17 Role Relationships
Understanding family dynamics and role relationships is essential to the delivery of health care services to children and adolescents in all pediatric settings. However, pediatric primary care providers carry the major responsibility for advising parents on how to effectively handle relationship issues with children at home, in school, and in the community. Parents and other family members are solely responsible for the health and welfare of their young children and must learn key communication and interaction skills to effectively rear their child. The pediatric provider must be sensitive to the roles that parents or caregivers, siblings, extended family members, and peers have in shaping the developing child. Likewise the community is an extension of the family and serves as a major component in the widening circle of influence that affects the lives of children and adolescents. Chapter 2 outlines important considerations and appropriate tools to be used when assessing family systems. This chapter discusses the family life cycle and family variations. In addition, it covers the assessment and management of situations or events that the provider is likely to encounter in a primary care setting related to family relationship problems, sibling rivalry, violence, and child maltreatment or neglect. Preventive interventions for role-relationship problems directed at specific individuals or groups at risk (selective interventions) as well as at the population as a whole (universal interventions) are identified. Advice about securing safe, nurturing, and developmentally appropriate childcare is also discussed.
Standards of Care
Healthy People 2020 addresses issues of violence and abusive behavior and their negative effect on children, families, and society (U.S. Department of Health and Human Services [USDHHS], 2010a). Recommendations include:
• Reduce bullying, dating, and sexual violence.
• Decrease the percentage of public middle and high schools with a violent incident.
• Reduce physical assaults and physical fighting among adolescents.
Child maltreatment is recognized as a significant public health problem. The target goal of Healthy People 2020 is no more than 2.2 child maltreatment deaths per 100,000 children younger than age 18. The goal for reducing nonfatal child maltreatment is 8.5 per 1000 children younger than the age of 17 years. National, state, and local efforts must be dedicated to reducing preventable death and disability and to enhancing the quality of life for all children. Health professionals in their individual practice settings and as a collective group must commit to improving the quality of life by incorporating health promotion and disease prevention as integral components of health care for children and their families. Identification of at-risk families and referral for intervention must always be viewed as priorities.
Family Relationships and Dynamics
Family Life Dynamics
The family is a dynamic social system that is usually the most powerful and constant influence of a child’s development and socialization. The family provides emotional connections, behavioral constraints, and modeling that affect the child’s development of self-regulation, emotional expression, and expectations regarding behaviors and relationships (Coley, 2009). Changes in one family member’s behavior affect everyone else in the family unit.
Healthy families are cohesive and adaptable, with positive communication patterns. Family cohesion is an indication of the strength of the emotional bonding between family members and can range from the extremes of very low (disengaged) to very high (enmeshed) bonding, with moderate to high (connected) bonding representing the middle ground. Family adaptability is the ability of a family system to change its power structure, role relationships, and relationship rules in response to situational and developmental stress. The range of adaptability varies from very rigid (very low) to chaotic (very high), with a middle ground between structured and flexible. A key element in adaptability is the ability to change as appropriate in a given situation. Communication patterns range from positive communication skills that convey messages such as empathy, reflective listening, and supportive comments, to negative communication skills that reflect double messages, double binds, criticism, and minimize opportunities to share feelings. Communication is one of the most crucial elements within an interpersonal relationship. Family cohesion and adaptability are threatened and thwarted with negative communication patterns. The result of negative communication is a chaotic household marked by high levels of family distress.
Each family has its own unique pattern of growth and development, and family systems evolve and change, demonstrating different dynamics depending on the stage of the family’s life cycle. Just as a child goes through stages of development, so do family units. Family life with young infants and preschool children is vastly different from family life with school-age children, with early versus late adolescents, or with young adults. Also different types of family units—nuclear, single-parent, divorced, or blended—express different styles or patterns of family life.
Dimensions of Family Functioning
Common themes exist within all families, and six key dimensions have a significant effect on family functioning, contributing to cohesiveness, adaptability, and positive communication (Box 17-1). To assist parents and children across the family life cycle and especially during times of stress, the provider must carefully assess these elements.
