; Durbin, 2011); nonetheless, data show that many children ride in automobiles without appropriate restraints (Greenspan et al., 2010; Lee et al., 2015; Macy et al., 2014). Likewise, using data from a national survey conducted during 2001-2003, Dellinger and Kresnow (2010) show that less than one-half of children ages 5-14 always wore bicycle helmets while riding, and 29 percent never did so. More recent data on parents' home safety practices and on helmet usage among young children are lacking. Evidence that families' home safety practices affect child safety comes from intervention research. A large meta-analysis of randomized and nonrandomized controlled trials of home safety education interventions for families (Kendrick et al., 2013) showed that the education was generally effective in increasing the proportion of families that stored medicines and cleaning products out of reach and that had fitted stair gates, covers on unused electrical sockets, safe hot tap water temperatures, functional smoke alarms, and a fire escape system. There was also some evidence for reduced injury rates among children. As discussed in Chapter 4, helping parents reduce hazards in the home is a component of some home visiting programs. Parents also protect their children's safety by monitoring their whereabouts and activities to prevent them from both physical and psychological harm. The type of supervision may vary based on a child's needs and age as well as parents' values and economic circumstances. For all young children, monitoring for the purposes of preventing exposure to hazards is an important practice. As children grow older, knowing their friends and where the children are when they are not at home or in school also becomes important. As noted previously, research suggests the importance of monitoring screen time to children's well-being. And monitoring of children's Internet usage may prevent them from being exposed to online predators (Finkelhor et al., 2000). Fundamental to children's positive development is the opportunity to grow up in an environment that responds to their emotional needs (Bretherton, 1985) and that enables them to develop skills needed to cope with basic anxieties, fears, and environmental challenges. Parents' ability to foster a sense of belonging and self-worth in their children is vital to the children's early development. In much the same way, parents contribute to children's emerging social competence by teaching them skills—such as self-control, cooperation, and taking the perspective of others—that prepare them to develop and maintain positive relationships with peers and adults. Parents can promote the learning and acquisition of social skills by establishing strong relationships with their children. The importance of early parent-child interactions for children's social competence is embedded in many theoretical frameworks, such as attachment (Ainsworth and Bowlby, 1991), family system theories (Cox and Paley, 1997), and ecocultural theories (Weisner, 2002). Parents socialize their children to adopt culturally appropriate values and behaviors that enable them to be socially competent and act as members of a social group. Research suggests that children who are socially competent are independent rather than suggestible, responsible rather than irresponsible, cooperative instead of resistive, purposeful rather than aimless, friendly rather than hostile, and self-controlled rather than impulsive (Landy and Osofsky, 2009). In short, the socially competent child exhibits social skills (e.g., has positive interactions with others, expresses emotions effectively), is able to establish peer relationships (e.g., being accepted by other children), and has certain individual attributes (e.g., shows capacity to empathize, has coping skills). Parents help children develop these social skills through parenting practices that include fostering and modeling positive relationships and providing enriching and stimulating experiences and opportunities for children to exercise these skills (Landy and Osofsky, 2009). Parents also help their children acquire these skills by having them participate in routine activities (e.g., chores, taking care of siblings) and family rituals (e.g., going to church) (Weisner, 2002). These activities are shared with and initiated by parents, siblings, and other kin; unfold within the home; and are structured by cultural and linguistic practices, expectations, and behaviors (Rogoff, 2003; Weisner, 2002). In this context, young children interact with their mothers, fathers, siblings, and grandparents who teach them implicitly or explicitly to acquire appropriate social behaviors, adapt to expected norms, and learn linguistic conventions and cognitive skills (Sameroff and Fiese, 2000). Another important aspect of parent-supported social development pertains to parents aiding their children in acquiring executive function skills needed to adapt to changing needs of the environment and regulate their impulses and responses to distressing situations (Blair and Raver, 2012; Malin et al., 2014; Thompson, 1994). Evidence, primarily from correlational research, suggests that parents who help their children regulate the difficulty of tasks and who model mature performance during joint participation in activities are likely to have socially competent children (Eisenberg et al., 1998). Parents also facilitate their children's development of friendships by engaging in positive social interaction with them and by creating opportunities for them to be social with peers (McCollum and Ostrosky, 2008). In one correlational study, children whose parents initiated peer contacts had more playmates and more consistent