DÄ internationalArchive42/2020Self-Reported Psychosocial Stress in Parents With Small Children

Original article

Self-Reported Psychosocial Stress in Parents With Small Children

Results From the Kinder in Deutschland–KiD-0–3 Study

Dtsch Arztebl Int 2020; 117: 709-16. DOI: 10.3238/arztebl.2020.0709

Lorenz, S; Ulrich, S M; Sann, A; Liel, C

Background: Psychosocial stress in early childhood can impair children’s health and development. Data on the prevalence of psychosocial stress in families with infants and toddlers in Germany are lacking. Such data could be used to determine the need for prevention and to plan the appropriate preventive measures.

Methods: In 2015, a representative cross-sectional study called Kinder in Deutschland—KiD 0–3 was conducted by questionnaire in pediatricians’ practices across Germany. Parents taking their children to the U3–U7a child development checks were asked to self-report information about stress in their families. The data were analyzed with descriptive statistics and chi-square tests.

Results: Data from 7549 families went into the analysis. Stressful situations commonly reported by the parents included unplanned pregnancy (21.3%), parenthood-related stress (e.g., self-doubt as to parenting competence, 29.6%), and lack of familial and social support for problems and questions arising in relation to the child, as well as for temporary child care (19.7%). Most types of psychosocial stress varied as a function of the child’s age group, as categorized by the particular examination for which the child was presenting at the time of the survey (U3–U7a). Couple distress, lack of social support, signs of depression or anxiety symptoms, or inner anger were more commonly reported by parents attending the later examinations. Such problems could be addressed by supportive measures (e.g., parent counseling, early child intervention).

Conclusion: Psychosocial stress affects a large percentage of the parents of small children. A large proportion of parents of small children suffer from psychosocial stress. This should be monitored for accumulation and stability across child development checks and addressed as appropriate. Family practitioners and pediatricians are important partners for effective cooperation between the social system and the health-care system, and for the provision of preventive measures where appropriate.

LNSLNS

Psychosocial stress, especially adverse childhood experiences, is disproportionately likely to influence child development in negative ways and often leads to risky health behavior, such as substance abuse, increased burden of disease and increased healthcare costs (1). In Germany, a retrospective survey showed that difficulties in the parental home as well as violence and deprivation experiences were associated with an increased likelihood of depression, anxiety, physical aggression, and low life satisfaction as an adult (2). While international studies identified several additional types of psychosocial stress associated with an increased risk of developmental abnormalities (3, 4, 5, 6, 7, 8), reliable prevalence estimates for Germany are available only for a few of these stressors and risks (9).

The clinical perspective

Knowledge of the significance of individual adverse psychosocial factors in the highly sensitive first period of life may be useful to develop approaches to prevention strategies. Currently, there is no reliable data on how many of the families with children who participate in the statutory child development checks suffer from psychosocial stress. On the side of the child, these characteristics can, for example, include negative emotionality, and on the side of the parents, parenting stress or, with regard to the family, frequent quarrels. In terms of targeting prevention services to young parents, this is important information. Parents’ subjective experience of psychosocial stress is a key criterion when it comes to taking the initiative for participating in prevention programs; thus, prevalence rates can be used to estimate the need for prevention. Over 99% of parents attend the child development checks (10), reflecting their high level of trust in pediatricians. Therefore, child development checks do not only provide an opportunity to detect biomedical diseases and monitor progress in the child’s development, but also to gain a first impression of the overall situation in the family (11, 12, 13, 14). While in the United States an overall concept for pediatricians has already been developed and evaluated which is designed to enable early identification and support of families experiencing psychosocial stress (15), in Germany a pediatric assessment form for the evaluation of psychosocial support needs (“pädiatrischer Anhaltsbogen”) is available to be used during the U3 to U6 child development checks (U screening) (16) as well as Interprofessional Quality Circles for Early Childhood Intervention (IQZ FH, Interprofessionelle Qualitätszirkel Frühe Hilfen) for physicians to anonymously share information about patients with psychosocial stress (17).