BOX 17-1 Six Key Dimensions Affecting Family Functioning
• Resources that are available to the family include a social support network of extended family members, friends, and community, in addition to financial and other material assets. Families with limited resources or social support networks are more vulnerable to stressful life events than are families with resources and support systems in place.
• Stresses and changes the family faces are numerous and can include financial strains, illness, marital strain, family transitions, losses, and lack of effective coping strategies. Life brings transitions that necessitate change. Many transitions are normal, some are anticipated, and others are unexpected; all can have a significant effect.
• Childrearing styles are composed of parenting behaviors and beliefs that influence the environmental milieu in which the child learns about the world. Certain childrearing styles (e.g., an uninvolved, permissive, or strict authoritarian parenting style) are ineffective and have dire consequences for the emotional health of a child.
• Values shared by family members provide a framework to guide, explain, and understand events being experienced and within which to find comfort, joy, and solace. Spiritual beliefs are one example of values that can support a family in its everyday life and in times of challenge.
• Roles and structures vary greatly from one family to another, within an individual family, and as family members grow and develop. Role responsibilities and structures often change in response to external demands experienced by the family; shifts in the role of one family member can affect the role functions of other family members.
• Coping style of the family speaks to the ways that demands are met, transitions handled, and concerns resolved. Positive or effective coping is characterized as a creative response to a change or stressor that results in a new behavior or attitude. Coping styles reflect habitual patterns of action. Over time, coping effort develops into a coping style.
The Interactive Family
A family is interactive, both within the family circle and between the family and its community. Within the family each member influences all other family members and is likewise affected by them. Maladaptive patterns of interaction among family members can place a child and family at risk for negative outcomes. For example, if the family unit does not provide a protective, interactive, supportive, and loving environment to nurture the child or fails in its responsibility to help the child learn self-discipline and the ability to socialize with others, the child often develops maladaptive behaviors.
Authoritative parents closely monitor their children with warmth and emotional support while maintaining firm boundaries. An authoritative style grants autonomy that is age-appropriate and permits the child to make decisions based on readiness factors; encourages the expression of feelings, thoughts, and desires; and promotes joint decision-making when appropriate as the young child matures and develops throughout childhood and adolescence. Research has demonstrated that parents with authoritative parenting styles have a positive influence on eating habits, teenage driving, and risk-taking behaviors (Ginsburg et al, 2009; Montgomery et al, 2008; Ventura and Burch, 2008).
There are factors that are protective and foster resiliency. Certain temperaments, a caring relationship and/or social support outside the immediate family, community resources and opportunities, and effective parenting can counter the negative effects of adverse risk factors and contribute to a child’s positive mental health. The degree of satisfaction as a couple and as parents is an important outcome measure of how well the family is functioning as a family unit. Single-parent households may face many challenges that can have a negative effect on the family unit, but can be enhanced by developing nurturing relationships in both the parent’s and the child’s life. Children are at risk for developing mental health problems as a result of environmental factors, such as living in poverty, living in a community with a high crime rate, living in a home marked by marital conflict or domestic violence, living in a home in which they or their siblings are the victims of child maltreatment or neglect, or having a parent who abuses alcohol or other substances, or has a mental illness.
Assessment of Family Relationships and Dynamics
In addition to stressful issues that may arise with “typical” family relationships, providers are likely to encounter not only parent- or child-initiated concerns, situations, and events related to relationship problems, but also violence, child maltreatment, or neglect. Families and children who are experiencing or who are at risk for stressful situations must be identified. Assessment of families is also discussed in Chapter 2.
Though the list is not exhaustive, Box 17-2 includes significant child, parent or caregiver, and social and environmental factors that can be used to alert the provider to areas that need further investigation.
BOX 17-2 Significant Factors for Assessment of High-Risk Family Relationships and Dynamics
Management for Health Promotion and Disease Prevention
Primary care providers are often approached by parents with concerns about developmental or role-relationship issues that can be managed with healthy parenting and good communication (see Chapters 4 through 8 and 19). A supportive health care professional is in a strategic position to prevent problems and empower parents and children by providing anticipatory guidance, education, motivational support, resources, and opportunities for counseling.