play companions in their preschool peer networks (Ladd et al., 2002). Research also shows that children who have increased opportunities for playing or interacting with children from diverse backgrounds are likely to develop less prejudice and more empathy toward others (Bernstein et al., 2000; Perkins and Mebert, 2005; Pettigrew and Tropp, 2000). Findings from experimental studies on parent training provide evidence of the types of parental practices that are associated with child emotional and behavioral health (i.e., fewer internalizing and externalizing problems) and social competence (i.e., relationship building skills, moral dispositions, and prosocial behaviors such as altruism). In one study for example, parent training designed to decrease the use of harsh discipline and increase supportive parenting reduced mother-reported child behavior problems in children ages 3-9 (Bjørknes and Manger, 2013). In another randomized study, mothers who received parent training to improve their empathy toward their children became less permissive with their 2- to 3-year-olds, who became less aggressive (Christopher et al., 2013). These relationships have been found to hold in experimental studies involving diverse samples. Brotman and colleagues (2005) found that a program designed to reduce parents' use of negative parenting and increase their provision of stimulation for child learning increased social competence with peers in young African American and Latino children who had a sibling who had been involved in the juvenile justice system. In a European study, Berkovits and colleagues (2010) studied ethnically diverse parents participating in an abbreviated parent skills training delivered in pediatric primary care aimed at encouraging children's prosocial behavior. The findings show significant increases in effective parenting strategies and in parents' beliefs about personal controls, as well as declines in child behavior problems. Improvements in child behavior as a consequence of parent training have been found not only for programs emphasizing better and more consistent discipline and contingency management, but also for those providing training that led to parents' greater emotional support for their children (McCarty et al., 2005). In addition, Stormshak and colleagues (2000) found that punitive interactions between parents and children were associated with higher rates of child disruptive behavior problems, and that low levels of warm involvement were characteristic of parents of children who showed oppositional behaviors. Internalizing disorders in young children include depression (withdrawal, persistent sadness) and anxiety (Tandon et al., 2009). They may occur simultaneously with and/or independently of externalizing disorders (e.g., noncompliance, aggression, coercive behaviors directed at the environment and others) (Dishion and Snyder, 2016). Studies focusing exclusively on the causes of internalizing disorders in young children are relatively limited. However, the results of the available studies lead to similar conclusions about the relationships among training, changes in parenting practices, and child internalizing problems. First, there is evidence that parental behaviors matter for child emotional functioning. Specifically, parents' sense of personal control and behaviors such as autonomy granting are inversely related to child anxiety in cross-sectional research (McLeod et al., 2007). Similarly, in another nonexperimental study, Duncombe and colleagues (2012) show that inconsistent discipline, parents' negative emotion, and mental health are related to child problems with emotion regulation. Second, there is evidence that parent training interventions can modify the parenting practices that matter. Third, some parent training interventions have positive effects on children's emotional functioning. In a review of randomized controlled studies of the effects of group-based parenting programs on behavioral and emotional adjustment, Barlow and colleagues (2010) found significant effects of the programs on parent-reported outcomes of children under age 4. Herbert and colleagues (2013) conducted a randomized clinical trial of parent training and emotion socialization for hyperactive preschool children in which the target outcome was emotion regulation. Not only did the intervention group mothers report lower hyperactivity, inattention, and emotional lability in their children, but also changes in children's functioning were correlated with more positive and less negative parenting and with less verbosity, greater support, and use of emotion socialization practices on the part of mothers. With respect to social competence, a number of studies point to a relationship with parenting practices and suggest that parent training may have an impact on both parenting practices related to and children's development of social competence. An experimental evaluation of the Incredible Years Program (discussed further in Chapter 5), for instance, found that parent training contributed to improved parenting practices, defined as lower negative parenting and increased parental stimulation for learning (Brotman et al., 2005), which, in turn, are related to children's social competence. Gagnon and colleagues (2014) found that preschool children with a combination of reactive temperament and authoritarian parents demonstrated low social competence (high levels of disruptive play and low levels of interactive play). In a community trial by Havighurst and colleagues (2010), training focused on helping parents tune in to their own and their children's emotions resulted in significant improvement in the parents' emotion awareness and