Article Text

Original research
Parenting attitude towards children with autism spectrum disorders: the Japan environment and children’s study
  1. Keita Kanamori1,2,
  2. Tomohisa Suzuki3,
  3. Chiharu Ota1,3,4
  4. Japan Environment and Children’s Study (JECS) Group
    1. 1 Department of Development and Environmental Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
    2. 2 Department of Pediatrics, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
    3. 3 Department of Pediatrics, Tohoku University Hospital, Sendai, Japan
    4. 4 Environment and Genome Research Center, Tohoku University Graduate School of Medicine, Sendai, Japan
    1. Correspondence to Dr Keita Kanamori; kanamori.keita.q5{at}dc.tohoku.ac.jp

    Abstract

    Objective The primary objective of this study was to investigate the parenting attitudes towards children with autism spectrum disorders in early childhood in Japan.

    Design This study was a cohort study. The participants were enrolled from January 2011 to March 2014. We obtained the prevalence of autism spectrum disorders at 3 years of age, parenting attitudes and other factors from questionnaires. We divided the participants into two groups, an autism spectrum disorders group and a non-autism spectrum disorders group, and compared the parenting attitudes.

    Setting This study used data from a Japanese birth cohort study: the Japan Environment and Children’s Study, conducted across 15 regional centres in Japan.

    Participants The full dataset of the Japan Environment and Children’s Study comprised 104 059 records. We excluded 17 889 records because the answer for the autism spectrum disorders in the questionnaire was blank. As a result, we analysed the remaining 82 411 mother–child pairs.

    Main outcome measures The primary outcome variable was parenting attitudes at 3.5 years of age, which was assessed using a questionnaire. We asked respondents 16 questions related to parenting attitudes, and they answered based on their behaviours. The independent variable was the prevalence of autism spectrum disorders at 3 years of age.

    Results Of the 82 411 participants, the children with autism spectrum disorders at 3 years of age were 372 (0.45%). In most questions about parenting attitudes, the autism spectrum disorders group had unfavourable responses. The difference was particularly noticeable when the parents taught their children social discipline. Unfavourable parenting attitudes were 16.6% in the autism spectrum disorders group and 0.8% in the non-autism spectrum disorders group in the question item with the largest difference between the two groups, a significant difference.

    Conclusions Parents of children with autism spectrum disorders tended to have unfavourable attitudes, suggesting the importance of parental training.

    • autism

    Data availability statement

    Data are available on reasonable request.

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • The relationship between parents and children has profound implications, and a healthy and positive relationship creates an environment that nurtures the development of children.

    WHAT THIS STUDY ADDS

    • The total number of participants was 82 411 in this study, and the prevalence of autism spectrum disorders at 3 years of age was 0.45% (n=372). Unfavourable parenting attitudes were 16.6% in the autism spectrum disorders group and 0.8% in the non-autism spectrum disorders group in the question item with the largest difference between the two groups, a significant difference.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Parents of children with autism spectrum disorders tended to show unfavourable attitudes, especially about social discipline. We emphasised the significance of comprehending these challenges in raising children with specific developmental characteristics and offering support to these parents.

    Introduction

    The relationship between parents and their infants has profound implications for the development of children. Social interaction may occur from the first moments of life when infants initiate and actively shape their encounters with caregivers. These repeated encounters foster lasting relational patterns that prepare the mind of the infant for culture and language. A healthy and positive relationship creates an environment that nurtures the physical, cognitive, emotional and social development of infants.1 Certain studies have indicated an association between parent–child interactions with mental health and behavioural disorders later.2–7 However, since families of children with autism spectrum disorders (ASD) experience more parenting stress,8 9 parents of children with ASD may encounter challenges in raising their children, which makes them prone to unfavourable parental behaviour.

    The objective of this study was to investigate the parenting attitudes adopted by parents of children with ASD by using data derived from a large Japanese birth cohort study, the Japan Environment and Children’s Study (JECS). Additionally, we aimed to assess the challenges they face in raising their children based on the results and underscore the significance of parental training.