Family Relationships and Challenges
Two-Parent Families
Two-parent families include married couples with children, unmarried couples with children, remarried couples with blended families (or stepfamilies), and gay or lesbian couples. Two-parent families experience the same stressors as do single-parent families, but children in two-parent families tend to have social, economic, and health advantages. Parent educational levels, economic status, and health status are generally higher in two-parent families than in single-parent families (Annie E. Casey Foundation, 2010). Parents often cite, although this is seldom researched, that even when the division of labor is uneven, it is still a relief to have another adult with whom to share the work of raising children. Several studies, however, show that children’s well-being depends on composition of the household and not just the number of adults present.
Working Parents and Child Care
In 2009, more than 59% of mothers with preschool-age children (younger than 6 years) were employed and 76% of those worked full-time. During the same year, 72% of women with children between 6 and 17 years old were employed (Bureau of Labor Statistics, 2010). According to the Children’s Defense Fund fewer than 10% of child care centers and fewer than 1% of family child care homes are accredited. Additionally the annual cost of child care in a center for a 4-year-old child is more than annual in-state tuition at a public four year college; in five states it is at least twice the cost (Children’s Defense Fund, 2010).
When a single parent works outside the home or both parents in a two-parent family work outside the home, the two roles of working parents need to be coordinated to promote positive family outcomes. Carter (1999) identified three unresolved problems related to work and families that can affect parenting: men’s unequal contributions to housework, workplace inflexibility, and the increasing number of hours both men and women are spending outside the home. Many studies have explored the effect of maternal employment on children. The outcomes are complex and depend not just on whether a mother is employed, but on the family circumstances, daycare, home environment, marital status, consistency of employment, work stress, and other variables (Halpern, 2005). Consistently shown, however, is that poverty operates to create negative outcomes for children and families; maternal employment may mitigate this factor. Research findings show that, generally, children can develop equally well regardless of the employment status of their parents; the home environment is more important (Halpern, 2005).
Separation and Divorce
Description
Divorce or the separation of parents has a profound effect on all family members. Divorce is an emotionally stressful and complex transition for families. It can lead to significant emotional disruption and disequilibrium in the lives of children who perceive divorce as a dramatic, painful, and challenging event in their lives. Behavioral changes are an expected reaction as the child attempts to adjust to the changing family situation. Custodial and visitation arrangements for children are variable. Joint custody is an option that allows both parents the opportunity to participate in mutual decision-making about their child’s life and welfare. Various living arrangements and visitation rights are possible with joint custody. There are instances in which single custody is in the best interest of the child, however, and the noncustodial parent may have limited contact and involvement in the child’s life.
Taking a developmental-behavioral perspective of understanding divorce as an ongoing process rather than a concrete event is key. Each child has a unique history and resultant possible new family life. Regardless of the parents’ perspective, divorce is a loss of family as the child knows it and therefore the child will experience grief. Important parent factors include a stable parenting foundation provided in early years and parental warmth and praise for the child through the divorce. Children with behavior problems and more difficult temperaments before the divorce tend to have more difficulty adjusting to divorce than children with an easy temperament, above-average intelligence, who are physically attractive, and have a sense of humor and better self-esteem (Tanner, 2009).
Research studies that investigate the psychological consequences of divorce on children have reported varying data about its negative effect. Although children from divorced families have more adjustment problems and depressive symptoms than children whose parents do not divorce (Ge et al, 2006), those problems may arise from the conflictive relationships existing before the divorce, rather than the divorce per se. Children whose parents were cooperative reported better relationships with their parents, grandparents, and siblings (Ahrons, 2007).
Divorce can also be positive when parents are able to develop a more civil relationship with each other that focuses on what is best for the child. The child may also gradually adopt roles that support self-reliance, awareness of needs of others, and an increase in responsibility (Tanner, 2009).