regulation, as well as the practice of emotion coping. The intervention decreased emotionally dismissive beliefs and behaviors among parents, who also used emotion labels and discussed the causes and consequences of emotions with their children more often than was the case prior to the training. The program improved parental beliefs and relationships with their children, and these improvements were related to reductions in child behavior problems (Havighurst et al., 2010). As explained in the National Research Council (2000) report How People Learn: Brain, Mind, Experience, and School, individuals learn by actively encountering events, objects, actions, and concepts in their environments. For an individual to become an expert in any particular knowledge or skill area, he or she must have substantial experience in that area which is usually guided (Dweck and Leggett, 2000; National Research Council, 2000). As children's first teachers, parents play an important role in their cognitive development, including their acquisition of such competencies as language, literacy, and numerical/math skills that are related to future success in school and society more generally. Enriching and stimulating sets of experiences for children can help develop these skills. Evidence of the potential importance of parenting for language development is found across studies of parent talk. This research offers compelling correlational evidence that providing children with labels (e.g., for objects, numbers, and letters) to promote and reinforce knowledge, responding contingently to their speech, eliciting and sustaining conversation with them, and simply talking to them more often are related to vocabulary development (Hart and Risley, 1995; Hirsh-Pasek et al., 2015; Hoff, 2003). In addition to the frequency of talking with children, research is beginning to show that the quality of language used by parents when interacting with their children may matter for children's vocabulary development. Studies using various types of designs have shown that children whose fathers are more educated and use complex and diverse language when interacting with them develop stronger vocabulary skills relative to other children (Malin et al., 2012; Pancsofar and Vernon-Feagans, 2006; Rowe et al., 2004). Language development studies have found that providing an instructional platform in a child's early language experience, such as offering a social context for communication and asking more “what,” “where,” and “why” questions, is associated with language acquisition (Baumwell et al., 1997; Bruner, 1983; Leech et al., 2013). Similar findings are provided by experimental research on dialogic reading, in which adults engage children in discussion about the reading material rather than simply reading to them (Mol et al., 2008; Whitehurst et al., 1988). A meta-analytic review of 16 interventions by Mol and colleagues (2008) showed that, relative to reading as usual, dialogic reading interventions, especially use of expressive language, were more effective at increasing children's vocabulary. The effect was stronger for children ages 2-3 and more modest for those ages 4-5 and those at risk for language and literacy impairment (Mol et al., 2008). Frequency of shared book reading by mothers and fathers is linked to young children's acquisition of skills and knowledge that affect their later success in reading, writing, and other areas (Baker, 2014; Duursma et al., 2008; Malin et al., 2014). Studies demonstrate that through shared book reading, young children learn, among other skills, to recognize letters and words and develop understanding that print is a visual representation of spoken language, develop phonological awareness (the ability to manipulate the sounds of spoken language), begin to understand syntax and grammar, and learn concepts and story structures (Duursma et al., 2008; Malin et al., 2014). Shared literacy activities such as book reading also expose children to new words and words they may not encounter in spoken language, stimulating vocabulary development beyond what might be obtained through toy-play or other parent-child interactions (Isbell et al., 2004; Ninio, 1983; Whitehurst et al., 1988). Regular book reading also may play a role in establishing routines for children and shaping wake and sleep patterns, as well as provide them with knowledge about relationships and coping that can be applied in the real world (Duursma et al., 2008). Children of low socioeconomic status and minority children frequently have smaller vocabularies relative to children of higher socioeconomic status and white children, and these differences increase over time (Markman and Brooks-Gunn, 2005). Some experts have theorized that this differential arises from variations in “speech cultures” of families, which are linked to socioeconomic status and race/ethnicity. The middle- and upper-class (primarily white) speech culture is associated with more and more varied language and more conversation, which contributes to bigger vocabularies and improved school readiness among children in these homes (Hart and Risley, 1999). Little research has focused on whether reducing these variations would help close the racial/ethnic gap in school readiness, however (Markman and Brooks-Gunn, 2005). Relative to their middle- and upper-class, mainly white, counterparts, low-income and immigrant parents are less likely to report that they read to their children on a regular basis and to have books and other learning materials in the home (Markman and Brooks-Gunn, 2005). Besides culture, this difference may be due to such factors as access to books (including those in parents' first language), parents' own reading