    Methods

    Participants and the study protocol

    This cohort study, which used data from the JECS, was based on the jecs-ta-20190930 and jecs-qa-20210401 datasets.10 To ensure the generalisability and applicability of the results of JECS to the Japanese population, the 15 regional centres were selected to cover wide geographical areas with various living environments.10 All procedures and experiments were performed after written informed consent was obtained from all participants. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

    Pregnant participants of the JECS from 15 Japanese regions were enrolled between January 2011 and March 2014. We obtained information on the following: parenting attitudes, ASD diagnosed by clinicians at 3 years of age, enrichment lessons, group childcare, screen time and outside time, cohabitation with parents, presence or absence of siblings and/or grandparents living together, highest educational level of parents, neurodevelopmental disorders of mother, family income and occupation of the mother through a questionnaire survey. Here, the enrichment lessons included swimming, sports (eg, gymnastics), dance, music, abacus, painting, handicrafts, preschool classes and cram schools. The jecs-qa-20210401 dataset comprised 104 059 records. The number of live births was 100 300, but we excluded 17 889 records because the answer for the ASD in the questionnaire was blank. As a result, we analysed the remaining 82 411 mother–child pairs (figure 1).

    Figure 1

    Selection process for participant. The whole dataset comprised 104 059 records. The number of live births was 10 0300, but we excluded 17 889 records because the answer for the ASD in the questionnaire was blank. As a result, we analysed the remaining 82 411 mother–child pairs. ASD, autism spectrum disorder.

    Measurements

    The primary outcome variable was parenting attitudes at 3.5 years of age, which was assessed using a questionnaire. We probed the respondents to answer the 16 questions exhibited in table 1 when their children were 3.5 years of age. They chose the most appropriate answer from the following four opinions: ‘absolutely inappropriate’, ‘slightly inappropriate’, ‘slightly appropriate’ and ‘absolutely appropriate’. These variables of parenting attitude were used as nominal. We decided ‘unfavourable’ or ‘favourable’ standard for each 16 questions based on the following references. Baumrind delineated parenting styles using three well-known classifications: authoritative, authoritarian and permissive.11 Additionally, a recent meta-analysis on the components of parenting styles identified four clusters: positive, controlling, harshness and uninvolved.12 The authoritative approach is widely recommended by experts, including the American Academy of Pediatrics.13 We defined attitudes towards questions 5, 13 and 14 as questions of unfavourable responses, and all others were defined as questions of favourable responses. The independent variable was the prevalence of ASD at 3 years of age. Respondents were asked the following question when their child turned 3 years of age: ‘Have they ever been diagnosed with ASD (eg, autism, pervasive developmental disorder, Asperger’s syndrome) by a doctor?’ to which they chose ‘yes’ or ‘no’.

    Table 1

    Questions about parenting attitudes

    Statistical analyses

    We divided the participants into two groups, an ASD group and a non-ASD group, at 3 years of age and compared the answers to each of the 16 questions about parenting attitudes using Pearson’s χ2 test. If we discovered significant differences in parenting attitudes depending on the presence of ASD, we conducted multiple regression analysis to demonstrate that these differences contributed to ASD, even after accounting for other factors that could potentially influence parenting attitudes. Based on past reports and the author’s experience, we set the covariates; enrichment lessons,14 group childcare,15 cohabitation with parents,16 presence or absence of siblings and grandparents living together,16 17 educational level of parents,18 family income,18 occupation of mother,16 and outside time,19 sex,20 neurodevelopmental disorder of the mother,21 and screen time.19 Data with missing values were excluded from the analysis. Statistical analyses were conducted using R (V.3.3.0+), and the significance level was set to a p<0.05.

    Results

    The total number of participants was 82 411 in this study with 42 223 boys and 40 188 girls. Table 2 indicates the characteristics of the participants. The prevalence of ASD at 3 years of age was 0.45% (n=372). In terms of the mothers’ occupation, 63.5% of the ASD group were engaged in housework, compared with 48.8% in the non-ASD group (p<0.001). Additionally, the ASD group exhibited prolonged screen time (p<0.001) and limited outdoor activities (p=0.004). In the ASD group, 10.6% of the participants spent more than 2 hours per day for screen time whereas the ratio was 2.8% in the non-ASD group (p<0.001). The non-ASD group showed a higher likelihood of having siblings, with 53.4% having older siblings and 31.1% having younger siblings. Conversely, in the ASD group, 41.1% had older siblings (p<0.001) and 24.8% had younger siblings (p=0.015). Furthermore, 25.3% of the non-ASD group participated in enrichment lessons, while only 17.3% of the ASD group did so (p=0.001). Table 3 reveals the differences in answers regarding parenting attitudes between the ASD and non-ASD groups. The ASD group answered ‘absolutely appropriate’ or ‘slightly appropriate’ to questions 13 and 14, and ‘absolutely inappropriate’ or ‘slightly inappropriate’ to the other questions when compared with the non-ASD group, and there were significant differences for questions 1, 6, 8–16. This trend was also observed in multiple regression analysis, and there were significant differences for question 4, 6, 8–16 (online supplemental etables 1–16). The maximum variance inflation factor was 1.56.