Epidemiology
The rate of divorce in the United States has been fairly stable for the last 20 years (Tanner, 2009). The Centers for Disease Control and Prevention (CDC) reported a provisional divorce rate of 3.4 per 1000 marriages in 2009, down slightly from the 3.5 per 1000 in 2008 and 3.6 in 2007. The marriage rate was 6.8 per 1000 in 2009 (down from 7.1 in 2008 and 7.3 in 2007) (CDC, 2009). Roughly 48% of all new marriages end in divorce within 20 years. Approximately 50% of the divorced adults remarry within 4 years (Tanner, 2009).
Assessment
The goal of assessment of the family experiencing separation or divorce is to determine both the needs and strengths of the family in order to assist the family with healthy coping. Child-related factors to consider include the developmental stage of the children and common psychosocial reactions to divorce likely at that stage. Additionally the psychosocial effect of the divorce on the parents and the economic consequences of divorce on the family unit must be determined (Box 17-3).
BOX 17-3 Assessment Factors in Divorce
Developmental Stage of Children
Common Issues for Children of Divorcing Parents
• Continued tension, conflict, and fighting between parents
• Litigation disputes over custody and visitation arrangements
• Abandonment by one parent or sporadic visitation (decreased availability) vs. denial of visitation
• Diminished parenting resulting from such factors as availability issues or emotional inaccessibility, distress, or instability
• Limited social support system outside nuclear family
Management
Anticipatory guidance given to parents who are in the process of separating and divorcing is outlined in Table 17-1.
TABLE 17-1 Key Anticipatory Guidance Issues for Families Experiencing Divorce or Separation
Patient Education and Prevention
The goal of health education for children and parents experiencing divorce is to help restore a sense of wholeness and integrity in children’s lives. Providers must stress those factors that have been shown to significantly affect whether the child will experience a healthful adjustment to the divorce (Box 17-4). Successful efforts implemented during initial periods of disequilibrium and reorganization will strengthen normal development and prevent future psychological trauma. In an early research study, Wallerstein (1983) identified six psychological tasks that children of divorce must master beginning from the time of parental separation and culminating in young adulthood (Box 17-5). These tasks continue to be relevant for children whose parents are divorced. If these psychological tasks are not achieved, the child’s mastery of normal developmental tasks associated with growing up is negatively affected. Long-range and preventive interventions need to focus on helping the child achieve these tasks or goals.
BOX 17-4 Factors Affecting a Child’s Ability to Achieve Healthy Adjustment to Divorce in His or Her Family
• The opportunity for continued participation of the noncustodial or visiting parent in the child’s life on a regular basis
• Custodial parent attempts to make visits with the other parent a routine event so there is consistent contact (phone, visiting, e-mail)
• The ability of the custodial parent to handle and successfully parent the child
• The ability of parents to separate their own feelings of anger and conflict and resolve their own hostility toward each other so that the child’s need for a relationship with both parents is met; divorced parents do not put the child in the middle
• The child does not become involved in parental conflict and does not feel rejected
• The availability of a social support network
• The ability of parents to meet the child’s developmental needs and to help the child master the developmental tasks before him or her
• The child’s overall personality and personal assets and deficits
BOX 17-5 Six Psychological Tasks Children of Divorce Must Master
• Acknowledge the reality of the marital breakup.
• Disengage from parental conflict and distress and resume customary pursuits.
• Resolve loss of familiar daily routine, traditions, and symbols and the physical presence of two parents.
• Resolve anger and self-blame.
• Accept the permanence of the divorce.
• Achieve realistic hope regarding relationships—the capacity to love and be loved.
Data from Wallerstein JS: Children of divorce: the psychological tasks of the child, Am J Orthopsychiatry 53:230-243, 1983.
It may be a good idea to schedule additional visits or telephone contacts with the family to monitor their adjustment. Support can be provided by focusing on the family’s positive strengths and ability to be resilient.