and literacy skills, and erratic work schedules (which could interfere with regular shared book reading before children go to bed, for example). As discussed in Chapter 4, limited experimental research suggests that interventions designed to promote parents' provision of stimulating learning experiences support children's cognitive development, primarily on measures of language and literacy (Chang et al., 2015; Garcia et al., 2015; Mendelsohn et al., 2005; Roberts and Kaiser, 2011). In one study, for example, interactions between high-risk parents and their children over developmentally stimulating, age-appropriate learning material (e.g., a book or a toy), followed by review and discussion between parents and child development specialists, were found to improve children's cognitive and language skills at 21 months compared with a control group, and also reduced parental stress (Mendelsohn et al., 2005). Early numeracy and math skills also are building blocks for young children's academic achievement (Claessens and Engel, 2013). To instill early math skills in young children, parents sometimes employ such strategies as playing with blocks, puzzles, and legos; assisting with measuring ingredients for recipes; solving riddles and number games; and playing with fake money (Benigno and Ellis, 2008; Hensen, 2005). Such experiences may facilitate children's math-related competencies, but compared with the research on strategies to foster children's language development, the evidence base on how parenting practices promote math skills in young children is small. A growing literature identifies general aspects of home-based parental involvement in children's early learning—such as parents' expectations and goals for their children, parent-child communication, and support for learning—that appear to be associated with greater academic achievement, including in math (Fan and Chen, 2001; Galindo and Sonnenschein, 2015; Ginsburg et al., 2010; Jeynes, 2003, 2005). More work is needed, however, to distill specific actions parents can take to promote math-related skills in their young children. At the same time, as noted earlier, some parents appear to be reluctant to engage their children in math learning—some because they lack knowledge about early math and may engage in few math-related activities in the home relative to activities related to language, and some because they view math skills as less important than other skills for their children (Blevins-Knabe et al., 2000; Cannon and Ginsburg, 2008; Vukovic and Lesaux, 2013). Given the demonstrated importance of early math skills for future academic achievement and the persistent gap in math knowledge related to socioeconomic status (Galindo and Sonnenschein, 2015), additional research is needed to elucidate how parents can and do promote young children's math skills and how they can better be supported in providing their children with these skills. Finally, there is some evidence for differences across demographic groups in the United States with respect to parents' use of practices to promote children's cognitive development. Barbarin and Jean-Baptiste (2013), for example, found that poor and African American parents employed dialogic practices less often than nonpoor and European American parents in a study that utilized in-home interviews and structured observations of parent-child interactions. Broadly defined, contingent responsiveness denotes an adult's behavior that occurs immediately after and in response to a child's behavior and is related to the child's focus of attention (Roth, 1987). Dunst and colleagues (1990) argue that every time two or more people are together, there is a communicative exchange in which the behavior (nonverbal or verbal) affects the other person, is interpreted, and is responded to with a “discernible outcome” (p. 1). Such communication exchanges between parents and their children are considered foundational for building healthy relationships between parents and children, as well as between parents (Cabrera et al., 2014). Within the multiple relationships and systems that surround parents and children, the quality of the relationship they share is vital for the well-being of both (Bronfenbrenner and Morris, 1998). The science is clear on the importance of positive parent-child relationships for children. Emotionally responsive parenting, whereby parents respond in a timely and appropriate way to children's needs, is a major element of healthy relationships, and is correlated with positive developmental outcomes for children that include emotional security, social facility, symbolic competence, verbal ability, and intellectual achievement (Ainsworth et al., 1974). The majority of children who are loved and cared for from birth and develop healthy and reciprocally nurturing relationships with their caregivers grow up to be happy and well adjusted (Armstrong and Morris, 2000; Bakermans-Kranenburg et al., 2003). Conversely, children who grow up in neglectful or abusive relationships with parents who are overly intrusive and controlling are at high risk for a variety of adverse health and behavioral outcomes (Barber, 2002; Egeland et al., 1993). The development of health-promoting relationships between parents and their children is rooted in evolutionary pressures that lead children to be born wired to interact with their social environment in ways that will ensure their survival and promote their eventual development (Bowlby, 2008). Through reaching out, babbling, facial expressions, and gestures, very young children signal to caregivers when they are ready to engage with them. Caregivers may respond by producing similar vocalizations and gestures to signal