A major challenge to pediatricians in fostering parenting is the wide range of family types present in modern America. This diversity includes major differences in marital status, sexual orientation, biological relationship to the child, parental age, racial and cultural background, and employment. Fortunately, outcome of the child depends more on family interrelationships than on the type of family. To be effective in dealing with parenting issues, we need to understand, respect, and support all types of families. This article will describe some of the special features of families with these differences and ways pediatricians can foster optimal parenting for them all.
Diversity rather than similarity describes modern families with regard to their caregiving composition.1 Only 26% of children in the United States are now living in married, two-parent families, and only 8% live in married families where the father works and the mother stays home (Census 1990). Many children are in joint-custody arrangements. At this time, 50% of children in the United States live in a single-parent household, 85% of which are headed by die mother. Two years after a divorce, 50% of children no longer have contact with their fathers.
Marital discord has been suggested as the factor affecting a child's development more than divorce itself. Because 45% of marriages end in divorce, an even larger percentage of children than this must be exposed to significant discord. After divorce, parenting tends to become disrupted in predictable ways.2 The single parent from any cause not only must deal with their own loss and personal needs but also care for and usually financially support themselves and their children. The single parent often provides less discipline and structure for chores and activities, and their children may become "adultized" and expected to earn money, care for siblings, perform more household duties, and become confidants for the adult. The noncustodial parent often tries to compensate for the child's losses by excessive indulgence and further lack of discipline. Both adults are prone to depression and a self-centeredness that makes them less able to attend to the child's needs. Emotional needs are especially likely to remain unmet because the parent has trouble facing the pain they have caused and discussion of the trauma reopens wounds for them. Relatives may take sides about the divorce, which removes them as supports for the child as well as the parents. Community friends may avoid the divorced family because of torn loyalty to both sides, judgmentalism, avoidance of the newly available adult, or unconscious concern about the "contagion" of divorce to their own marriage. On top of all these problems, custodial mothers almost always experience a drop in income, often to the point of poverty. This may necessitate moving to new housing away from friends and the child's school.
Pediatricians can be helpful to the children in a divorce, both acutely and long-term.3 First, we need to know that a separation is planned or has occurred. This may not be obvious because parents often identify the pediatrician as an authority figure or as a family friend and feel ashamed of what seems like a failure to them. It is important to ask about the marriage regularly when caring for children to detect problems. Helping parents, who are experiencing extreme pain and anger themselves, to understand that even young children have feelings about the divorce that need to be addressed is essential. They need to know how to interpret behavioral changes in children of different ages. These changes may include their apparent lack of concern, aggression, fears, and regression. The parents should be coached to inform the children clearly about the divorce and their continued love for them; absolve them of guilt; let them know the details of where the parents will be living; stabilize the daily schedule and living arrangements as soon as possible; avoid denigration of the exspouse or exposure to conflicts; avoid making the child a messenger to the other parent; tolerate regression; and remain involved in the child's activities as much as possible. The pediatrician may be the best person to let the children know that they may experience anger, sadness, shame, and conflicts of loyalty and to continue monitoring for these over time. Because 33% of girls and 27% of boys are not doing well 1 year later, the pediatrician is often the one who must encourage mental health referral for the child. Indications for referral include persistent school dysfunction, acting out behavior or withdrawal, somatic complaints, worsening of a chronic illness, or depression.
Much has been written about the poor psychological outcome of children of divorce. Wallerstein, who has conducted seminal studies of divorced families, is now challenging pediatricians to contribute to fostering marriages.4 Spouses who share thoughts and feelings, leisure interests, and basic life values and who spend time together apart from the children are most likely to remain married. Having a supportive spouse is one of the chief factors associated with good adaptation to parenthood, adult coping with stress, and subsequent psychological well-being of their children as adolescents. One way we as pediatricians can promote optimal parenting is to promote stable, satisfying marriages. After the birth of a child, marital satisfaction ratings almost invariably decline. Some of this effect is probably inevitably due to fatigue, role strain, changes in the sexual relationship, financial pressures, etc, but some is also due to unrealistic expectations about parenthood and its effect on the marriage. Prenatal classes can be useful preparation for this aspect of "self postpartum care" as can parent support groups for parents of infants. We have been conducting such groups for several years and have found discussions about marriages and how they are changed by new parenthood to be one of the most helpful topics. Including the question "How has this infant/child affected your marriage?" in health supervision visits is a good way to monitor the well-being of the parental relationship. Follow-up suggestions for time alone together, regular "dates," visits to the pediatrician to discuss disputes over parenting practices, or referral for marriage counseling are useful. These are best initiated before emotions are so strong, positions so enmeshed, or emotional damage so great that the relationship cannot be saved. Don't hesitate to address these topics. They are all within the pediatrician's domain of helpfulness.