Single-Parent Families
Description
Numerous circumstances lead to single-parent households, including unemployment, divorce, births to unmarried mothers, abandonment of the family by a parent, incarceration of a parent, or death of a parent. Although the vast majority of single parents are women, increasingly fathers are raising their children in single-parent homes. Single-parent households may be headed by a divorced parent or by a parent who has never been married. Today single parents may range from adolescents enrolled in welfare programs to company executives with live-in nannies. In general, children living with a divorced parent have an advantage; divorced parents tend to be older, with more years of completed schooling, and with higher levels of income than do parents who have never been married. Children in single-parent families benefit when both parents are involved in their lives, regardless of marital or living arrangements. Clearly, understanding the family context is fundamental to assessing these families.
Single parents across socioeconomic parameters all experience the demands and burdens of raising a child alone. Even with help, the weight of responsibility is felt and exacerbated by lack of time and role strain. Single mothers who are employed experience more distress than partnered employed women but factors such as income adequacy, psychological work quality, and work-family conflict also affect the outcomes (Dziak et al, 2010). Single parents sometimes have difficulty accessing health care. Research suggests that affordability is a more significant issue than time pressures or workplace demands (Kneipp, 2002). The relatively large proportion of single parents who are classified as “working poor” puts them above the income level for subsidized care and below the level where they could realistically afford health insurance.
Studies demonstrate higher levels of depressive symptoms and problematic substance use in children living in single-parent families compared with mother-father families (Barrett and Turner, 2005). Barrett and Turner report that this relationship probably is linked more with exposure to stress and association with deviant peers. Likewise, living in a single-parent household is strongly associated with poorer child health, largely as a factor of an associated accumulation of social disadvantage (Bauman et al, 2006). Cohabitation of a parent and a nonparent is considered to be more detrimental to children than a single parent living alone. Rates of divorce are higher among those who later marry, and breakups occur during the cohabitation period. More children experience child abuse, and poverty rates tend to be higher than with married families.
Single-parent families are distinguished from multigenerational families, which are defined as families with a single parent or a married couple living with their children, their parents, their in-laws, or their grandchildren.
Epidemiology
About 22.6 million children (32%) lived in single-parent households in 2008. African-American children are more likely (65%) to live in a single-parent than a two-parent household unlike children from all other racial groups (Annie E. Casey Foundation, 2010). Single mothers are overrepresented among the very poor and those needing social assistance. The incidence of single-parent families varies by geographic, racial, and ethnic demographics.
Assessment
Several key areas are important to assess when working with single parents and their children. They can be divided into parent- and child-related factors.
Parent-related factors include the following:
• Emotional and physical well-being of the parent
• Availability of emotional support from their social network
• Living situation, presence of financial difficulties, insurance coverage
• Availability of financial and emotional support from a noncustodial parent
• Availability and quality of child care for parents who must work
• Opportunities for the single parent to have a social life and relationships or personal time
• Ability of the parent to maintain consistency in discipline, in addition to a positive outlook and commitment to parenting
Child-related factors include the following:
• Role of the child in the family; responsibilities for taking care of siblings
• Relationship with custodial parent
• Location of and relationship with the noncustodial parent
• Availability of emotional support from his or her social network
• Availability of opportunities to accomplish age-appropriate developmental tasks (e.g., is child doing well in school? Does he or she have friends? Is child participating in sports or club activities?)
• Signs of problem behavior at school, at home, or with social activities
• The presence of children in the home with special needs (e.g., developmental disability, cognitive delay, or chronic illness)
Management
Resiliency in single-parent families is associated with individual characteristics of optimism, perseverance, faith, expressions of emotions, and self-confidence (Greeff and Ritman, 2005). Many single families cope well with the demands they face, benefiting from advice, anticipatory guidance, encouragement, and support of the provider. On an individual level, several critical factors promote successful childrearing in single-parent homes. The availability of a social support network and positive communication patterns are key (Box 17-6). Social organizations such as Big Brothers Big Sisters offer a supportive role model for children in single-parent families. Parents Without Partners is a national organization that offers social activities and support for single parents.