    Supplemental material

    Table 2

    Characteristics of participants, n=82 411

    Table 3

    Parenting attitudes at 3.5 years of age, n=82 411

    The heatmap in figure 2 illustrates the log ORs of the ASD group compared with the non-ASD group for their responses to each of the 16 questions. The outcome was the proportion corresponding to each answer. In the heatmap, the log ORs of 0 were depicted in white, positive values were illustrated in red and negative values were in blue. Additionally, the intensity of the colour deepened with the absolute value. For instance, in question 1, 1.8% in the ASD group provided an absolutely unfavourable answer, compared with 1.2% in the non-ASD group. The resulting OR was 1.51, yielding a logarithm of 0.41. Consequently, the colour representing absolutely unfavourable responses for question 1 appeared as light red. In figure 2, the items were arranged from left to right in descending order of the log OR of absolutely unfavourable responses. Each map exhibits the different directions of parental attitudes regarding social discipline or affection, concern or respect for children. In the social discipline-related questions, the OR for exhibiting unfavourable responses was higher than that for questions that related to affection/concern/respect for children.

    Figure 2

    Parenting attitudes of the ASD group. This heatmap illustrates the log ORs of the ASD group compared with the non-ASD group for their responses to each of the 16 questions about parenting attitudes. The outcome was the proportion corresponding to each answer. Red colour represents high odds in the ASD group whereas the blue colour represents low odds in the ASD group. *Regarding Q3, since participants who answered ‘absolutely inappropriate’ were few in both the ASD group (0/857 participants, 0%) and the non-ASD group (80/77 280 participants, 0.001%), OR was not calculated. ASD, autism spectrum disorder.

    Discussion

    We verified that parents of children with ASD tend to have unfavourable parenting attitudes by using data obtained from a nationwide large birth cohort study in Japan. The novelty of this study was that we researched what kind of attitudes parents tended to take, and found that unfavourable attitudes were conspicuous when they taught their children social discipline.

    Of the 16 questions on parenting attitudes, questions 1–5, 7 and 8 pertaining to the expression of parental affection, concern and respect for children. The remaining questions were related to the aspect of discipline. Multiple regression analysis revealed that parents of children with ASD had unfavourable parenting attitudes in questions 4, 6 and 8–16, the majority of which pertained to discipline, except for questions 4 and 8. The rate of parents exhibiting unfavourable parenting attitudes was more than twofold greater in the ASD group compared with the non-ASD group for questions 6, 11, 13, 15 and 16, and all these questions pertain to this discipline. Children with ASD often encounter difficulties in speaking and comprehension, which can lead to challenges in communication between parents and children.22 Additionally, the development of communication and language skills in children with ASD has been identified as a significant predictor of parents' emotions and attitudes.23 Therefore, it was plausible that significant differences existed between the two groups in behaviour patterns requiring language skills, such as those observed in question 6. This result further underscored the critical importance of speech and language intervention for individuals with ASD as has been shown before.24 Several studies indicate that a positive relationship between mothers and children is important for healthy development.5 25 26 Though parental expression of affection, concern and respect for their children is crucial, the results of this study suggest that parental attitudes towards teaching social discipline to children are equally significant. However, this study also revealed that parents of children with ASD often faced difficulty and in showing appropriate parenting attitudes. While intervention effects in ASD are not clearly verified, behavioural and educational interventions have been frequently employed, with some reports indicating the efficacy of early intervention.27–29 Moreover, it is crucial for the parents to understand and incorporate the effective parenting skills both at home and in the community.27 In light of this, we recommend early child-rearing training programmes for the parents of children with ASD. Furthermore, we strongly advocate for educational institutions and local communities to embrace diversity and create supportive environments for the parents of children with specific developmental characteristics. In recent years in Japan, since ‘praising parenting’ has been emphasised to develop a child’s self-esteem, parents hesitate in scolding or issuing warnings to their child. However, we believe that relying solely on praise is insufficient and that it is equally important to teach social discipline when necessary. ‘Praising parenting’ is not an alternative to scolding or issuing warnings. The essence of ‘praising parenting’ is to praise an effort or a motivation without results. The previous study shows that positive maternal feedback, particularly when linked to children’s actions or products, is overall related to children’s later persistence.30 Praising conveys parents’ affection and expectations to the children which leads to promoting self-esteem without comparing to others and enhancing self-discipline and autonomy. In particular, praising that emphasises children’s effort, actions and strategies may develop a motivational framework in the cognitive and sociomoral domains.31 ‘Praising parenting’ is one of techniques to teach social discipline to any children not limited to children with ASD. The positive parenting is also important for general parenting practices as shown in previous studies.32–35

