KeywordsFamily dysfunction, adoption, foster care, substance use, attachment
A family is a dynamic system of interactions among biologically, socially, or legally related individuals. As such, families have a unique power to influence a child’s social, emotional, and physical health, shape their brain development, and impact his/her overall developmental trajectory. When a family functions well, interactions support the physical and emotional needs of all members and the family can serve as a valuable resource for any individual member in need. Alternatively, the problems of an individual member or the negative interactions between members may interfere with the ability of the family system to satisfy the physical and emotional needs of members, and ultimately lead to physical and/or emotional harm. The consequence of a social practice or behavior pattern that undermines the stability of a family unit is referred to as family dysfunction .
The functions that families carry out in support of their children can be considered within the broad categories of physical needs, emotional support, and education and socialization ( Table 24.1 ). Within these groupings, all families have strengths and weaknesses. The amount of support that an individual child needs in each domain varies with the child’s developmental level, personality, temperament, health status, personal experiences, and stressors. In a healthy family, parents can be counted on to provide consistent and appropriate support for their children. Either too much or too little support can interfere with optimal child health and development. In the case of child neglect the family underfunctions, providing inappropriate or inadequate support for the child’s basic needs. Further, the violation of basic boundaries of appropriate behavior and infringement on safety is considered child abuse. In contrast, a family that overfunctions may limit a child’s opportunity for growth and development of independence skills, creating feelings of helplessness and inadequacy. Parental anxiety and perfectionism creates intense pressure on children around achievement and sets them up to become anxious and fearful themselves.
|Health and health care|
|EDUCATION AND SOCIALIZATION|
Toxic stress can accumulate when the child experiences intense, frequent, and prolonged adversity whether it be from physical/emotional abuse, caregiver substance abuse or untreated mental illness, exposure to violence, or the secondary effects of economic hardship. Regardless of the type of family dysfunction, prolonged activation of stress response systems can disrupt the development of vital brain architecture and increase the risk for stress-related disease and cognitive impairment into adulthood.
The traditional family consists of a married mother and father and their biological children. The diversity in the structure of the family in the United States has increased dramatically; in 2010 only 65% of children were being raised by married parents. Today, children may live with unmarried parents, single parents of either gender, a parent and a stepparent, grandparents, parents living as a same-sex couple, or foster care families. There is little evidence that family structure alone is a significant predictor of child health or development. Regardless of family structure, the best predictor of secure child health and development is the presence of a loving adult or adults serving in a parental role committed to fulfilling a child’s basic needs. Stressful life experiences can test a family’s ability to promote optimal developmental outcomes, and different family structures face different challenges.
At any one point in time, approximately 30% of children are living in single-parent families, and more than 40% of children are born to unmarried mothers. In some instances, a child is born to a single mother by choice, but oftentimes the child is the result of an unplanned pregnancy. Children may also live in single-parent families as the result of divorce or the death of a parent (see Chapter 26 ). Although most children in single-parent families are raised by mothers, single-father families are increasing; in 2009 nearly 5% of children lived in single-father families.
Single parents may have limited financial resources and social supports. For single-mother households, the median income is only 40% of the income in two-parent families, and for single-father households, it is only 60% of the income of two parent families. Thus the frequency of children living in poverty is three to five times higher in single-parent families. These parents must also rely to a greater extent on other adults for child care. Although these adults may be sources of support for the single parent, they also may criticize the parent, decreasing confidence in parenting skills. Fatigue associated with working and raising a child independently contributes to parenting difficulties. Single parents are likely to have less time for a social life or other activities, intensifying feelings of isolation and negatively impacting mental health. When the increased burdens of single parenting are associated with exhaustion, isolation, and depression, the evolution of developmental and behavioral problems in the child is more likely.
In the case of a teenage mother in the role of single parent, challenges associated with parenting may be even more impactful (see Section 12 ). Being a teenage parent is associated with lower educational attainment, lower paying jobs without much opportunity for autonomy or advancement, and lower self-esteem. Teenage mothers are even less likely than adult single mothers to receive any support from the child’s father. Children of adolescent mothers are at high risk for cognitive delays, behavioral problems, and difficulties in school. Referral to early intervention services or Head Start programs is imperative in these situations.