In our study, psychosocial stress was assessed using self-reports of parents. These reports were obtained during the child development checks (U3–U7a screening) in community-based pediatric practices. Our study is based on data of the “Children in Germany“ national prevalence survey (Kinder in Deutschland—KiD 0–3). It was conducted within the framework of the scientific support for the German federal initiative “Networks for Early Childhood Intervention and Family Midwives” (Netzwerke Frühe Hilfen und Familienhebammen) within the German National Center for Early Prevention (Nationales Zentrum Frühe Hilfen, NZFH), a collaboration between the Federal Center for Health Education (Bundeszentrale für gesundheitliche Aufklärung) and the German Youth Institute (Deutsches Jugendinstitut e. V.). It was financially supported by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ, Bundesministerium für Familie, Senioren, Frauen und Jugend). At the interface between health system and social system, Early Childhood Intervention (Frühe Hilfen) is intended to provide non-stigmatized access to support for families experiencing psychosocial stress. The goal is to enable every child to grow up healthy and without violence. This study has the following aims:

  • To present frequencies of sociodemographic data and prevalence rates of psychosocial stress for families with children aged 0 to 48 months, living in Germany.
  • To show differences in the prevalence rates of individual stress characteristics and of three or more cumulative characteristics between age groups corresponding to the U3 to U7a screening examinations.

Methods

The representative KiD 0–3 main study, designed as a cross-sectional survey, is embedded in an extensive study program (18). For sample recruitment, a two-step selection procedure was used: In the first step, a stratified random sample was drawn from community-based pediatric practices in Germany. In the second step, all mothers and fathers taking their children to any of these practices for a child development check (U3–U7a screening) were invited to complete a written questionnaire. Altogether, 271 medical practices participated in the study (response rate of 15% of the gross sample). They handed out the questionnaires and documented the participating and non-participating families. The participating parents (altogether 8063; response rate of 75%) completed the questionnaire independently and in an anonymized form. Further information about the study design is provided in the eMethods section.

The questionnaire included questions about biographical and perinatal characteristics as well as psychosocial stress characteristics. The characteristics were selected based on English systematic reviews on risk factors for abnormal child development and child maltreatment (5). Data were collected using established survey instruments, if available. In the eTable, the operationalization of all measures of stress is described, including, for example, couple distress (e4), parenting stress (e6) and signs of depression or anxiety symptoms (e8).

Operationalization of the psychosocial stress characteristics
eTable
Operationalization of the psychosocial stress characteristics

Data analysis was performed using the statistical software package STATA 15.1. The measured stress characteristics, if available, were dichotomized based on clinical cut-off values to differentiate between families exposed and non-exposed to psychosocial stress (risk definition). The analysis comprised descriptive statistics and Chi-square testing. The measures of stress were then added up to show the proportion of families with three or more risk factors, who were more likely to experience psychosocial stress. The cut-off value of three stress characteristics is commonly used in the literature (6, 7). Based on the complex, clustered sampling strategy, design weighting to adjust for German federal states (“Bundesländer”) and a post-stratification procedure were used. By using this strategy, the sample was adjusted for age, citizenship, education, and vocational training of the mother as well as household constellation to the German Microcensus (own calculations based on [19]). Frequencies of psychosocial stress measures (point prevalence rates) are presented taking into account the survey weighting and excluding missing values. The no-response rate was generally below 5%, with the exception of a rate of 6.7% found for negative emotionality of the child. Only questionnaires completed by biological parents were included. Children with missing age information and children aged older than 48 months were excluded from the calculations for this study. Children were allocated to the child development checks based on self-defined age limits (Table 1).

