Rudolph's Pediatrics, 22nd Ed.

CHAPTER 19. Family Function and Birth of a Child

William I. Cohen

FAMILY FUNCTION

A discussion of family transitions and their effects on children requires consideration of the function and structure of families beginning with the biological family (parents and children). This basic grouping provides the context and crucible for a child’s development. It is important to note, however, that many other family constellations successfully provide for the needs of children in addition to the two biologic-parents model: single-parent families, children raised by extended kinships (including grandparents), same-sex couples, adoptive families, foster families, blended families, and communal families. Despite moral, religious, and legal issues (as is the case of single-parent families and same-sex couples in the early 21st century in the United States), each of these can be as successful in this task as the biological family can be unsuccessful (Table 19-1).

The family serves as a microcosm of society, transmitting core values and beliefs. The children, in turn, learn these values and, in many instances, transmit them to the next generation. These values are not, however, universal: Consider societies where women have inferior status or where children are considered property. In our culture, with its Judeo-Christian tradition reflected in our Western legal tradition, children are protected from physical, emotional, and sexual maltreatment, and the role of the family is to prepare the child for independent functioning.

Picturing the family as a mobile (like those which often hang over an infant’s crib) provides a visual representation of an important aspect of its structure: Each level corresponds to a different generation, reflecting a natural hierarchy (Fig. 19-1). The interconnectivity of family members is also well-represented by this model. As constructed, mobiles are in balance. This balance is dynamic because the elements can move through three dimensions. A force that disturbs the mobile will swing the elements wildly about, but within a short period of time, the mobile returns to its balanced configuration. This homeostatic quality is a fundamental characteristic of families as well. The preservation of the status quo is a strength when it helps the family weather external forces and changes. At the same time, rigidity and inflexibility can be a liability. Add or subtract a member, and the balance will change. Changing the role of any member may also change the balance: An illness or loss of job can have the effect of diminishing the impact of a parent, and the mobile will again shift to a different balance point. The family is in constant motion, seeking stability through dynamic motion. Nevertheless, this homeostatic function is dynamically opposed to the inevitability of change.

The transitions discussed in this and the next three chapters address events that perturb and disturb the equilibrium of a family in a variety of ways, most of them predictable. The ultimate effect on the unit, however, depends on the ability of the family to adapt to the changes: changes in roles and changes in rules. Shonkoff and colleagues1 discuss these issues in more depth.

Students of family systems have observed a natural progression referred to as the family life cycle,2 which begins with the formation of a couple from dating through courtship to a committed relationship or/marriage, followed by the addition of children (via birth or adoption). This last step adds a parental role to the spousal roles already in place. As the children grow and move toward autonomy and ultimately leave home, the couple must renegotiate their relationship and focus predominantly on each other’s needs as the parental role fades. More recently, economic circumstances in the United States have led to the return of adult children into the household, with a variety of dilemmas, mostly associated with hierarchy: These individuals often feel the acute loss of their hard-won autonomy as they are asked to live again under their parents rules. For the parents, economic dislocation caused by loss of employment may affect household functioning not only because of a change in the financial circumstances but also because of the emotional effect on the former breadwinner. The addition of aging, infirm grandparents may be coupled with activation of latent conflict over divided loyalties between one’s parents and children that had been previously suppressed. The family life cycle reminds us that at each juncture in the cycle, the roles and relationships among family members change, and families commonly experience difficulties when these shifts do not occur smoothly.2,3 Some families become stuck and experience great distress requiring professional assistance to move to the next stages.

Table 19-1. Changes to the Family Constellation

A. Additions to the Family

1. Child

a. Newborn by birth or adoption

i. Healthy

ii. Medical problems

iii. Developmental disabilities

b. Older child

i. Foster care

ii. Adoption

iii. Stepsiblings

2. Adults added to family

a. Adult children returning home

b. Grandparent or other family member

i. For economic reasons

ii. For health reasons

c. Parental partner/spouse (or same-sex partner)

3. Return from separation of parent/partner

4. Return of parent/partner from employment, military service, or incarceration

B. Losses

1. Death of sibling

2. Death of parent

3. Death of grandparent

4. Loss of parent/partner (separation or divorce)

5. Temporary loss of parent/partner

a. Move for employment

b. Military service

c. Incarceration

6. Loss of function (and attendant role) of family member

a. Acute or chronic illness

b. Injury

FIGURE 19-1. The mobile as a metaphor of the family system. (From Coleman WL. Family Focused Behavioral Pediatrics. Lippincott William & Wilkins, 2001, p. 11.)