However, when a single parent has adequate social supports, is able to collaborate well with other care providers, and has sufficient financial resources, he or she is likely to be successful in raising a child. Pediatricians can improve parental self-esteem through education about child development and behavior, validation of good parenting strategies, positive feedback for compliance, and demonstrating confidence in them as parents. Demonstrating empathy and acknowledging the difficulties faced by single parents can have a healing effect or help a parent feel comfortable to share concerns suggesting the need for a referral to other professionals.
Children Living With Sexual Minority Parents
An estimated 23% of all lesbian/gay/bisexual (LGB)-identified adults (regardless of relationship status) were raising children under age 18 based on the 2013 National Health Interview Survey. Sexual minority adults can build families in a variety of ways. Many children with an LGB parent were conceived in the context of a heterosexual relationship. Alternatively, single LGB parents, as well as same-gender couples, enter into parenthood through adoption, donor insemination, or surrogacy. It is estimated that there are almost 200,000 children being raised by same-sex couples in the United States. Combined with those children being raised by single sexual minority parents, an estimated 2 million children in the United States have LGB parents.
LGB parents and children born from a heterosexual relationship experience unique challenges. Navigating the complex network of past and present, opposite- and same-gender relationships can be stressful for the child who may already have difficulty accepting the change in family structure, living environment, and disclosure of sexual orientation. In general, earlier disclosure of a parent’s homosexuality to children, especially before adolescence, is associated with better acceptance. Parents may have concerns that the child will encounter teasing by peers, disapproval from adults, and stress or isolation related to a social stigma associated with having an LGB parent. Although there is some evidence that children of sexual minority parents may have an increased likelihood of being teased at certain stages of development, strong parent-child relationships and a school curriculum addressing acceptance can offer some protection to overall child well-being.
Evidence suggests that there is no causal relationship between having a sexual minority parent and a child’s emotional, psychosocial, and behavioral development. Growing up in a same-gender parent family is not associated with academic achievement. Additionally, having an LGB parent does not influence gender role and psychosexual development; the majority of children with an LGB parent identify as heterosexual. Importantly, extensive research has demonstrated that the psychological adjustment of children and adolescents is impacted by the quality of the parent-child relationship, the quality of the relationship between adult caregivers, and the availability of social and economic resources.
Adoption is a legal and social process that provides full family membership to a child who is not the adult parent’s biological offspring. Most adoptions in the United States involve U.S. parents adopting U.S. children, but shifting cultural trends have increased the diversity in the ways in which adoptions occur; the process can involve biologically related and unrelated children, stepchildren, adoption through private and public agencies, domestic and international adoptions, and independent and informal adoptions. Based on data from the U.S. Department of Health and Human Services, the number of adoptions that are finalized each year has remained relatively stable (between 50,000 and 53,500) over the last decade. Approximately 2% of children in the United States are adopted. In 2009–2011, 13% of adopted children under 18 were internationally adopted. Over that same period, there were 438,000 transracially adopted children under the age of 18 (over a third of whom were foreign born), or 28% of all adopted children under 18. Increasing numbers of same-gender couples or single-LGB adults are raising children via adoption. Each type of adoption raises unique issues for families and health care providers. Data suggests that adopted children live in households that have higher incomes, a lower percentage in poverty, and a higher percentage with a parent with at least a bachelor’s degree than stepchildren or biological children. Open adoptions in which the biological parents and birth parents agree to interact are occurring with increased frequency and create new issues for the adoption triad (biological parent, adoptive parent, and child).
Pediatricians are in an ideal position to help adoptive parents obtain and evaluate medical information, consider the unique medical needs of the adopted child, and provide a source of advice and counseling from the preadoption period through adolescence. A preadoption visit may allow discussion of medical information that the prospective parents have received about the child and identify important missing information such as the medical history of the biological family and the educational and social history of the biological parents. The preadoption period is the time that families are most likely to be able to obtain this information. Depending on the preadoption history, there may be risks of infections, in utero substance exposure, poor nutrition, or inadequate infant care that should be discussed with adoptive parents.
When the adopted child is first seen, screening for medical disorders beyond the typical age-appropriate screening tests should be considered. If the child has not had the standard newborn screening tests, the pediatrician may need to obtain these tests. Documented immunizations should be reviewed and, if needed, a plan developed to complete the needed immunizations (see Chapter 94 ). Children may be at high risk for infection based on the biological mother’s social history or the country from which the child was adopted, including infection with human immunodeficiency virus, hepatitis B, cytomegalovirus, tuberculosis, syphilis, and parasites. A complete blood count may be needed to screen for iron deficiency.