back to infants that they have heard and understood (Masataka, 1993). Cabrera and colleagues (2007) found that children of fathers who react to their behavior in a sensitive way by following their cues, responding, and engaging them are more linguistically and socially competent relative to children of fathers who do not react in these ways (Cabrera et al., 2007). This “serve and return” interaction between caregivers and children, which continues throughout childhood, is fundamental for growth-promoting relationships (Institute of Medicine and National Research Council, 2015; National Research Council and Institute of Medicine, 2000). A consistent give and take with responsive caregivers provides the child with tailored experiences that are enriching and stimulating; forms an emotional connection between caregiver and child; builds on the child's interests and capacities; helps the child develop a sense of self; and stimulates the child's intellectual, social, physical, and emotional and behavioral growth (Institute of Medicine and National Research Council, 2015; National Research Council and Institute of Medicine, 2000). This give and take is particularly important for language development. It is believed that through this process, the child learns that she or he is loved and will love others in return, and that she or he is accepted and cared for and will also eventually accept and care for others. For infants, social expectations and a sense of self-efficacy in initiating social interactions are influenced by their early interactions with their caregivers. McQuaid and colleagues (2009) found that mothers' contingent smiles (i.e., those in response to infant smiles) in an initial interactive study phase predicted infant social bids when mothers were still-faced in a subsequent study phase, a finding consistent with results of earlier research (Bigelow, 1998). The adult's response to the child's overtures for interaction needs to be contingent on the child's behaviors. Infants' spontaneous vocalizations are characterized by pauses that enable caregivers to respond vocally. Children who have experience with turn taking are able to vocalize back to the caregiver in a synchronized manner (Masataka, 1993). Young children's social and emotional development is influenced by the degree to which primary caregivers engage them in this kind of growth-promoting interaction (Cassidy, 2002). As described in Chapter 1, securely attached infants develop basic trust in their caregivers and seek the caregiver's comfort and love when alarmed because they expect to receive protection and emotional support. Infants who trust their caregivers to respond to their needs in a sensitive and timely manner are able to explore and learn freely because they can return to their “safe base” if they encounter unfamiliar things and events (Bowlby, 2008; Cassidy, 2002). In the face of the demands of daily life, with parents being unable to offer individualized responsiveness and synchronized, attuned interactions all of the time, sensitive caregiving makes it possible to manage and repair disruptions that inevitably occur in day-to-day parenting. High-quality “serve and return” parenting skills do not always develop spontaneously, especially during infancy and toddlerhood, before children have learned to speak. Some research indicates that lower-income families are at higher risk for not engaging in these types of interactions with their children (Paterson, 2011), but there is variability within and across economic and cultural groups (Cabrera et al., 2006). Differences among racial/ethnic groups in mothers' interactive behaviors with their young children have also been noted (e.g., Brooks et al., 2013; Cho et al., 2007). In a study of mothers of premature infants, for example, American Indian mothers relative to African American mothers looked and gestured more with their infants based on observer ratings (Brooks et al., 2013). Such differences may be related to variation in sociocultural norms or to other factors. Parents who experience such stressors as low income, conflict with partners or other adults, depression, and household chaos face more challenges to engaging in emotionally responsive parenting because of the emotional toll these stressors can exact (Conger and Donnellan, 2007; Markman and Brooks-Gunn, 2005; McLoyd, 1998). Building the capacities of all caregivers to form responsive and nurturing relationships with their children is crucial to promoting child well-being. As detailed in Chapters 4 and 5, experimental studies largely confirm evidence from correlational studies showing that sensitive parenting and attachment security are related to children's social-emotional development (Van Der Voort et al., 2014). One international study found that an intervention focused on responsive stimulation could promote positive caregiving behaviors among impoverished families (Yousafzai et al., 2015). Another study found that home visiting for parents of preterm infants that entailed promotion of more sensitive and responsive parenting skills modestly improved parent-infant interactions (Goyal et al., 2013). These and other interventions that successfully promote positive parent-child interactions, secure attachment, and healthy child development have been developed for parents of both infants (Armstrong and Morris, 2000) and preschoolers (Bagner and Eyberg, 2007). Some research shows that such an intervention provided first in infancy, followed by a second dose during the toddler/preschool years, is most effective at improving maternal behaviors and child outcomes (Landry et al., 2008). However, the success of preventive interventions in improving the