The family’s functional status predictably affects its ability to respond to the changes it experiences. Optimally functioning families have clear boundaries between the generations. Parent-child alliances, such as a father-daughter coalition against the mother, are not tolerated. Rules are clear and communication is open. If there is a boundary violation or a breach of a rule, it is addressed openly and quickly and the issues rectified. Any rule that prevents communication, such as “We don’t talk about that in our family,” will lead to significant dysfunction. In well-functioning families, the extended family and kinship systems (biological family or family by choice) support autonomous decision making. The physical and emotional needs of all members are respected, and problem solving occurs in an open and generous manner. However, the principle of hierarchical boundaries is not abrogated: The family is not a democracy but rather a benevolent dictatorship, where the parents listen to the children’s thoughts and feelings, taking them into account as appropriate. Nevertheless, the ultimate decision occurs at the parental level. Optimally functioning families represent an ideal that occurs in perhaps 5% of cases. The “good-enough” family (reflective of the majority of families) do an adequate job in meeting the needs of the children. It is also important to remember that all individuals, including the children, may provide strengths and vulnerabilities that affect the family function. The behavioral style (temperament) of the typically developing child is an important predictor of the goodness of fit in the family constellation.4

THE ROLE OF THE PHYSICIAN

Primary care practitioners who care for children often have accumulated much useful information to assist children and families during transitions. When one cares for children, one must also care for the whole family.5-7 The pediatrician’s knowledge of and relationship with the family provides an opportunity to help the family through the transitions in the life cycle. The physician’s medical database provides useful information about who lives in the household and about the physical, emotional, and financial health of the family members. Most medical practices often learn about changes in the constellation via naturally occurring life-cycle events and through community connections of the practitioner and his or her office staff. This natural flow of information through schools, civic organizations (eg, scouting), and religious communities provides an awareness of such events as illness of parents or grandparents, trauma, and loss of job. Sensitively using this information allows the provider to monitor the family’s adaptation and to guide families through change with honesty, care, and compassion. Referral of the family to skilled mental health and social service professionals is occasionally useful to allow a family to move forward in a positive and healthy direction.

CHANGES IN THE FAMILY CONSTELLATION

The two main categories of change are (1) additions and losses of family members and (2) change in the role of a family member. Some losses are quickly followed by additions: separation or divorce may be quickly followed by the addition of a stepparent or significant other, so that there may be a double challenge to the children. The impact of a change in the family constellation depends on a variety of factors. Anticipated changes are less likely than unexpected changes to be disruptive. The death of an elderly or infirm grandparent, for example, is more likely to be anticipated by the family than is the death of a child or a young parent from sudden illness or trauma. The birth of a child, while anticipated, has an enormous impact on a family and can be particularly difficult for the infant’s older siblings.

THE BIRTH OF A CHILD

In the face of behavioral concerns, pediatricians generally seek to identify events associated temporally with the onset of the problem. The birth of a baby is often at the root of the older sibling’s change in behavior. The major impact on the older child is the loss of his or her parent’s full engagement. Whether the primary caregiver was engaged in full-time childcare or provided childcare after coming home from work, the child will feel the loss of now having to share the parent’s attention with a “newcomer.” Even a completely healthy infant requires a great deal of instrumental care, and the older sibling will be aware of the shift in the caregiver’s focus. Young children, 3 and under, are more likely to experience this loss than are preschool and school-aged children, who are likely to have moved to a more autonomous state and are less likely to feel threatened by the younger sibling. Older children are also more able to connect with the parents via caregiving of their own.

It is not inevitable that every younger child will struggle with accepting a new sibling. Multiple factors may minimize or amplify the impact. For example, grandparents and other members of the extended family, trusted caregivers, and childcare providers may provide sufficient support to allow the parents to adapt to this new stage of their family life. Children raised in a loving, supportive environment that meets their physical and emotional needs are better able to adjust to these changes. Recognizing the legitimacy of the older child’s need for connection, parents can help the child by making (not finding) special time focused only on that child’s needs and interests. Explaining why mommy is too tired to read a book or pleading for understanding will likely fail to meet the child’s needs and might well amplify resentment. The quantity of the time spent is less important than the quality and the regularity.

