Single-Parent Families

Some children live in single-parent families because of divorce or the death of a parent (see Chapter 26). More than 20% of children are born to unmarried mothers. Many of these children live in single-parent families for some, if not all, of their childhood. Although some women elect to have children without getting married, in many situations the single parent is a young mother who had an unplanned pregnancy.

Single parents often have fewer financial resources and social supports. The mean income of households headed by single mothers is only 40% of that of two-parent families. More than half of these households live in poverty. Single parents also must 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. This decreased confidence, in combination with the fatigue associated with working and raising a child, makes consistent discipline more difficult to maintain, which may exacerbate behavioral problems. These parents are likely to have less time for a social life or other activities, which may increase their isolation. When the increased burdens of being a single parent are associated with exhaustion, isolation, and depression, optimal child development is less likely.

When the parent is a teenage mother, problems of parenting may be exacerbated further (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. They are even less likely than other single mothers to have 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 important in these situations.

When a single parent has good 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 confidence through education about child development and behavior and validation of parenting behaviors. Empathetic understanding of the difficulties of being a single parent can have a healing effect or help a parent to discuss difficulties that may suggest the need for a referral to other professionals.

Children Living with Homosexual Parents

Many children with a gay or lesbian parent were conceived in the context of a heterosexual relationship. Some parents were unaware of their homosexuality at the time that they married, whereas others may view themselves as bisexual or marry despite the recognition that they are homosexual. Gay men and lesbian women also become parents on their own or in the context of an already established relationship with a same-sex partner through adoption, insemination, or surrogacy. Children living with homosexual parents may encompass many possible family structures.

Parents in these families are likely to have concerns about how disclosure of the homosexuality and the associated social stigma will affect the child. In general, earlier disclosure of a parent’s homosexuality to children, especially before adolescence, is associated with better acceptance. Most children of homosexual parents experience some social stigma associated with having a gay or lesbian parent; this may occur in the form of teasing by peers, disapproval from adults, and stress or isolation related to keeping the parent’s homosexuality a secret.

Evidence suggests that having a homosexual parent does not cause increased problems in the parent-child relationship or the child’s social-emotional development. Gender and gender role behaviors are typical for the child’s age. Nonetheless, distress related to teasing or maintaining the parent’s secret may be great for some children, especially in early adolescence when issues of peer acceptance, sexual identity, and separation from one’s parents are especially strong.

Adoption

Adoption is a legal and social process that provides full family membership to a child not born to the adoptive parents. Approximately 2% of children in the United States are adopted. A significant proportion of legal and informal adoptions are by stepparents or relatives of the child. Most adoptions in the United States involve U.S. parents adopting U.S. children, but shifting cultural trends and a shortage of healthy U.S. children available for adoption have increased the diversity in the ways in which adoptions occur (e.g., international adoptions, privately arranged adoptions, and the use of a surrogate parent). These types of adoption each raise unique issues for families and health care providers. Open adoptions in which the biologic parents and birth parents agree to interact are occurring with increased frequency and create new issues for the adoption triad (biologic parent, adoptive parent, and child). Adoptions by single parents create another set of issues.

Pediatricians are in an ideal position to help adoptive parents. Pediatricians can help 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 the issues that may arise when the child is an adolescent. A preadoption visit may allow parents to address the medical information they have received about the child and identify important pieces of the medical history that may be missing, such as the medical history of the biologic family and the educational and social history of the biologic parents. The preadoption period is the time that families are most likely to be able to obtain this information. When children are adopted from another country, there may be risks of infections, in utero substance exposure, poor nutrition, or inadequate infant care that are specific to individual countries and 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 biologic 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 biologic parents, and there may be new challenges as the child begins to interact more with individuals outside 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 biologic 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. 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 biologic parents.

Although adopted children have a higher rate of school, learning, and behavioral problems, much of this increase is likely to be related to biologic and social influences before 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.

Foster Care

Foster care is a means of providing protection for children who require out-of-home placement, most commonly because of homelessness, parental inability to care for the child, parental substance abuse, or child neglect or abuse. The number of children in foster care doubled between 1987 and 2001, and currently more than 0.5 million children live in foster care. For these children, reunification with the biologic family is the goal for approximately 40%, and adoption or placement with relatives is the goal for 25% to 35%. Ten percent of children are in long-term foster care. For the remaining 20%, no long-term goal has been established.

Children 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; 40% to 70% of foster children have chronic illnesses. More than half have significant developmental delays, and behavioral disorders are common. Ideally, foster care provides a healing service for these children and families, leading to reunification or adoption. Too often, inadequate programs contribute to the ongoing difficulties of the children.