quality of parent-infant attachment, a parent's relationship with her or his child, and the resulting child mental and physical outcomes depends upon the quality of the intervention (Chaffin et al., 2004), the number of sessions (a moderate number may be better than either more or less) (Moss et al., 2011), and the degree to which other parts of the parent-child system (e.g., separation due to parental incarceration or other reasons) are considered (Barr et al., 2011). Although much of the literature has focused on non-Hispanic white and black families, and mainly on mothers, preventive interventions with successful maternal and child outcomes have also been developed for Hispanic and Asian families (Ho et al., 2012; McCabe and Yeh, 2009) and can be designed to include fathers (Barr et al., 2011). Observational research suggests that children's development is enhanced by parents' use of predictable and orderly routines. Family routines, such as those related to feeding, sleeping, and learning, help structure children's environment and create order and stability that, in turn, help children develop self-regulatory skills by teaching them that events are predictable and there are rewards for waiting (Evans et al., 2005; Hughes and Ensor, 2009; Martin et al., 2012). Conversely, an unpredictable environment may undermine children's confidence in their ability to influence their environment and predict consequences, which may in turn result in children's having difficulty with regulating their behavior according to situational needs (Deater-Deckard et al., 2009; Evans and English, 2002). Although family routines vary widely across time and populations, studies have associated such routines with children's developmental outcomes (Fiese et al., 2002; Spagnola and Fiese, 2007). It is particularly difficult, however, to infer causal effects of routines on child outcomes in correlational studies because of the many contextual factors (e.g., parental depression or substance abuse, erratic work schedules) or factors related to economic strain (e.g., homelessness, poverty) that may make keeping routines difficult and at the same time adversely affect child development in other ways. Several literatures have developed around routines thought to promote particular developmental targets. For example, Mindell and colleagues (2009) describe results from a randomized controlled trial in which mothers instructed in a specific bedtime routine reported reductions in sleep problems for their infants and toddlers (see also Staples et al., 2015, for a recent nonexperimental analysis of bedtime routines and sleep outcomes). De Castilho and colleagues (2013) found in a systematic review of randomized controlled trials consistent associations between children's oral health and elements of their family environment such as parents' toothbrushing habits. And in a nationally representative cross-sectional study, Anderson and Whitaker (2010) report strong associations between exposure to various household routines, such as eating meals as a family, obtaining adequate sleep, and limiting screen time, and risk for obesity in preschool-age children. As discussed above, a growing body of literature also reports associations between more general aspects of children's healthy development, such as social competence, and the organization and predictability of a broader set of day-to-day experiences in the home (see Evans and Wachs, 2010). In some cases, however, routines are difficult to establish because of demands on parents, such as the nonstandard work schedules some parents are forced to keep. Reviewing the cross-sectional and longitudinal literature on nonstandard work schedules, for example, Li and colleagues (2014) found that 21 of the 23 studies reviewed reported associations between nonstandard work schedules and adverse child developmental outcomes. They found that while parents working nonstandard schedules, particularly those who work night or evening shifts, may be afforded more parent-child time during the day, such schedules can lead to fatigue and stress, with detrimental effects on the parent's physical and psychological capacity to provide quality parenting. Other research has looked at the impacts on children of living in home environments that are marked by high levels of “chaos,” or instability and disorganization (Evans and Wachs, 2010; Vernon-Feagans et al., 2012). A few studies have found a relationship between measures of household instability and disorganization and risk of adverse cognitive, social, and behavioral outcomes in young children. In a longitudinal study, for example, Vernon-Feagans and colleagues (2012) found that a higher level of household disorganization in early childhood (e.g., household density, messiness, neighborhood and household noise) was predictive of poorer performance on measures of receptive and expressive vocabulary at age 3. This finding held after taking into account a wide range of variables known to influence children's language development. Household instability (e.g., number of people moving in and out of the household, changes in residence and care providers) was not predictive of adverse language outcomes (Vernon-Feagans et al., 2012). In another longitudinal study, a questionnaire was used to assess household chaos based on whether parents had a regular morning routine, whether a television was usually on in the home, how calm the home atmosphere was, and the like when children were in kindergarten. Parent-reported chaos accounted for variations in child IQ and conduct problems in first grade beyond other home environment predictors of these outcomes such as lower parental education and poorer home literacy