On the other hand, the parent’s inabilities to emotionally and physically respond to the increase in demands has ramifications for all family members, especially for older siblings. In some instances, these children find themselves in caregiving roles for which they may be ill suited. This process has been called parentification and can occur in single-parent family situations and any time inadequate resources places the older child in a position of responsibility. The natural role of providing anticipatory guidance provides the opportunity to explore the parents’ expectations of the impact of the new baby on the household. (See Table 19-2.)

Table 19-2. Preparing for the Birth of a Sibling

Schedule a prenatal visit to discuss both parents’ experience as siblings.

What do they remember about being an older (or younger) brother or sister?

What was positive about this experience?

What would they like to do differently?

Explore the impact of the birth of the new baby.

on their relationship.

on their other child or children.

Provide information about available literature or online information. (See resources at the end of this chapter.)

When the new baby is born prematurely or has a complicated delivery requiring a prolonged hospital stay, young children are likely to experience as much distress as the parents, especially if the complication occurs unexpectedly. Babies with congenital malformations requiring emergent intervention will likewise evoke great distress. The interconnectedness of the family often leads to a resonance of emotion from one generation to another. The greater the parents’ distress, the more likely the children will be affected by the disruption of caregiving and emotional support that would ordinarily be forthcoming at such a difficult time. The need for one or both of the parents to spend time at the hospital will necessitate mobilizing an extended care network. If the young children have a close relationship with the individuals who step in to provide care (eg, grandparents or close family friends), there is likely to be less of a disruption.

The diagnosis of a condition associated with a life-long chronic physical or developmental disability (such as spina bifida or Down syndrome) presents another challenge to the family. First, the adults must understand the nature of the condition and the immediate needs for care, such as surgery. When such conditions occur unexpectedly, the family must adapt to the realization of the life-long consequences of the condition as well as to the loss of the expected, healthy child. In the case of a child with a developmental disability, the anticipated joy at welcoming a new baby may be replaced by fear, sadness, and perhaps anger, which will confuse the children primed to welcome their new baby brother or sister. They may wonder why mommy cries and people speak in hushed tones on the phone about the new baby. Younger children, for whom magical thinking is a powerful determinant of making sense of the world, may begin to believe that they caused the problem, especially if they were secretly dreading the new baby.

In these situations, adults often gather as much information as possible to help them weather this crisis. This information should not be shared: In the case of a new baby with Down syndrome, for instance, specific information about extra chromosome 21 will likely confuse most children. What the children need to know is that something is “different” about the baby and that the parents are working with the doctors to take care of the situation. The most important principle is to be certain to acknowledge the emotion that the family is experiencing and the children are noticing. The family that communicates early and openly will create the environment in which the children can question the family when they are ready. Ultimately, the success of the family rests on the ability to first make a place for the chronic condition in the family and then put that condition in its place. Following are a few tips that may help the physician smooth the family’s adjustment.

• Suggest that family actively include the children in discussions about the baby using age-appropriate descriptions and avoiding too much detail: “Your sister was born early and she is staying at the hospital so she can grow big enough to go home. This is not what we expected and we were worried. We know the doctors are doing everything to get her healthy enough to come home as soon as she can.”

• If possible, allow the children to visit the hospital, taking care to prepare them for the experience. Children read the nonverbal behaviors and overhear adults talking, and they quickly discern when the words of comfort directed to them are not consistent with the worried, whispered telephone conversations or the parent’s tearful demeanor in the face of medical setbacks.

• In the case of a child with Down syndrome, the parents could be advised to say, “When your brother was born, the doctors noticed some things that make them think he may grow a little differently and develop a little slower than you. We will know more about this when they do some tests.” After the diagnosis is confirmed, the discussion might continue, as follow: “The tests showed that your brother has Down syndrome, and we are going see some more doctors to make sure that he stays healthy. We are going to have people help to be sure that he develops as best as he can.”

• Help the family connect with the specialized services for children (pediatric cardiology, spina bifida, cystic fibrosis, sickle cell, Down syndrome), which most often have team members available to provide support to parents. Contact with local, family-run support groups are often most effective, offering practical suggestions and instrumental as well as emotional support. Statewide groups include the Parent-to-Parent organization, which also has a national network to provide support for parents of children with physical and developmental disabilities as well as special health care needs, behavioral or mental health issues, educational issues, and adoption/foster care questions. http://www.p2pusa.org.