It is estimated that 50% of all people in the United States will experience a step family member role at some time in their lives.1 Step-family formation often entails merging children as well as requiring new negotiations about parenting practices. It often takes several years before the step parent has the relationship with step children to be able to provide discipline in the home. Including step parents in medical discussions subtly acknowledges their new role in the family to the child and facilitates a family systems approach to any parenting problems. One recommendation for every family, especially for blended families, is to institute family meetings. These should be regularly scheduled, conducted with rules for no interruptions and respectful listening by all, and oriented toward solving problems in the family through joint efforts for change.
Altering Practices to Demonstrate Openness to Different Family Types
Two percent of children in the United States are adopted, many by relatives or step parents.5 Adopting parents have often suffered from infertility with its long course of uncertainty, emotional turmoil, expense, marital stress, and potential loss of selfesteem. When these parents finally receive a child, it is often sudden. This may leave little time for preparation or decision making even when the child has several medical or legal risk factors. Other challenges include that friends and colleagues are less likely to show support through celebrations and baby showers. There has been little formal support for adopting parents (although those adopting high-risk children or children out of foster care may be offered some parent training or counseling). Other potential problems include the following. Childbirth Education Association groups or groups for parents of newboms may feel inappropriate. Older children being adopted are at high risk for emotional problems from their past family situations or traumas and also test their new families in an unconscious attempt to precipitate the rejection that their past experiences led them to expect. Relatives are not uniformly supportive of the parents of adopted children and may even reject the children completely. Social stereotypes about the feared characteristics of children adopted with histories of drug exposure, sexual abuse, or HIV infection can influence how even devoted parents deal with child behaviors at any point in development.
Exploration of these fears and education about real and mythical risks are helping possibilities unique to the pediatrician. We can also provide preadoption visits to get to know the parents and review information known about the child and anticipate problem areas; conduct any health or developmental screenings needed because of the child's background; encourage early disclosure about adoption to the child; monitor for emotional or behavioral adjustment problems and refer as needed; and advise the older child about the normality of desires to search for their birth parents, their legal rights, and the advisability of delaying this.5
Single parents by choice, by birth or by adoption, are a growing proportion of families. Often, these adults adopt children of a different racial background than their own. Although they may have more resources and planning about begetting or adopting the child, they may experience the same social isolation and even more criticism than separated, divorced, or widowed parents. Some people may even consider cross-racial adoption as a form of genocide by stealing children from their native culture. The parents and, later, their children may face discrimination from both groups. These parents can derive support from others choosing similar paths and may need help locating resources about how to teach their children about the culture of their biological roots and develop an identity that embraces their origin.
It is estimated that 8 to 10 million children in the United States are living with gay or lesbian parents.6 Many of these children were conceived during heterosexual marriages, but increasing numbers are being born in the context of a lesbian household or patented by gay men. Whereas dealing with divorce seems routine, addressing the special parenting issues of same-sex parenting can be a challenge. This is in part because social stigmatisation may evoke personal feelings that make the pediatrician uncomfortable about bringing up the subject. Studies have shown that the psychological adjustment of children raised by gay and lesbian parents is no different, including in gender identity and sexual adjustment, than that of children of heterosexual parents. However, there are still parenting issues that stem from social Stressors and may require support. Disclosure and resulting stigmatization, or threats to employment, housing, and child custody can be a constant worry for parents and even for older children of same-gender parents. Secrecy can make it impossible for the pediatrician to discuss or assist with resolution of family relationship problems. Gay or lesbian parents are not likely to feel comfortable getting support or education from typical parent support organizations. Relatives sometimes do not recognize the homosexual parenting relationships or even the child's existence. All these factors remove the usual sources of support and advice, so that social isolation and lower self-esteem are potential outcomes for both parents and children in these families. On the other hand, children raised in families with such a basic difference may be more sensitive to others and more open minded than the norm. The gay and lesbian communities have banded together and established a variety of supportive organizations that set ve the function of extended family.
It has been recommended that pediatricians can demonstrate an openness to differences in sexual orientation by practicing in a way that demonstrates more openness for families with any kind of difference (Table). Other approaches specific to homosexual parenting include having information available on gay and íesbian parent support services and relevant activities in the community, therapists with a special interest or openness to gay and lesbian orientation, and legal services to help deal with discrimination or custody issues. Keep in mind that the significant other is also important to the child, and can be a major source of strength for him or her. Conversely, loss of a parent's significant other can be as much a loss to the child as a divorce. Parents (and even children) may not give information about a significant other for fear of losing child support or risking moral judgment against themselves. This makes it valuable for the pediatrician to ask who is important in the child's life. Acknowledging the social problems that are likely in an individual situation can create a supportive parent -doctor relationship. This can help the parent accept suggestions for improving those aspects over which they have some control and for how to best portray the situation to the children.
