Family Pediatrics

Abstract

ABSTRACT/EXECUTIVE SUMMARY Why a Task Force on the Family? The practice of pediatrics is unique among medical specialties in many ways, among which is the nearly certain presence of a parent when health care services are provided for the patient. Regardless of whether parents or other family members are physically present, their influence is pervasive. Families are the most central and enduring influence in children’s lives. Parents are also central in pediatric care. The health and well-being of children are inextricably linked to their parents’ physical, emotional and social health, social circumstances, and child-rearing practices. The rising incidence of behavior problems among children attests to some families’ inability to cope with the increasing stresses they are experiencing and their need for assistance. When a family’s distress finds its voice in a child’s symptoms, pediatricians are often parents’ first source for help. There is enormous diversity among families—diversity in the composition of families, in their ethnic and racial heritage, in their religious and spiritual orientation, in how they communicate, in the time they spend together, in their commitment to individual family members, in their connections to their community, in their experiences, and in their ability to adapt to stress. Within families, individuals are different from one another as well. Pediatricians are especially sensitive to differences among children—in their temperaments and personalities, in their innate and learned abilities, and in how they view themselves and respond to the world around them. It is remarkable and a testament to the effort of parents and to the resilience of children that most families function well and most children succeed in life. Family life in the United States has been subjected to extensive scrutiny and frequent commentary, yet even when those activities have been informed by research, they tend to be influenced by personal experience within families and by individual and cultural beliefs about how society and family life ought to be. The process of formulating recommendations for pediatric practice, public policy, professional education, and research requires reaching consensus on some core values and principles about family life and family functioning as they affect children, knowing that some philosophic disagreements will remain unresolved. The growing multicultural character of the country will likely heighten awareness of our diversity. Many characteristics of families have changed during the past 3 to 5 decades. Families without children younger than 18 years have increased substantially, and they are now the majority. The average age at marriage has increased, and a greater proportion of births is occurring to women older than 30 years. Between 1970 and 2000, the proportion of children in 2-parent families decreased from 85% to 69%, and more than one quarter (26%) of all children live with a single parent, usually their mother. Most of this change reflects a dramatic increase in the rate of births to unmarried women that went from 5.3% in 1960 to 33.2% in 2000. Another factor in this change is a slowly decreasing but still high divorce rate that is roughly double what it was in the mid-1950s. Family income is strongly related to children’s health, and the financial resources that families have available are closely tied to changes in family structure. Family income in real dollars has trended up for many decades, but the benefits have not been shared equally. For example, the median income of families with married parents has increased by 146% since 1970, but female-headed households have experienced a growth of 131%. More striking is that in 2000, the median income of female-headed households was only 47% of that of married-couple families and only 65% of that of families with 2 married parents in which the wife was not employed. Not surprising, the proportion of children who live in poverty is approximately 5 times greater for female-headed families than for married-couple families. The composition of children’s families and the time parents have for their children affect child rearing. Consequent to the increase in female-headed households, rising economic and personal need, and increased opportunities for women, the proportion of mothers who are in the workforce has climbed steadily over the past several decades. Currently, approximately two thirds of all mothers with children younger than 18 years are employed. Most families with young children depend on child care, and most child care is not of good quality. Reliance on child care involves longer days for children and families, the stress imposed by schedules and created by transitions, exposure to infections, and considerable cost. An increasing number and proportion of parents are also devoting time previously available to their children to the care of their own parents. The so-called “sandwich generation” of parents is being pulled in multiple directions. The amount and use of family time also has changed with a lengthening workday, including the amount of commuting time necessary to travel between work and home, and with the intrusion of television and computers into family life. In public opinion polls, most parents report that they believe it is more difficult to be a parent now than it used to be; people seem to feel more isolated, social and media pressures on and enticements of their children seem greater, and the world seems to be a more dangerous place. Social and public policy has not kept up with these changes, leaving families stretched for time and stressed to cope and meet their responsibilities. What can and what should pediatrics do to help families raise healthy and well-adjusted children? How can individual pediatricians better support families? Family Pediatrics The American Academy of Pediatrics (AAP) Board of Directors appointed the Task Force on the Family to help guide the development of public policy and recommend how to assist pediatricians to promote well-functioning families (see Appendix). The magnitude of the assigned work required task force members to learn a great deal from research and researchers in the fields of social and behavioral sciences. A review of some critical literature was completed by a consultant to the task force and accompanies this report. That review identified a convergence of pediatrics and research on families by other disciplines. The task force found that a great deal is known about family functioning and family circumstances that affect children. With this knowledge, it is possible to provide pediatric care in a way that promotes successful families and good outcomes for children. The task force refers to that type of care as “family-oriented care” or “family pediatrics” and strongly endorses policies and practices that promote the adoption of this 2-generational approach as a hallmark of pediatrics. During the past decade, family advocates have successfully promoted family-centered care, “the philosophies, principles and practices that put the family at the heart or center of services; the family as the driving force.” Most pediatricians report that they involve families in the decision making regarding the health care of their child and make an effort to understand the needs of the family as well as the child. Family pediatrics, like family-centered care, requires an active, productive partnership between the pediatrician and the family. But family pediatrics extends the responsibilities of the pediatrician to include screening, assessment, and referral of parents for physical, emotional, or social problems or health risk behaviors that can adversely affect the health and emotional or social well-being of their child. Family Context of Child