BOX 17-6 Significant Determinants for Successful Childrearing in a Single-Parent Home
• Support persons in the child’s life who:
• Adults in child’s community who provide support, including teachers, school officials, health care providers, and support person(s) for the parent
• Capacity of parent to communicate with child in open, direct, and understanding manner
• Ability of parent to recognize child’s need for opportunities for enjoyment and accomplishment outside the home and to provide for the child
• Economic stability and well-being that is adequate to meet family’s needs
Single parents commonly seek advice about dating situations and explaining money problems to their children. Suggest that the parent meet his or her date outside the home until a decision is made as to the direction of the adult relationship. Young children tend to quickly attach to individuals who are kind and spend time with them, whereas an older child may become jealous or see the individual as a threat. Financial concerns frequently are issues in single-family homes. Urge the parent to explain the family’s money situation in a way the child can understand based on age. When money is limited or tight, the child can be told simply and briefly that the family may have to wait to buy or limit buying “extras” or that some activities may have to be curtailed. The child can be helped to learn about the value of saving money for special treats.
If parents request specific help or demonstrate signs of being exhausted, depressed, overwhelmed, burdened, or socially isolated, a referral for more specialized services such as counseling may be appropriate. Similar signs in children plus deviant behaviors, emotional adjustment problems, or school disciplinary, academic, or behavioral problems can be indicators for mental health referral.
Patient Education and Prevention
Although individual families may be helped to gain better coping skills, significant positive change in the quality of life of single-parent families depends on restructuring and increasing economic, educational, and family support resources in the community. Primary care providers should be informed about the effect that social service legislation has on the families they serve and be willing to advocate for policy changes.
Remarriage: the Blended Family
Description
A blended family is one in which two adults create a reorganized family by joining with their children from previous relationships. Although this term usually refers to families created by remarriage after divorce, it is also used to describe families created by remarriage after the death of spouses. The introduction of a stepparent and possibly stepsiblings can be beneficial for a child or can be a time of difficult adjustment. The majority of children within blended families gradually adjust well to their new family situations.
Epidemiology
Approximately 50% of women and men who divorce or are widowed remarry within 4 years (Tanner, 2009). With remarriage, children become members of blended families. Blended families can present unique parenting challenges in family adaptation, cohesiveness, coping, and role relationships.
Assessment
Assessing how the children are coping with the significant changes in their lives and realignment of family roles can help both the provider and the parents direct their attention (Box 17-7).
Management
The goal of primary care interventions is to foster positive parenting behaviors, protect the development of the children, and enhance family functioning. Some counseling tips are listed in Box 17-7. Carefully assess any behavioral concerns. Whether the family is given guidance and followed closely by the primary care provider or given a referral to mental health services depends on the presence of significant behavioral or mental health problems. Providers should investigate community services that assist blended families, such as a self-help group for stepparents or a parenting group. Written information including telephone numbers of community resources should be maintained in a handbook or resource guide kept in the practice setting.
BOX 17-7 Assessment of and Counseling Tips for Children in Blended Families
Assessment
Developmental Stage of Child
• Age and developmental stage of child greatly affect child’s response to the remarriage and ability of child to cope with change and new family relationships.
• Early adolescence is often a time of greatest difficulty in adjustment to remarriage.
• A mother’s subsequent pregnancy is often a time of increased frequency and intensity of problems with young children.
Common Issues for Children in Blended Families
• Complex relationship with new family members
• Altered relationships with own family members and possible feelings of betraying other biologic parent or being torn between parents
• Possible relocation and separation from family members and friends
• Continued or new tensions between parents and tensions between stepparents; rivalries between parents and stepparents
• Establishing new family traditions and values
• Continuing to respect earlier family history, traditions, and loyalties that may be in conflict with new family ties
• Unrealistic expectations by child of stepparent
• Unrealistic expectations by stepparent for instant love, respect, and obedience from child
• Tensions within blended family household, creating anxiety and fear of another family breakup
Characteristics of Problem Behaviors in Blended Families
• Problems can occur at home and at school.
• Children in divorced and blended families experience more behavioral, social, emotional, and educational problems than do children from nondivorced families.
