Parenting attitude towards children with autism spectrum disorders: the Japan environment and children’s study

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).

Request permission

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.

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.

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.

Request permission

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.