Health The power and importance of families to children arises out of the extended duration for which children are dependent on adults to meet their basic needs. Children’s needs for which only a family can provide include social support, socialization, and coping and life skills. Their self-esteem grows from being cared for, loved, and valued and feeling that they are part of a social unit that shares values, communicates openly, and provides companionship. Families transmit and interpret values to their children and often serve as children’s connection to the larger world, especially during the early years of life. Although schools provide formal education, families teach children how to get along in the world. Often, efforts to discuss families and make recommendations regarding practice or policy stumble over disagreements about the definition of a family. The task force recognized the diversity of families and chose not to operate from the position of a fixed definition. Rather, the task force, which was to address pediatrics, decided to frame its deliberations and recommendations around the functions of families and how various aspects of the family context influence child rearing and child health. One model of family functioning that implicitly guided the task force is the family stress model (Fig 1). Stress of various sorts (eg, financial or health problems, lack of social support, unhappiness at work, unfortunate life events) can cause parents emotional distress and cause couples conflict and difficulty with their relationship. These responses to stress then disrupt parenting and the interactions between parent and child and can lead to short-term or lasting poor outcomes. The earlier these events transpire and the longer that the disruption lasts, the worse the outcomes for children. The task force favors efforts to encourage and support marriage yet recognizes that every family constellation can produce good outcomes for children and that none is certain to yield bad ones. Unequivocally, children do best when they are living with 2 mutually committed and loving parents who respect and support one another, who have adequate social and financial resources, and who are actively engaged in the upbringing of their children. Conclusions From its discussions with family experts, its review of research literature, and its own intensive discussions, the task force was able to draw about the American family a limited number of conclusions that are relevant to pediatrics. Two overriding conclusions were apparent. First, children’s outcomes—their physical and emotional health and their cognitive and social functioning—are strongly influenced by how well their families function. Second, there is much that practicing pediatricians can do to help nurture and support families and, thus, promote optimal family functioning and children’s outcomes. Other conclusions were organized into 4 categories: 1) family function and structure, 2) family circumstances, 3) pediatric practice, and 4) policy. Within the first category, there are conclusions about the effect of family structure, values, beliefs, roles, and relationships on child rearing and child outcomes. The second category, family circumstances, summarizes information on the emotional climate within and outside the home that can promote or impede children’s healthy development. Third, to provide appropriate care for children, pediatricians must expand their practices to encompass the assessment of family relationships, health, and behaviors. They must have the skills and comfort to inquire and learn about individual families, address family issues realistically, and link families to support groups and community resources. Pediatricians’ ability to practice family pediatrics is influenced by training, personal experience and orientation, the work environment, and professional relationships. Finally, there is a need to develop policies that support reimbursement of pediatricians for services for families; that acknowledge the importance of marriage, parenting, and families for children; and that set clear expectations for parents while providing opportunities for them to obtain desired support. Recommendations The task force intended that its recommendations follow logically from the conclusions it was able to draw. The scope of family issues that were reviewed and discussed was very wide; consequently, in some cases, the conclusions are broad and the associated recommendations are numerous. The 80 recommendations also were organized into 4 categories to facilitate their consideration by individual physicians and various bodies within the pediatric profession. The first category, education, offers suggestions on family content for resident training and for continuing education for practitioners. It also contains some guidance on priority topics that should be addressed by parent education materials published by the AAP. The second category, policy and advocacy, suggests public policy positions that would support families and promote good child outcomes. It also addresses reimbursement policies, including diagnostic and procedure coding, which could enable pediatricians to practice family pediatrics. Some suggestions for internal AAP policies that would highlight the importance of a family orientation for the organization also are provided. Finally, opportunities are identified for the AAP to promote local and national policies and activities that support and strengthen families through its chapters and its relationships with other professional organizations. The third and most extensive category comprises recommendations about pediatric practice. This category includes suggestions for how pediatricians can modify their practice behaviors to promote good family functioning and effective parenting. Included are recommendations for how pediatricians can help strengthen parental partnerships in different family types, screen for family circumstances that put children at risk, and help create family-friendly practice environments. For additional guidance, some characteristics of a family-friendly pediatrician are listed in the final table of the report. The final category makes recommendations for research that the AAP should encourage or undertake to better enable pediatricians to provide family-oriented care. Areas for research include the mechanics, content, and effectiveness of family-oriented pediatrics practice; public policies and programs that promote family functioning and family-oriented care; and progress toward adopting the principles and content of family pediatrics among health care organizations, insurers, and AAP members. Taken as a whole, the recommendations provide a comprehensive plan for the AAP and pediatricians to assist families to function well and meet the needs of their children. The scope of work that is required is extensive and touches on nearly every aspect of the work done by the organization. It also requires modifications in pediatric practices to accommodate changes in the characteristics and circumstances of families that are served. Next Steps to Ensure Implementation The task force report is only the first step in what needs to be an ongoing process to ensure that children’s health care is effectively provided in the context of their families. Attention to families should become integrated into the work of the AAP. This report should be reviewed and discussed by AAP staff, committees, sections, and members to determine which recommendations apply to their work and to plan strategies for their implementation. A single entity needs to take ongoing responsibility for monitoring and promoting activities related to the task force’s recommendations. These responsibilities should be assigned with high priority to a standing committee of the AAP.