Distribution of the sample by age group and child development check
Table 1
Distribution of the sample by age group and child development check

Results

Altogether 7549 families with children aged between 0 and 48 months were included in the analyses. The mean number of participating families per practice was 14 (min = 3, max = 36). In 90.5% of cases, the biological mother answered the questions (age in years: mean [M] = 31.6; standard deviation [SD] = 5.1), in 7.3% of cases the biological father (age in years: M = 35.0; SD = 6.6) and in 2.2% of cases mother and father jointly completed the questionnaire (mean age of the primary carer: M = 31.6; SD = 6.5). Of the included families, 19.5% reported that they had received social welfare benefits during the last 12 months. 14.5% of the primary carers had no vocational qualification and no higher educational attainment than an intermediate secondary school (“Realschule”) leaving certificate. By contrast, 31.5% had a university degree or a master craftsman‘s certificate. The mean age of the children was 14.3 months (M = 11; SD = 12.3). 50.4% of the children were male and 49.6% female. In 30.5% of cases, the child had a migration background (pursuant to Sec. 6 of the German Migration Background Survey Ordinance: if the child has no German citizenship, one parent immigrated to Germany or was born abroad).

The psychosocial stress situation of the parents at the time of the child development check may be influenced by events and adverse perinatal characteristics which date back some time (Table 2). In 7.4% of families, the mother was not older than 21 years at the time of giving birth. In 21.3% of families, the pregnancy was unplanned. Altogether, 4.5% of parents stated that they had considered abortion. One in ten families reported regular maternal smoking during pregnancy (9.8%). In 3.0% of families, the parents reported that the antenatal check-ups by a gynecologist or midwife were only irregularly attended. 8.8% of the parents reported a preterm birth before the completion of 37 weeks‘ gestation; 7.1% low birth weight <2500 g; 2.1% multiple birth; and 1.5% a disability or severe disease of the child. With regard to their own biographical characteristics, 10.8% of parents reported adverse experiences as a child (e.g. not much love, harsh punishment) and 9.0% violence experienced in a partnership. In 2.4% of the families, indications of present or past addiction problems of a parent are found.

Prevalence rates of adverse biographical and perinatal characteristics
Table 2
Prevalence rates of adverse biographical and perinatal characteristics

The current psychosocial stress experienced by the parents at the time of the survey is presented by child development checks, from U3 through to U7a (Table 3): Only few parents stated that they are not in a partnership (6.0%) or that the current partner is not the biological parent of the child (1.8%). Lack of support from the family/social environment regarding questions in relation to the child, couple distress, and lack of partnership were reported more frequently during later child development checks.

Prevalence rates of psychosocial stress characteristics (%. weighted *) by U3–U7a child development checks
Table 3
Prevalence rates of psychosocial stress characteristics (%. weighted *) by U3–U7a child development checks

Parental characteristics regarding psychosocial stress (Table 3) included signs of depression or anxiety symptoms (overall: 4.3%), frequent inner anger (overall: 12.6%). Here, an increased proportion is seen at the U7a child development check compared to earlier U screening examinations. The frequency of parenting stress is differentiated by the subscales of the Parenting Stress Index(German version) and varies between 15.6% and 30.1% (e6).

Child stress characteristics were found as follows (Table 3): The prevalence of negative emotionality (e.g. difficult to comfort or frequent tantrums) is with 2.8% and 2.4% at the U4 and U5, respectively, lower and with 7.0% and 7,8% at the U7 and U7a higher compared to the overall prevalence of 4.8% across all child development checks. The objective stress caused by the child’s crying behavior, i.e. if a child is crying more than three hours a day, three times per week for three weeks (“rule of threes”) (e10), is found reduced at later child development checks (e.g. 1.4% at the U7a) compared to earlier examinations (e.g. 5.3% at the U3). The parents reported no age-dependent differences in their subjectively perceived stress caused by the child’s crying behavior (overall: 12.8%). In the other child regulation areas, differences in the parental stress experience were found between the child development checks, peaking at the U3 examination for sleeping behavior (14.3%) and eating behavior (6.0%).

Three or more stress characteristics are shown by 10.1% of the families based on the cumulative biographical and perinatal characteristics and by 29.1% of the families based on cumulative psychosocial stress (Table 4). Due to the static character of the adverse biographical and perinatal characteristics, differences between the child development checks are found only in the area of psychosocial stress. The proportion of families with three or more psychosocial stress characteristics is with 33.1% increased at the U7a examination compared to a proportion of 26.6% and 26.3% at the U4 and U5 examinations, respectively. As already shown for the individual stress characteristics, the level of psychosocial stress is higher with later child development checks. When all 20 biographic, perinatal and psychosocial measures are added up, 40.4% of the families have a cumulation of three and more stressors. At this total value, no differences are found between the child development checks.