• Parental conflict more than family structure is the critical factor that influences both marital and family adjustment.
Counseling Tips
• Discuss upcoming changes with your child before remarriage and address possible fears, feelings, and expectations.
• Keep the marriage strong by a nurturing husband-and-wife relationship.
• Blended-family parents need to agree on discipline issues, how to set limits, and type of discipline; remembering to be consistent.
• Start new family traditions, such as weekly family meetings.
• Be patient and as flexible as possible; do not expect your child(ren) to have an immediate positive relationship with the new stepparent.
• Spend quiet, alone time with your child as much as possible and preferably every day.
• Do not force your child to align with the new parent and remember that a second parent does not replace the first; support and help maintain the relationship of your child with the other birthparent.
Patient Education and Prevention
Before remarriage, counseling and guidance that looks at coping with transition in a blended family should be explored with parents. Many children go on to develop strong and meaningful attachments to their stepparents if the relationship is cultivated over time with careful sensitivity to the needs of the child.
Adoptive Parent Families
Description
Adoption is the legal process that gives individuals who are not birth parents legal and permanent parental responsibility for children. Birth parents terminate their rights, and the adoptive parent(s) are awarded legal custody. Thus a new nuclear family is created.
Adoptive parents come in every variety—married couples, single parents, intrafamily adoption, subsidized adoption of children with special needs, gay and lesbian parents, grandparents, or other extended family members. Independent, identified, and international adoptions; surrogacy arrangements; and open adoptions are examples of various forms of adoption. Public and private agencies, independent adoption through attorneys, and foreign adoption services are potential avenues to assist in the placement of children.
Epidemiology
Since 1975, with the dissolution of the National Center for Social Statistics, there have been no federal agencies or nonprofit organizations collecting data on the annual number of total adoptions in the U.S. The Adoption and Safe Families Act of 1997 requires states to collect information about the adoptions of children in public foster care, but these are the only adoption-related statistics regularly reported by governments. Beyond that, most statistics kept today are kept by private agencies. The Adoption History Project (AHP) (2010) reports that even at the height of their popularity in 1970 when 175,000 adoptions were reported, adoption is rare, with 125,000 adoptions per year in the U.S. However, as adoption has become more visible with growing numbers of transracial and international adoptions producing families in which parents and children look nothing alike, attention attracted by these adoptive families has led many Americans to believe that adoption is increasing.
Assessment
Assessment of these families includes asking about the legal status of the adoption, the timing of the adoption in the child’s life, arrangements regarding involvement of the birth parents or other family members, decisions about how and when to tell the child about being adopted, and potential health concerns related to the birth parents or family, if known.
Important information that the provider should attempt to ascertain when assisting adoptive families includes the following:
• Legal arrangements and circumstances surrounding adoption process
• What, if any, contact will the birth parent or parents have with the child
• Timing of finalization of the adoption and length of waiting period
• Support services available for the adoptive family if an agency is arranging the adoption
• Knowledge of medical and psychosocial history of birth parents and child
• Any known or suspected medical (including growth and development) problems
• Information about the pregnancy, delivery, and neonatal period or subsequent medical problems
• Children adopted from foreign countries can be at risk for medical problems. Routine recommended screening tests are outlined in Box 17-8. If the reliability of prior vaccination history is questionable, an acceptable practice is to repeat the vaccinations (AAP, 2009).
BOX 17-8 Recommended Screening Tests for Children Adopted from Foreign Countries
• Newborn metabolic screening panel (all infants)
• Complete blood count with differential, platelet count, and indices
• Iron studies (ferritin, serum iron, iron saturation)
• Vitamin D (250 A total vitamin D), calcium, phosphorus
• Thyroid stimulating hormone, free thyroxine
• Tuberculin skin test, despite any previous BCG vaccination; if positive result, obtain chest x-ray (see Chapter 23)
• Stool for ova and parasites, Giardia antigen, and Cryptosporidium
• Hepatitis B panel, including surface antibody and antigen and core antibody
• Developmental, dental, hearing, and vision screening
• Hemoglobin electrophoresis (Asian, Latin-American, and African children)
• G-6-phosphate dehydrogenase assay (Asian, Mediterranean, and African children)
• Malaria (PCR) (children from tropical or subtropical regions and those with fever of unknown origin)
• Rickets (radiograph) (Chinese children)
• Lactose intolerance (black, Latino, American-Indian, and Asian children)
BCG, Bacille Calmette-Guérin; HIV, human immunodeficiency virus; PCR, polymerase chain reaction.
