The Pediatrician's Role in Family Support and Family Support Programs

The health and welfare of children depend on the ability of their families, supported by systems in their communities, to foster positive emotional and physical development. Recent scientific research confirms that brain growth and neurophysiologic development during the first years of life respond directly to the environmental influences of early emotional relationships. The neurologic pathways produced then have profound effects on the behaviors of children and adolescents and affect their interactions within their families and extended society across the life course. The enormous effect the family has on this developmental process led the American Academy of Pediatrics (AAP) to make the “promotion of nurturing families for all children” a priority among AAP resolutions in 1993 and 1994 and, subsequently, to develop the AAP Task Force on the Family. The task force published a thorough and extensive report in 2003 that informs pediatricians and guides policy-makers regarding the effect that family has on children's functioning and the expectations for pediatricians to promote optimal family functioning for their patients.¹  Pediatricians play a unique role as family health advisors during the formative period of a child's development and during crucial developmental stages throughout childhood and adolescence. Pediatricians need expertise in working with families to identify strengths, stresses, and needs and to identify priorities and goals with families. They also need to develop expertise in counseling skills and knowledge regarding community-based resources to offer strategies and resources to families. The structure and support of families involve forces that are often outside the agenda of the usual pediatric health supervision visits. Pediatricians must ensure that their medical home efforts promote a holistically healthy family environment for all children.² 

Stresses accompanying contemporary American life can challenge families' efforts to promote successful developmental and emotional outcomes for their children. The structure of families and patterns of family life in the United States have changed profoundly in the past quarter century. Five percent of all births in 1960 were to unmarried women; this figure increased to almost 37% by 2005.³  Since 1960, the divorce rate has more than doubled⁴ ; 40% to 50% of all first-time marriages end in divorce.⁵  Divorce rates seem to have leveled overall since the 1980s, but factors exist that increase the risk for some couples (eg, lower educational level or younger age at the time of marriage).⁶  Although remarriage rates are high, more than one-third of remarried couples divorce again.⁷  As a consequence, approximately 14% more children are now living in 1-parent households than approximately 40 years ago (25.8% in 2007 versus 11.8% in 1968).⁸ 

Another change in family life is that, by 2005, approximately 63% of all mothers with preschool-aged children were in the labor force, which reflects a twofold increase since 1970.⁹  Three-fourths of the mothers of school-aged children work.¹⁰  In 2-parent households, this means a marked increase in homes in which both parents work. Despite the majority of American mothers being in the workforce, half of female-led single-parent households lived below the poverty level in 2004.⁹  A decline in the purchasing power of family income and the lack of comparable wages for women have added to the stress on families. Social disparities have also contributed to the growing percentage of children who live in poverty, and poverty is the strongest predictor of poorer health and well-being for children.^1,11  Residential mobility has separated many families from the natural support systems provided by their extended families, which may leave parents feeling socially isolated and prevents the intergenerational transmission of cultural and community-specific advice and support. Economic and social inequalities have led to increasingly impoverished neighborhoods, more working families living in or near poverty, and weakening of community ties. Longer hours away from their children, disconnection from close extended family support, and disintegration of traditional community interdependence all reduce the time, energy, and external supports available for rearing healthy children. The stress and speed of social change has weakened the support systems for many American families.¹² 

Despite these enormous pressures working against families, intact and successful families do exist. Although it is evident that the risk of poorer outcomes for children is lowest among 2-parent households,¹³  there is not a specific family constellation that makes poor outcomes inevitable. How a family influences children's outcomes is embedded within the interactions among its members. Table 1 lists characteristics that positively contribute to a family's success in raising children and, ultimately, to communities and society.¹⁴ 

Social institutions have begun to offer various family support services to help parents carry out essential functions on behalf of their children. Many pediatricians have perinatal exposure to families who need community-based support for a variety of reasons, and all community pediatricians begin providing comprehensive health services for children as soon as they are discharged from the newborn nursery. Many pediatricians are already familiar with some types of family support programs. Examples of successful programs include prenatal and infant home visitor programs, comprehensive early childhood education programs (eg, Early Head Start, Head Start), early screening and referral programs, crisis care programs, parent support and/or education groups, early reading and parental literacy, and early intervention programs for children with special needs (eg, Individuals With Disabilities Education Act, Part C).^{1,10,15,–,18}  Because of significant variability regarding the effectiveness of available support programs, pediatricians should be aware of the evidence base for different types of programs and, specifically, the programs available in their communities. Home visitation programs, for example, can lead to improvements for families (eg, detecting postpartum depression, reducing the frequency of unintentional injury, improving parenting skills), but the relative effect depends on the qualities of the program; for example, programs that use professionals (ie, nurses) rather than paraprofessionals¹⁹  and programs targeted at specific populations (eg, infants born prematurely) have more measurable effects on child outcomes.²⁰ 

Many comprehensive, community-based family support programs have been established around the country. These programs aim to support family relationships and promote parental competencies and behaviors that contribute to parental and infant/child/adolescent health and development. The best programs offer a spectrum of services that involve informal and structured groups. Topics may include information on child development, personal growth, family relationships, parenting education, peer support groups, parent-child activities, early developmental screening, community referral and follow-up, job skills training, and/or adult education, especially language and literacy education.^21,22  Services should be available to all families regardless of economic or ethnic background. The programs operate on the premise that no family is entirely self-sufficient and that most can benefit from some external support.²³  Pediatricians should search for, become familiar with, and refer families to high-quality family support services in their communities.