Cumulative stress characteristics (%. weighted*) by U3–U7a child development check
Table 4
Cumulative stress characteristics (%. weighted*) by U3–U7a child development check

Discussion

In Germany, data of a nationwide survey of psychosocial stress in families has until now only been collected during child development checks, using the pediatric assessment form for the evaluation of psychosocial support needs, in a small sample (16). According to the participating pediatricians, 37 children (7.2% of the total sample) were exposed to psychosocial stress (20). The author herself noted that the prevalence rates of the clinically relevant symptoms (4.5% sleeping difficulties, 2.9% feeding difficulties, 1.4% excessive crying) were significantly lower compared to previous estimates (12,8% sleeping difficulties, 15.9–19.1% feeding difficulties and 9.7–16.3% excessive crying) (9, 21, 22). Health-related comparative data from the literature are in line with the findings of the KiD 0–3 study. These include, for example, self-reported maternal smoking during pregnancy in about 10% (23, 24), preterm birth before the completion of 37 weeks‘ gestation in about 9% (25, 26) and low birth weight <2500 g in about 7% (27).

The results presented here focused on age-specific differences in the prevalence rates of various psychosocial stress measures at the time of the U3–U7a child development checks. Age-specific differences were found for almost all stress characteristics, except for loud quarrels (7.3%), constraints due to parenting role (26.1%) and subjective experience of stress due to crying behavior (12.8%). The cross-sectional findings indicate temporal variability of parental challenges as the result of the child’s development. The results of the KiD 0–3 study are in line with longitudinal study results which show that parents increasingly express dissatisfaction with their partnership with increasing age of the child (28). The results indicate that 19.7% of the families have a growing need for social support with increasing child age. This need may be explained by changes in the child’s developmental requirements or the parents’ circumstances (e.g. return of the mother to the workforce) (29). This underlines the importance of universal prevention services for families aimed at extending the social networks of families (e.g. parent cafes, parent-child groups).

The results of the KiD 0–3 study provide evidence that parents—especially mothers—feel to some extent more stressed by the behavior of their child in three regulation areas if the child is breastfed (30). Furthermore, the study shows that the perceived stress due to a child’s screaming and crying is less dependent on the age of the child compared to the stress associated with the child’s sleeping and eating behavior. With regard to the child’s crying, the subjective stress also appears to be less age-dependent than it would be expected based on the objective measurement obtained using the “rule of threes“. The prevalence of objectively stressful screaming and crying (5.1% and 2.1% in children aged <3 months and <6 months, respectively) measured in the KiD 0–3 study is lowered compared to the findings of a nationwide telephone survey in Germany for the birth cohorts 1999 to 2003 (5.8% and 2.5% among children aged <3 months and <6 months, respectively) (21). These prevalence rates from the KiD 0–3 study deviate from the data presented in Table 3 because the age limits are located within the age groups of the U4 and U5 examinations, respectively (Table 1).

The data reported here provide evidence that there is a relevant variation in psychosocial stress caused by individual stressors depending on the respective child development check-up. If one looks at the cumulative psychosocial stress data, it can be seen that the level of psychosocial stress is higher in later child development checks. Consequently, the pediatrician’s role as a support person is an ongoing requirement.

From a methodological perspective, it should be noted that just adding up stress characteristics only allows limited conclusion about the type of stressor or specific support needs (31). In international comparative studies, usually an additive risk index was used to screen for child maltreatment and to determine support needs. Studies conducted in Florida and Alaska found that families with three and more risk factors accounted for 13% (7) and 18% of the families, respectively, in the 0–3-month age group (6). A pilot project of the German Early Childhood Prevention (Frühe Hilfen) found a proportion of 21% (32). The findings of the KiD 0–3 study related to the assessment of support needs and the links between psychosocial stress and child abuse and neglect have already been reported elsewhere (31, 33). The comparatively high proportion of 29% presented here can be attributed to the fact that the KiD 0–3 study incorporated a relatively high number of risk factors in order to broadly cover the overall psychosocial situation of the families.