environment (Deater-Deckard et al., 2009). In other studies, children rating their homes as more chaotic have been found to earn lower grades (Hanscombe et al., 2011) and to show more pronounced conduct and hyperactivity problems (Fiese and Winter, 2010; Hildyard and Wolfe, 2002; Jaffee et al., 2012; Repetti et al., 2002; Sroufe et al., 2005). Household chaos has strong negative associations with children's abilities to regulate attention and arousal (Evans and Wachs, 2010). Children raised in chaotic environments may adapt to these contexts by shifting their attention away from overstimulating and unpredictable stimuli, essentially “tuning out” from their environment (Evans, 2006). In the short term, this may be an adaptive solution to reduce overarousal. In the long term, however, it may also lessen children's exposure to important aspects of socialization and, in turn, negatively affect their cognitive and social-emotional development. Emerging evidence suggests that the relationship between household chaos and poorer child outcomes may involve other aspects of the home environment, such as maternal sensitivity. In chaotic environments, for example, longitudinal research shows that parents' abilities to read, interpret, and respond to their children's needs accurately are compromised (Vernon-Feagans et al., 2012). Furthermore, supportive and high-quality exchanges between caregivers and young children, thought to support young children's abilities to maintain and volitionally control their attention, are fewer and of lower quality in such environments (Conway and Stifter, 2012; Vernon-Feagans et al., 2012). This association is likely to be of particular importance in infancy, when children lack the self-regulatory capacities to screen out irrelevant stimuli without adult support (Conway and Stifter, 2012; Posner and Rothbart, 2007). Even ambient noise from the consistent din of a television playing in the background is associated with toddlers' having difficulty maintaining sustained attention during typical play—a building block for the volitional aspects of executive attentional control (Blair et al., 2011; Posner and Rothbart, 2007). Studies with older children and adults show that chronic exposure to noise is related to poorer attention during visual and auditory search tasks (see Evans, 2006; Evans and Lepore, 1993). In addition, household chaos likely serves as a physiological stressor that undermines higher-order executive processes. Theoretical and empirical work indicates that direct physiological networks link the inner ear with the myelinated vagus of the 10th cranial nerve—a key regulator of parasympathetic stress response (Porges, 1995). Very high or very low frequencies of auditory stimuli such as those present in ambient and unpredictable noise directly trigger vagal responses indicative of parasympathetic stress modulation (Porges et al., 2013). In the same way, novel unpredictable and uncontrollable experiences can activate the hypothalamic-pituitary-adrenal (HPA)1 axis (Dickerson and Kemeny, 2004). General levels of chaos play a role in children's autonomic nervous system and HPA axis functioning (Blair et al., 2011; Evans and English, 2002) in ways that may negatively affect executive functioning (Berry et al., 2012; Oei et al., 2006). Highly chaotic environments also may affect children's language and early literacy development through similar mechanisms. Overstimulation, which may overtax children's attentional and executive systems, may challenge young children's ability to encode, process, and interpret linguistic information (Evans et al., 1999). The lack of order in such an environment also may impair children's emerging executive functioning abilities (see Schoemaker et al., 2013). Better executive functioning has been found in longitudinal research to be strongly associated with larger receptive vocabularies in early childhood (Blair and Razza, 2007; Hughes and Ensor, 2007), as well as with lower levels of externalizing behaviors (Hughes and Ensor, 2011). Other longitudinal studies have found positive relationships between family routines and children's executive functioning skills during the preschool years (e.g., Hughes and Ensor, 2009; Martin et al., 2012; Raver et al., 2013). Parental guidance or discipline is an essential component of parenting. When parents discipline their children, they are not simply punishing the children's bad behavior but aiming to support and nurture them for self-control, self-direction, and their ability to care for others (Howard, 1996). Effective discipline is thought to require a strong parent-child bond; an approach for teaching and strengthening desired behaviors; and a strategy for decreasing or eliminating undesired or ineffective behaviors (American Academy of Pediatrics, 1998). Effective discipline entails some of the parenting practices discussed earlier. In children's earliest years, for example, discipline includes parents' use of routines that not only teach children about the behaviors in which people typically engage but also help them feel secure in their relationship with their parent because they can anticipate those daily activities. As infants become more mobile and begin to explore, parents need to create safe environments for them. Beginning in early childhood and continuing as children get older, positive child behavior may be facilitated through parents' clear communication of expectations, modeling of desired behaviors, and positive reinforcement for positive behaviors (American Academy of Pediatrics, 2006). Over time, children internalize the attitudes and expectations of their caregivers and learn to self-regulate their behavior. Parents' use