Some schools are providing after-school programs for children whose parents cannot be at home when classes end; others are providing school-based or associated health services to ensure that children receive timely health care and counseling. School curricula have expanded to include topics such as conflict resolution, sex education, and community service. Some employers offer family-oriented benefits such as flexible work hours, shared jobs, and child care. Religious congregations in some communities have developed a full array of social services and supports. The Family and Medical Leave Act of 1993 is an example of government acting in support of families, as are more established programs such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Temporary Assistance for Needy Families (TANF).

High-quality programs operate on the following principles^1,24,25 :

• The primary responsibility for the development and well-being of children lies within the family.

• Families are part of a community, and support should be provided in the context of community life and through collaborative links with community resources.

• The kinds of support provided should be determined by individual and community needs. Although participation should be voluntary, it should be encouraged for at-risk families such as those led by single and/or socially isolated parents and those living in poverty.

• Support offered by friends, neighbors, and community-based resources is as vital as access to professional support services. Families are resources for themselves, for other families, and for communities and programs.

• The support given should enhance the strengths found within the family unit and among family members and empower families to use those strengths. The aim of support is to strengthen the family unit and the community while preventing alienation and family dysfunction.

• Support is available for all families and provided with an awareness of and sensitivity toward the culture, race, and native language of families and communities.

Family support programs play an important and, in some instances, essential role in promoting the positive functioning of families and ensuring the well-being of children. Their effectiveness, at least with certain populations (eg, low-income families, young single mothers, low birth weight infants, children with behavioral problems, children with special health care needs) is well documented.^17,20,26  All families need knowledge, skills, and support to raise their children and to foster normal growth, development, and learning. The AAP encourages public policies, professional practices, and personal behavior that support the caregiving role of families, advocate comprehensive approaches to child health and encourage prevention and early intervention strategies oriented toward the family.

1. Pediatricians should be aware of the increasing number of families experiencing stress and should learn to recognize situations (eg, maternal depression) that interfere with successful child rearing. The AAP Bright Futures guidelines recommend using open-ended questions to screen for and assess family stress during health supervision visits, with sample questions provided to probe for stressors such as parental depression, domestic violence, separation/divorce, and substance abuse. In addition, Bright Futures has a chapter titled “Promoting Family Support,” which outlines the importance of family development to a child's overall growth and development.²⁷ 

2. As medical homes, pediatric practices should collaborate with patients and their caregivers and provide family-centered care with an awareness of cultural diversity. By having open and ongoing relationships with parents, pediatricians can facilitate discussions; monitor and guide developmental progress; address parental concerns; and support parental care, capacities, and needs. Focus should be on fostering those characteristics (Table 1) known to be associated with successful family functioning.

3. Pediatricians should interview families with a real awareness of the significant influence that family factors (socioeconomic status, discipline style, cultural beliefs, parental health and mental health, etc) have on children's development and behavior.²⁸  Continuing medical education programs on pediatric family interviewing and psychosocial issues in pediatric practice can enhance the pediatrician's skills and opportunities for counseling families. As recommended by the Task Force on the Family, the AAP advocates for pediatricians to have “adequate time, resources, billing options, and reimbursement to provide family-oriented care.”¹ 

4. Pediatricians can provide family support by engaging in a relationship with parents based on collaboration and shared decision-making so that parents feel and become more competent. The AAP provides pediatricians with guidance for supporting families in the prevention of violence and injury and the enhancement of parent-child communication on the basis of individual families' needs in the Connected Kids program (www.aap.org/ConnectedKids/ClinicalGuide.pdf). This collaboration with parents might also be in the form of parent councils and other partnerships that allow parents to provide input to practices and programs.

5. Pediatrician counseling of parents should include considering the needs and resources of the family and helping them benefit from the support of members of extended family and the community.

6. Pediatricians should work to identify, develop, refer to, and participate in community-based family support programs to help parents secure the knowledge, skills, support and strategies they need to raise their children. Having information easily available for families within the pediatric office that includes information and schedules of parenting classes, volunteer and community organizations incorporating family participation, and child care resources is also extremely helpful. The Maternal and Child Health Library provides an online directory to assist families and health providers to locate services within their own communities (www.mchlibrary.info/KnowledgePaths/kp_community.html).

7. Pediatricians should actively participate in sustaining the social capacity of their communities through their personal participation in local recreational, social, educational, civic, or philanthropic activities and associations. By participating in community-based family support programs, pediatricians can provide technical advice on health and safety aspects of services, serve as a source of professional information for families, and learn from these programs how best to contribute to the healthy development of children, families, and communities.

8. Pediatricians need to work within their communities to develop plans for identifying and coordinating care for families in need of more extensive social support services. An opportunity the AAP provides that might support pediatricians in this endeavor is the Community Access to Child Health (CATCH) program. CATCH provides pediatricians funding, training, technical assistance, and networking opportunities to ensure that all children have access to needed health care services within their communities.²⁹ 

Jill J. Fussell, MD

Pamela C. High, MD, Chairperson

Elaine Donoghue, MD

Jill J. Fussell, MD

Mary Margaret Gleason, MD

Paula K. Jaudes, MD

Veronnie F. Jones, MD

David M. Rubin, MD

Elaine E. Schulte, MD, MPH

Chet D. Johnson, MD

Claire Lerner, LCSW

Zero to Three

Jennifer Sharma, MA

Child Welfare League of America

Mary Crane, PhD, LSW