Management
Often parents request a preadoption consultation. This is an ideal time to review any identified issues. Other families may be in a foster care situation and considering adoption. Support through this process, before adoption is finalized, is crucial because there may be many hurdles with which to contend. Once adoption is finalized, close monitoring and support by the primary care provider during the initial adoption period are important. Scheduling of additional or more frequent health supervision visits is appropriate even when all appears well, but especially if high-risk situations or conditions are identified. If problems arise, prompt referral to specialty medical services, mental health, or social service agencies is imperative. Children with known special needs who are adopted are often eligible for federal and state financial support and services. The presence of a social support network is important. Adoptive parents face the same parenting challenges as biologic parents do when their child passes through the various developmental stages of childhood. In addition, adoption is a lifelong commitment that can present special challenges for parents. Excellent books about adoption for adults and children are available.
Families adopting children with special needs may require extra assistance with family bonding, behavioral, mental health, and physical needs. Such families seek social support when experiencing emotional pain, using informal social support systems first and then looking for professional help when other interventions have been found inadequate, often as a crisis intervention. These families need preventive resources, reassurance of competence, and encouragement to strengthen social support networks before child placement.
Patient Education and Prevention
When considering adoption, parents often benefit from a preadoption visit to the health care provider who will take care of their child. Parents often have many questions about the initial adoption period and the establishment of a family relationship. Issues that the provider should address with parents include the following:
• There should be a gradual disclosure of the adoption to the child. Such disclosure should be done earlier rather than later, and children should always be told the truth about where they came from and why they were adopted.
• Discussions of the adoption should be open, keeping in mind the child’s developmental stage, cognitive abilities, and emotional needs. It is important for adoptive parents to reassure the child in words and actions that he or she is loved, and the adoptive parents will always be there for the child.
• Discussions with the parents should address any myths, concerns, or fears that the parents might have about adoption and their adopted child.
• Parents need to understand that their child’s wish to know about or seek out the biologic parents is not a rejection of them.
• Adolescence can be difficult for adoptive children as they seek their own identity and deal with the fact that they are adopted. If teenagers wish to seek out their biologic parents, states usually will not release information until after the child is 18 years of age.
• Adoption of an older child may present an extra challenge, especially if the child has been shuffled between homes or emotionally scarred by abuse or neglect. Telling parents about such challenges can help them to be better prepared to handle some of the difficulties that may lie ahead for their family and seek counseling early if needed.
Variations in the Family Unit
There are a number of variations in the family unit. Some reflect changes in American family life and the diversity of parental experiences. Each situation is unique and requires a thorough assessment. Discussion regarding key issues related to some of these variations follows.
Adolescent Parents
Description
Adolescents who become parents generally face the problems inherent when a major role is assumed before the adolescent is developmentally ready. Adolescent parents have developmental needs of their own and, not infrequently, their needs are in conflict with those of their children. Adolescent pregnancy is marked by lower self-esteem, poorer educational and vocational outcomes, and socioeconomic disadvantages for the mother. Often adolescent mothers feel isolated, exhausted, and depressed. Children of adolescent mothers are more likely than children of older mothers to have a low birth weight, to have ongoing health problems during childhood, to grow up in homes without fathers, and to be raised in poverty or near poverty. They are also at high risk for cognitive delays, behavioral problems, and difficulties in schooling (Hoffman, 2008). Some teens can successfully parent their infant if given support. However preexisting family and individual factors that lead a teenager to become a mother before completing the educational and developmental tasks necessary for adult life are more relevant predictors of successful parenting.
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