A knowledgeable pediatrician also can be a valuable source of support and advice about psychosocial issues. The pediatrician should help the adoptive parents think about how they will raise the child while helping the child to understand the fact that he or she is adopted. Neither denial of nor intense focus on the adoption is healthy. Parents should use the term adoption around their children during the toddler years and explain the simplest facts first. Children’s questions should be answered honestly. Parents should expect the same or similar questions repeatedly and that during the preschool period the child’s cognitive limitations make it likely the child will not fully understand the meaning of adoption. As children get older, they may have fantasies of being reunited with their biological parents and there may be new challenges as the child begins to interact more with individuals outside of the family. Families may want advice about difficulties created by school assignments such as creating a genealogic chart or teasing by peers. During the teenage years, the child may have questions about his or her identity and a desire to find his or her biological parents. Adoptive parents may need reassurance that these desires do not represent rejection of the adoptive family but the child’s desire to understand more about his or her life. Feelings of loss and grief, as well as anger, anxiety, or fear, may occur more often during certain milestones, such as birthdays, graduation, or the death of a parent. In general adopted adolescents should be supported in efforts to learn about their past, but most experts recommend encouraging children to wait until late adolescence before deciding to search actively for the biological parents.
In general, adopted children are within range of nonadopted peers academically and emotionally; however, the likelihood of emotional and academic problems is higher for children adopted after 9 months of age or for children who experienced multiple placements before being adopted. Difficulties in school, learning, and behavioral problems are thought to be more often secondary to biological and social influences that preceded the adoption. The pediatrician can play an important role in helping families distinguish developmental and behavioral variations from problems that may require recommendations for early intervention, counseling, or other services.
The foster care system in the United States is a means of providing care and protection for children who require out-of-home placement due to reasons of abuse and/or neglect. A foster or kinship setting is beholden with the responsibility to promote child well-being by assuring access to health, safety, and stability. Ultimately, the goal of foster care is to achieve permanency through reunification or an alternative permanent arrangement (adoption, guardianship, or placement with relatives).
From the late 1990s through 2005, over half a million children were in foster care, but between 2005 and 2010, the number of children living in foster care decreased by about 20% as a result of changes in federal and state policies; in 2013, approximately 641,000 children spent some time in foster care placement. The Adoption and Safe Families Act passed by congress in 1997 mandated timely permanency leading to a significant reduction in the length of stay in foster care. In 2008, the enactment of the Fostering Connections to Success and Increasing Adoptions Act increased subsidies and supports to incentivize kinship care, guardianship, and adoption out of foster care. Additional reforms have prioritized the improvement of outcomes for children and youth in foster care by emphasizing monitoring of child development and the availability of mental health supports to ensure emotional well-being.
Children and adolescents in foster care are at extremely high risk for medical, nutritional, developmental, behavioral, and mental health problems. At the time of placement in foster care, most of these children have received incomplete medical care and have had multiple detrimental life experiences. Comprehensive assessments at the time of placement reveal many untreated acute medical problems. Nearly half of foster children have a chronic illness. Developmental delays and serious behavioral or emotional disorders are common.
Ideally foster care provides a healing service for these children and families, leading to reunification or adoption. Too often, children experience multiple changes in placement within the foster care system, further exacerbating challenges in forming a connection between the child and adult caregivers and culminating in child resistance to foster parents’ attempts to develop a secure relationship. This detachment from the foster parent may be emotionally difficult for the foster parent to bear, further perpetuating a cycle of placement failures. The history of trauma or neglect that originally led to the need for foster care, in combination with instability of placements, predisposes the foster child to enduring problems. Foster care alumni report rates of anxiety disorders, depression, substance abuse, and post-traumatic stress disorder that are two to six times higher than the general population. Furthermore, although the protections of the foster care system often end at 18 years of age, these adolescents rarely have the skills and maturity needed to allow them to be successful living independently. Thus the Fostering Connections to Success and Increasing Adoptions Act of 2008 mandates that effective transition to adulthood planning be done with youth in foster care including the provision of targeted resources for emancipated youths as they enter adulthood.
The challenges for the foster care system are great. However, when children are placed with competent and nurturing foster parents and provided with coordinated care from skilled professionals, significant improvements in child health status, development, and academic achievement typically ensue.