    Furthermore, as secondary findings, environmental factors such as enrichment lessons, group childcare and cohabitation with siblings might also be associated with positive parenting attitudes. Interactions with diverse people are also linked to positive parenting attitudes and play an important role in child development, particularly in developing social skills.36 37 Previous reports showed that participating in enrichment lessons was correlated with development of children and later occupational success.38 39 Furthermore, Sylva et al established that spending more hours in group childcare was connected to higher cognitive functions, while spending more hours in individual care was associated with lower levels of orientation/engagement.15

    This study had certain limitations. First, the causal relationship between unfavourable parenting attitudes and ASD remains unclear. It was challenging to determine whether unfavourable parenting attitudes led to the development of ASD, or whether the presence of ASD influenced parenting attitudes. This relationship is likely to be influenced by the complex interplay of diverse factors. Second, this study used a questionnaire survey; therefore, the dataset was based on questionnaires filled out by caregivers. Third, since the diagnosis of ASD is often made after the age of three,40 it is worth noting that the non-ASD group may include cases that are later diagnosed with ASD. Finally, this study recruited the general population, and participation was voluntary and at the discretion of the participants. Hence, this may have contributed to a selection bias for parents with higher health literacy at the time of participation.

    Conclusion

    Our study investigated the correlation between parenting attitudes and ASD, revealing that parents of children with ASD often exhibit unfavourable attitudes. To tackle this issue, we emphasise the importance of early parenting training and providing support to parents facing difficulties in raising children with specific developmental characteristics. In this study, we used specific questions to identify the types of inappropriate behaviours exhibited by the participants. We considered that professionals involved in parenting training, such as doctors, psychologists, school teachers and others, can use this data as a reference when providing guidance.

    Data availability statement

    Data are available on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Ministry of the Environment’s Institutional Review Board on Epidemiological Studies and the Ethics Committees of all participating institutions (Ethical Number: 100910001). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    The authors thank participants, research co-ordinators, doctors, the staff and medical editor at Tohoku University and Editage (www.editage.com) for English language editing.

    References

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Collaborators Members of the JECS Group as of 2023: Michihiro Kamijima (principal investigator, Nagoya City University, Nagoya, Japan), Shin Yamazaki (National Institute for Environmental Studies, Tsukuba, Japan), Yukihiro Ohya (National Center for Child Health and Development, Tokyo, Japan), Reiko Kishi (Hokkaido University, Sapporo, Japan), Nobuo Yaegashi (Tohoku University, Sendai, Japan), Koichi Hashimoto (Fukushima Medical University, Fukushima, Japan), Chisato Mori (Chiba University, Chiba, Japan), Shuichi Ito (Yokohama City University, Yokohama, Japan), Zentaro Yamagata (University of Yamanashi, Chuo, Japan), Hidekuni Inadera (University of Toyama, Toyama, Japan), Takeo Nakayama (Kyoto University, Kyoto, Japan), Tomotaka Sobue (Osaka University, Suita, Japan), Masayuki Shima (Hyogo Medical University, Nishinomiya, Japan), Seiji Kageyama (Tottori University, Yonago, Japan), Narufumi Suganuma (Kochi University, Nankoku, Japan), Shoichi Ohga (Kyushu University, Fukuoka, Japan), and Takahiko Katoh (Kumamoto University, Kumamoto, Japan).

    • Contributors KK conceived and designed the study, collected the data, drafted the initial manuscript, carried out the initial analyses, and reviewed and revised the manuscript. TS critically reviewed the data analyses and the manuscript. CO collected the data and critically reviewed and revised the manuscript. All the authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. KK was the guarantor and accepted full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding This study was funded by the Ministry of the Environment, Japan (2022-016).

    • Disclaimer The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the Japanese Ministry of the Environment.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.