The field access via medical practices to the families has proven useful since the U screening program for children in Germany is accepted by much of the population. The pediatricians’ response rate to study participation was with 15% relatively low; however, the comparison of the KiD 0–3 sample with the German Microcensus shows no loss of representativeness on the family level (33). A mild middle class bias showing as a more frequent participation of better educated families compared to the lower participation rate of less educated families could not be avoided. The insights into the families’ psychosocial stress are based on information self-reported by parents. Underestimation of sensitive issues, such as alcohol and drug abuse, is likely since a socially desirable response behavior can be assumed. Measures of psychosocial stress at the time of the child development checks were reported stratified for the respondents’ age, but not gender. Designed to cover a broad range of psychosocial stress characteristics and to systematically collect these data, the KiD 0–3 study can provide deep insight into the psychosocial situation of families with infants and toddlers in Germany.

Acknowledgement

The KiD 0–3 study is a team effort with the further collaboration of Dr. Christian Brand, Prof. Dr. rer. nat. Andreas Eickhorst, Dr. Birgit Fullerton, Dr. phil. Katrin Lang, Dr. phil. Ulrike Lux, Dr. phil. Daniela Salzmann, Dr. rer. nat. Andrea Schreier, Caroline Seilbeck, and Prof. Dr. phil. Sabine Walper of the German Youth Institute (DJI) in Munich and Dr. phil. Anna Neumann, Ilona Renner and Mechthild Paul of the Federal Center for Health Education (BZgA) in Cologne. We would like to thank them all for their support and the families in this study for their readiness to provide information.

Financial support

The KiD 0–3 study was supported with funds of the federal initiative “Networks for Early Childhood Intervention and Family Midwives” by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ).

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 6 December 2019, revised version accepted on 6 April 2020

Translated from the original German by Ralf Thoene, MD.

Corresponding author
Susanne Marlene Ulrich
Deutsches Jugendinstitut e. V.
Nockherstr. 2,
81541 München, Germany
ulrich@dji.de

Cite this as:
Lorenz S, Ulrich SM, Sann A, Liel C: Self-reported psychosocial stress in parents with small children: results from the Kinder in Deutschland—KiD 0–3 study. Dtsch Arztebl Int 2020; 117: 709–16. DOI: 10.3238/arztebl.2020.0709

Supplementary material

For eReferences please refer to:
www.aerzteblatt-international.de/ref4220

eMethods, eTable:
www.aerzteblatt-international.de/20m0709

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Kübber E: Aspekte seelischer Gesundheit im Kleinkindalter. Entwicklung und Validierung eines Screening-Instruments zur Früherkennung von Entwicklungsauffälligkeiten. Inaugural Dissertation. Ludwig-Maximilians-Universität (LMU) 2014.
e10.
Wessel MA, Cobb JC, Jackson EB, Harris GS, Detwiler AC: Paroxysmal fussing in infancy, sometimes called „colic“. Pediatrics 1954; 14: 421–35.
Department of Family and Family Politics, National Center for Early Prevention, German Youth Institute (DJI, Deutsches Jugendinstitut e.V. ), Munich, Germany: Simon Lorenz, Susanne Marlene Ulrich, Alexandra Sann, Dr. phil. Christoph Liel
Key messages
Distribution of the sample by age group and child development check
Table 1
Distribution of the sample by age group and child development check
Prevalence rates of adverse biographical and perinatal characteristics
Table 2
Prevalence rates of adverse biographical and perinatal characteristics
Prevalence rates of psychosocial stress characteristics (%. weighted *) by U3–U7a child development checks
Table 3
Prevalence rates of psychosocial stress characteristics (%. weighted *) by U3–U7a child development checks
Cumulative stress characteristics (%. weighted*) by U3–U7a child development check
Table 4
Cumulative stress characteristics (%. weighted*) by U3–U7a child development check
The clinical perspective
Operationalization of the psychosocial stress characteristics
eTable
Operationalization of the psychosocial stress characteristics
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