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

Child Factors	Parent/Caregiver Factors	Social and Environmental Factors
• Chronologic age and developmental level • Present or past history of physical, emotional, or cognitive problems • Personality traits, characteristics, and temperament • Prior maltreatment or significant negative life events • Special care needs • School performance	• Physical, intellectual, or emotional functioning, illnesses, or limitations • Level of involvement in childcare and life events of child • Level of parenting skills, childrearing style, and communication skills • Beliefs about discipline and corporal punishment • Parental role and supports • Parental history of experienced dysfunctional childrearing practices or any maltreatment or neglect • A victim or perpetrator of domestic violence • Current or previous history of substance abuse • Financial resources, especially if poverty or limited finances are an issue	• Sibling assessment • Type and strength of family social support network or social isolation • Peer group relationships • Stresses, crises, or conflicts in the home environment • Cultural belief system • Environmental condition of home and surrounding community • Stresses in the neighborhood environment • Availability and accessibility of community support systems and partnerships

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.

Providers are typically involved in universal preventive interventions related to both physical and mental health issues. Universal preventive interventions are directed at enhancing the parent-child relationship. Universal interventions address the population as a whole and stress promoting wellness, improving communication, and strengthening relationships. Selective preventions are directed at individuals or groups at risk for the development of mental health and/or relationship problems. Indicated preventions are for high-risk individuals who are experiencing symptoms or who have biologic markers for mental illness. Selective and indicated preventions often use a multidisciplinary approach, with community resources and other professionals from various social fields joining together. The provider must develop a plan of action with goals and outcome measures and specific criteria that indicate when there is need for referral to a mental health or other professional.

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

Developmental Stage of Children

• Age and developmental stage of children greatly affect their response to separation and divorce of parents.

• Common reactions of children to divorce by age group:

2-5 years: Regression, irritability, sleep disturbances, aggression

6-8 years: Open grieving and feelings of rejection or being replaced; whiny, immature behavior; sadness; fearfulness

9-12 years: Fear and intense anger at one or both parents

>13 years: Worried about own future, depressed, or acting-out behaviors (e.g., truancy, sexual activity, alcohol or drug use, suicide attempts)

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

• Feelings of loneliness or emotional abandonment, or both

Economic Consequence of Divorce

• Often devastating economic hardships and decline in living standards (especially for women)

• Nonpayment or delinquency in payment of child support

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

Anticipatory Guidance Issue	Discussion Points With Parents
Advise parents to prepare the child for the impending breakup.	If possible tell the child in advance of the breakup. Children who are appropriately prepared may cope better with the separation and change in family structure. Discussions should focus on supporting the child’s needs for reassurance and stability, not on blame, recriminations, or the parent’s needs.
Explain to parents the need to discuss the following key issues with their children.	Assure children they will continue to see the departing parent when possible. Explain what divorce means in language appropriate to the child’s cognitive and developmental level; offer an explanation of reasons for the divorce in the same terms. Reassure children that they did not cause the divorce or separation, that they cannot correct their parents’ unhappiness in the marriage, and that the divorce is the parents’ decision.Explain what the family structure will look like afterward and what changes will be necessary in the way the family functions.Explain the visitation arrangements as soon as they are established.Reassure children that they will be cared for, and they are not being abandoned by either parent, unless a parent has disappeared or refuses involvement.Tell children that feelings of sadness, anger, and disappointment are normal; encourage them not to “take sides,” but love both parents.
Discuss the need for consistency.	Parents should strive to maintain consistent daily routines between the two households; encourage the use of security items that the child may depend on or carry familiar items between the homes during the transitional period.Be consistent in disciplinary practices.
Suggest self-help measures.	Children and parents may benefit from attending divorce recovery workshops, classes about families in transition, or peer support groups.School counselors, religious groups, or community and social service agencies may be helpful resources.
Acknowledge grief.	Providers should acknowledge the grief that both the parent and child are experiencing, and provide support.
Discuss when referral for mental health counseling might be indicated.	Children often demonstrate internalized or externalized psychosocial problems in response to divorce. Counseling may be indicated for the family members.

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.

• 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

• 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:

Collaborate with the single parent

Develop quality relationships with the child

Are available for the child

• 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