Laurie J. Bauman and Ruth E. K. Stein
Pediatricians provide care for children who live in a variety of family situations. Children may live with two working parents, unmarried parents, grandparents, or another nonparental caregiver, or they may live in single-parent families where the mother may be divorced or never married, or they may live with gay parents, in foster homes, or in blended families. The traditional nuclear family, consisting of a mother and a father who are married and living with their biological children, is becoming rare; in fact, only 25% of households fit this description.1
The notion of family is universal in all cultures and societies, but the definition is changing, confused, and often vague. The US Bureau of the Census defines a family as two or more persons who live together and are related by blood, marriage, or adoption.
SOCIETAL FUNCTIONS OF THE FAMILY
Historically, the family as a social institution served several functions. Its primary purpose was the care, rearing, and socialization of children and the legitimization of sexual union. However, over time, sexual liaisons outside of marriage have become more common, and childbirth frequently occurs outside of the marital tie. In 1950, only 4% of children were born out of wedlock; today, more than 40% of first births are to unmarried mothers.3 This is accepted in many cultures.
TYPES OF FAMILIES
In its simplest form, a family consists of the husband, wife, and nonadult children, and it is called the nuclear, conjugal, elementary, immediate, or simple family. This family structure consists of two generations, parents and children. In industrial societies, nuclear families tend to live in a separate household that often is far removed from relatives. In extended families, several generations live together, and grandparents often have some responsibility for child rearing. As a result of parent incapacity, abandonment, or death, 1.4 million children live with a grandparent and no parent,5 and 4.5 million live in households headed by a grandparent.6 In this configuration, the children may have experienced the loss of a parent and may have had to move, leaving behind his or her home, friends, and school.
Most children develop loving, caring relationships with new caregivers, but some relationships between children and custodians are ambivalent or antagonistic, and on occasion, custodians may be antagonistic to the living biological parent(s). If the parent has died, all may be grieving.
Single-parent families are increasingly common, and most are headed by women.7 Almost one quarter of all children under 18 years of age live in single-parent families.8
Single parents face special challenges. Most importantly, they tend to have far fewer economic resources and a much lower standard of living. If the parent is working outside the home, they must make childcare arrangements, which can be complex, costly, and difficult to find. Older siblings may be given significant responsibility, and some may experience school and peer problems. Despite the many issues that single parents face, there is strong evidence that most single families raise healthy, secure children. Resources facilitating a positive outcome include parental organizational skills, adequate support networks, and closer proximity to extended family.
Blended families are common. Remarriage often eases the financial problems of single parenthood, but complex new family relationships result. For example, there may be significant friction between the child and the stepparent as the child struggles for the biological parent’s attention and tries to negotiate new roles. These relationships may be more complicated when both of the child’s biological parents are involved with new partners. In addition, new siblings may be introduced from the stepparent’s family or as a product of the parent’s new relationship. It may be difficult for the child to maintain these multiple new relationships and live by the rules and standards of his or her different families, especially if they have different cultural values.
Many children live with unmarried parents who have made a commitment to stay together. The lack of permanence can be difficult for all family members; there may be conflict between partners about where the relationship is going. The instability of the relationship may draw attention away from the children, but if the parental figure and the child have a strong bond, this family form can work well.
Homosexual families are often overlooked as a family form. Sometimes a parent realizes after having children that he or she is gay. Divorce may result, and the child may live with or visit a homosexual parent. In other instances, a homosexual couple forms a primary relationship and actively chooses to parent a child. The small body of research on the children of homosexual parents has found that children can be nurtured effectively in this family form (see Chapter 16).
Few adolescents are prepared for the demands of teenaged parenthood. Married teenagers with children are more likely than married teenagers without children to have marital problems, to have additional children at an accelerated pace, and to leave school earlier. Inherent in “children parenting children” is the tension between the developmental needs of the adolescent and those of the child. Most adolescent parents live at home with their parents, which creates an extended family system. There may be conflict between the adolescent and her mother over caregiving responsibilities for the infant and the adolescent’s own independence and autonomy.
EFFECTS OF SOCIAL TRENDS ON FAMILIES
Several social changes in the United States are affecting families of many types. One that affects an increasing number of families is the deinstitutionalization of elderly, disabled, and mentally ill persons. Mothers of young and adolescent children may confront the additional demands of caring for an ill or elderly parent, spouse, or child. Social, economic, and psychological supports for these women are often inadequate, which may adversely impact child rearing and the responsibilities of older children in the family unit.
Another societal evolution that will continue to affect families is changing gender roles. More married mothers are in the workforce, and more men are sharing or taking primary responsibility for child rearing. Recent economic trends have forced many families to rely on two incomes. In 66% of nuclear households with children under 18, both parents work, 70% of mothers with children under 18 work, and 60% of mothers with children under 3 years work.2 Families with two working parents tend to be smaller, younger, more educated, and have a higher income. Child rearing in families with two working parents can be stressful, and it requires effective and flexible external sources of childcare. However, lack of stable childcare arrangements may be difficult—for the parents and the children—and is especially problematic when there are significant ongoing health conditions. When both parents work, there may be special concerns; these families are likely to have latchkey children—children who are left alone after school until the parents come home from work. It is especially important to provide guidance concerning when this is developmentally appropriate and to provide guidelines for accident prevention.
CLINICAL IMPLICATIONS OF THE CHANGING FAMILY
The variability of family forms, and the different values and norms that go along with them, pose challenges to clinicians, whose values and standards may differ from those of their patients. Families often behave in ways that are counter to the health care provider’s own beliefs or to traditional health advice. These differences may create problems in communication or may lead to inappropriate attempts to enforce family conformity.
The clinician must be aware of the potential for encountering a wide range of different family types and must recognize them during interactions with families. There are many ways that family structure and values influence child development and behavior. The degree to which understanding of the family affects practice depends on the nature of the encounter and the type of information and interaction that are required to meet the child’s needs and to care for the child’s condition.12 Sensitivity to difference is family structure is important during all care provider interactions with families. These issues are discussed in detail in Chapters 3, 7, 16, and 123. Because family structure may not be stable the clinician should inquire periodically about changes in caregiving, living arrangements, and responsibility for the child.
Issues of family organization and management often are relevant in the care of children with acute intercurrent illness. When a child is on a short course of antibiotics, for example, it may be desirable to know whether the person who brings in the child for care can depend on other caregivers to adhere to the medication schedule and whether the babysitter or daycare provider will cooperate. It also may be important to obtain history about the onset of symptoms from the person who was actually with the child when the problem first presented. When there are marked differences in health beliefs, other family frictions, or conflicting agendas such as in custody disputes, cooperation may be impaired and the acute care of the child jeopardized. The clinician may need to address such issues if they interfere with the delivery of effective pediatric care.13
The majority of children who are reared in any given family type will grow and thrive. During the course of normal child development, the stability of caregiving arrangements and provision of supportive and affectionate nurturance of the child are central issues, and the availability of multiple adults who are related to the child may offer some advantage to the child’s emotional development. The clinician who has a trusting and respectful relationship with a child and family can play a critical role in helping them through a wide range of adaptive challenges.