Consistent, multidisciplinary, and coordinated care is needed to address the complex needs of children entering foster care. For children in foster care for more than 1 year, more than 40% experience three or more home placements, and for children in foster care for more than 4 years, this figure is approximately 60%. Poor case coordination in conjunction with these multiple placements leads to frequent changes in schools and medical providers, further fragmenting the health care and education these children receive. In some locations, one third of children received no immunizations while in foster care. Frequent changes in placement exacerbate the problems foster children often have in forming a secure relationship with adult caregivers. Children may manifest this difficulty by resisting foster parents’ attempts to develop a close relationship. This detachment from the foster parent may be difficult for the foster parent to endure, which may perpetuate a cycle of placement failures. Although the protections of the foster care system end at 18 years of age, these adolescents rarely have the skills and maturity that allow them to live independently. In the first 2 years following discharge from the foster care system when they become 18, approximately 25% of males and 10% of females are incarcerated at least once.

When health care providers see a child in foster care, it is crucial that they perform a comprehensive health assessment for acute and chronic medical problems and developmental and behavioral disorders. When children are placed with competent and nurturing foster parents and provided coordinated care from skilled professionals, significant improvements in a child’s health status, development, and academic achievement usually occur.

Physical Needs

Failure to meet a child’s physical needs for protection or nutrition results in some of the most severe forms of family dysfunction (see Chapters 21 and 22). There are many other ways in which parental behaviors can interfere with a child having a healthy and safe environment, such as prenatal and postnatal substance abuse. Prenatal use of alcohol exposes children to potentially devastating consequences of this teratogen. Children with fetal alcohol syndrome have in utero and postnatal growth retardation, microcephaly, mental retardation, and a characteristic dysmorphic facial appearance. Even in the absence of growth retardation and a dysmorphic appearance, some children exposed to alcohol in utero develop problems with coordination, attention, hyperactivity, impulsivity, and other learning or behavioral problems related to the alcohol exposure. In the past, these children have been described as having fetal alcohol effects, but the currently recommended terminology is alcohol-related neurodevelopmental disorder.

Other substances also may affect the fetus, but investigation of these effects is complicated by the fact that often more than one substance is used, and nutrition and prenatal care are not optimal. Cigarette smoking during pregnancy is associated with lower birth weight and increased child behavioral problems. Use of cocaine in the perinatal period has been associated with intracranial hemorrhages and abruptio placentae. Similarly, although exposure to opiates in utero can result in a neonatal withdrawal syndrome, significant cognitive deficits do not seem to be associated with the use of opiates alone. Cocaine- and opiate-exposed infants often have coexisting high risk factors for cognitive deficits, such as low birth weight.

Parental substance abuse after the child’s birth is associated with increased family conflict, decreased organization, increased isolation, and increased family stress related to marital and work problems. Family violence may be more frequent. Despite the fact that these parents often have difficulty providing discipline and structure, they may expect their children to be competent at a variety of tasks at a younger age than non–substance-abusing parents. This sets the children up for failure and contributes to increased rates of depression, anxiety, and low self-esteem. The parents’ more accepting attitude toward alcohol and drugs seems to increase the chance that their children will use substances during adolescence.

Parents also may expose children directly to the harmful effects of other substances, such as exposure to second-hand cigarette smoke, which is consistently associated with increased rates of childhood respiratory illnesses, otitis media, and sudden infant death syndrome. Despite these effects, only a few parents restrict smoking in their homes. There are many other ways in which parents may not physically protect their children. Failing to immunize children, to childproof the home adequately, and to provide adequate supervision are other examples.

Parents’ attempts to provide too much protection for their child also can cause problems. One example of this is the vulnerable child syndrome. A child who is ill early in life continues to be viewed as vulnerable by the parents despite the fact that the child has fully recovered. Behavioral difficulties may result if parents are overindulgent and fail to set limits. Parental reluctance to leave the child may contribute to the child having separation anxiety. Parents may be particularly attentive to minor variations in bodily functions, leading them to seek excess medical care. If the physician does not recognize this situation, the child may be exposed to unnecessary medical procedures.

Emotional Support, Education, and Socialization

Failure to meet a child’s emotional or educational needs can have a severe and enduring negative impact on child development and behavior. Infants need a consistent adult who learns to understand their signals and meets the infant’s needs for attention as well as food. As the adult caregiver learns these signals, he or she responds more rapidly and appropriately to the infant’s attempts at communication. Through this process, often referred to as attachment, the special relationship between parent and child develops. When affectionate and responsive adults are not consistently available, infants often are less willing to explore the environment and may become unusually clingy, angry, or difficult to comfort.

Appropriate stimulation also is vital for a child’s cognitive development. Children whose parents do not read to them and do not play developmentally appropriate games with them have lower scores on intelligence tests and more school problems. In these situations, early intervention has been shown to be particularly effective in improving skill development and subsequent school performance. At the other extreme, there are increasing concerns that some parents may provide too much stimulation and scheduling of the child’s day. There may be such emphasis on achievement that children come to feel that parental love is contingent on achievement. There are concerns that this narrow definition of success may contribute to problems with anxiety and self-esteem for some children.