of corporal punishment as a disciplinary measure is a controversial topic in the United States. Broadly defined as parents' intentional use of physical force (e.g., spanking) to cause a child some level of discomfort, corporal punishment is assumed to have as its goal correcting children's negative behavior. Many researchers and professionals who work with children and families have argued against the use of physical punishment by parents as well as in schools (American Psychological Association, 2016; Hendrix, 2013). Although illegal in several countries, in no U.S. state is parents' use of corporal punishment entirely prohibited, with some variation in where states draw the line between corporal punishment and physical abuse (Coleman et al., 2010; duRivage et al., 2015). The state laws are consistent with the views of many Americans who approve of the use of spanking, used by many parents as a disciplinary measure with their own children (Child Trends Databank, 2015a; MacKenzie et al., 2013). In a 2014 nationally representative survey of attitudes about spanking, 65 percent of women and 78 percent of men ages 18-65 agreed that children sometimes need to be spanked (Child Trends Databank, 2015a). Among parents participating in the Fragile Families and Child Well-Being Study, 57 percent of mothers and 40 percent of fathers reported spanking their children at age 3, and 52 percent of mothers and 33 percent of fathers reported doing so when their children were age 5 (MacKenzie et al., 2013). Although physical punishment often results in immediate cessation of behavior that parents view as undesirable in young children, the longer-term consequences for child outcomes are mixed, with research showing a relationship with later behavioral problems. In a systematic review of studies using randomized controlled, longitudinal, cross-sectional, and other design types, Larzelere and Kuhn (2005) found that, compared with other disciplinary strategies, physical punishment was either the primary means of discipline or was severe was associated with less favorable child outcomes. In particular, children who were spanked regularly were more likely than children who were not to be aggressive as children as well as during adulthood. More recent analyses of data from large longitudinal studies conducted in the United States show positive associations between corporal punishment and adverse cognitive and behavioral outcomes in children (Berlin et al., 2009; Bodovski and Youn, 2010; MacKenzie et al., 2013; Straus and Paschall, 2009). Using data from two cohorts of young children (ages 2-4 and 5-9) in the National Longitudinal Survey of Youth, Straus and Paschall (2009) found that children whose mothers reported at the beginning of the study that they used corporal punishment performed worse on measures of cognitive ability 4 years later relative to children whose mothers stated that they did not use corporal punishment. In the Early Head Start National Research and Evaluation Project, Berlin and colleagues (2009) found that spanking at age 1 predicted aggressive behavior problems at age 2 and lower developmental scores at age 3, but did not predict childhood aggression at age 3 or development at age 2. The overall effects of spanking were not large. In the Fragile Families and Child Well-Being Study, MacKenzie and colleagues (2013) found that children whose mothers spanked them at age 5 relative to those whose mothers did not had higher levels of externalizing behavior at age 9. High-frequency spanking by fathers when the children were age 5 was also associated with lower child-receptive vocabulary at age 9. These studies controlled for a number of factors besides parents' use of physical punishment (e.g., parents' education, child birth weight) that in other studies have been found to be associated with negative child outcomes. Some have proposed that the circumstances in which physical discipline takes place (e.g., whether it is accompanied by parental warmth) may influence the meaning of the discipline for the child as well as its effects on child outcomes (Landsford et al., 2004). Using data from a large longitudinal survey, McLoyd and Smith (2002) found that spanking was associated with an increase in problem behaviors in African American, white, and Hispanic children when mothers exhibited low levels of emotional support but not when emotional support from mothers was high. Time-out is a discipline strategy recommended by the American Academy of Pediatrics for children who are toddlers or older (American Academy of Pediatrics, 2006), and along with redirection appears to be used increasingly by parents instead of more direct verbal or physical punishment (Barkin et al., 2007; LeCuyer et al., 2011). Yet for some parents, use of time-out may not be optimal, and parents who consult the Internet for how best to use this disciplinary technique may find the information to be incomplete and/or erroneous (Drayton et al., 2014). Research on best practices for the use of time-out continues to emerge, generally pointing to relatively short time-outs that are shortened further if the child responds rapidly to the request to go into time-out and engages in appropriate behavior during time-out (Donaldson et al., 2013), or may be lengthened if the child engages in inappropriate behavior during time-out (Donaldson and Vollmer, 2011). However, these studies are limited by very small sample sizes. States, seeking to shape briefer and more effective uses of the technique and to avoid prolonged seclusion, are just beginning to prescribe how time-out should be administered in schools (Freeman and Sugai, 2013). |
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