Many parents who give birth while single are teenagers. Teens are more likely tp have less information and skill in caring for children. They tend to be more immature in their own social skills and emotional development, and this interferes with teaching and modeling for the child. Studies of child outcomes show normal development when there is a supportive grandmother involved but many deficits if a teen mother is isolated while rearing her children.7 Pediatricians should involve the grandparents (who are often angry at the teen) while building the skills and parent identity of the young parents. Groups that allow grandparents to vent anger can make individual pediatrie visits more productive. Sometimes it is useful to visit with the teen parent and child first and then meet with grandparents. This avoids overt criticism and provides more complete details about the child's circumstances. Many grandmothers turn responsibility for the child exclusively to the mother as soon as she graduates from high school or the child becomes a feisty toddler. It is better for the child and mother if the teen has attached to her child and developed parenting skills by then. Encouraging grandmother's continued support is thus an important goal of pediatrie care.
It is helpful to follow the same principles in providing medical care for the children of teen parents as one applies to caring for adolescents as patients. This will help the pediatrician gain the rapport necessary to be in a position to counsel teens about their parenting. Some alterations in office practices can make young families more comfortable. A separate waiting area, appointments clustered so that several teen parents are in the office simultaneously, attention to the teenager's own medical or psychosocial needs at the same visit, teen parent support groups, and a team approach for other staff to get to know the families may be helpful. Specific invitations may be needed to have fathers attend the visits, because they may have concerns about being viewed judgmentally for out-of-wedlock birth or for being reported to authorities to alter child-support arrangements. Pediatricians can encourage and show value for the fathers' involvement and perhaps assist in maintaining his and his relatives' support for the child and mother.
RACIAL AND CULTURAL DIVERSITY
In 1993, the United States Bureau of the Census projected that by the year 2050, the US population will be 22.5% Hispanic, 14-4% African-American, 9.7% Asian- American, and 0.9% Native American. In 1990, 25.6% of all children in the United States younger than 5 lived in minority homes.8 Parenting practices are especially likely to have deep cultural roots that require respectful understanding by the pediatrician if they are to be assessed or influenced. This may seem daunting at first, especially if one practitioner is serving families from a dozen cultures. In fact, the basic approaches should be the same as when families are of the same cultural background as the clinician. We must enter each new relationship with a family with an outlook of respect and openness and the intention of helping them reach the goals they identify for their child and their family. We need to listen to each family member to understand their perspectives and goals rather than imposing our own. Pediatricians need to work outside their own value framework and life experiences long enough to let families teach them about their capabilities.9 Physicians are more likely to be empowering for families if they are self-aware and selfrespectful, curious about what they can learn from others, genuine and accepting, and egalitarian as opposed to paternalistic in their approach. We must emphasize competencies in counseling, ask questions rather than offer solutions, and let the family negotiate and fit the solutions to their situation.
For families who have immigrated to the United States, it is important to keep in mind the importance of the immigration experience as a source of strength or stress. We may need to ask who comprises the family (biologically, legally, culturally, emotionally), how they are related, what the lines of authority are, what their expectations are of other family members, and how those expectations are being negotiated. We may need to know how situations similar to the one the child presents with would be handled in their original culture and how different members feel about those approaches. Families from other cultures have models for the causes of illnesses, symptoms, behaviors, the importance of stress, and what treatments are thought to be helpful or acceptable and these may not match modem western medical or psychological thinking. Their models of authority in the family, discipline, expectations for the child's role, health beliefs, and views of sharing intimate information about family functioning with outsiders may determine which approach could be helpful. A different set of family members may need to be present during a visit than is routine (eg, great-grandmother or spiritual guide) to accomplish the goals. This is because "parenting" may be more of a community activity than in nuclear families. On the other hand, some families may be quite isolated because of their culture so that creativity about accessing culture-specific needs and resources may be the essential ingrethents. With all families, especially those with culturally different backgrounds, it is important to ask about the family's strengths and how they have solved problems in the past to build on those coping strategies. This is respectful and more likely to result in a plan that the family will choose to endorse and that can use intrinsic resources instead of more expensive, less culturally syntonic, agency resources. These latter are generally only short-term anyway.10
Information may be needed about the family's sources of financial support, living arrangements, language abilities, and immigration status in order to understand and support them. However, immigrants may be less willing to reveal these out of fear of deportation, misunderstanding, or shame. Obtaining a history from people whose first language is not English can be problematic. When the history concerns sensitive matters of family relationships and parenting practices, the need for a child or family friend to translate may make it impossible for the family to be candid. A professional translator hired by the health program or a telephone translating service11 can facilitate this kind of communication. Handouts in several languages can be helpful for common problems and for resource lists. In working with all families, it is vital for clinicians to be aware of the assumptions they make based on their race, socioeconomic class, culture, immigration history, and work to be especially open about these areas.
CHILD CARE CHOICES
More than 60% of mothers of children younger than I year are in the full-time workforce in the United States. Sometimes, it may seem as though we have the wrong caregivers (ie, someone other than the mother) in our office to advise regarding "parenting." One aspect of guiding optimal parenting is to advise families about their choices of child care providers. High-quality child care, especially that which is less than 20 hours per week, does not adversely affect the child's development or attachment to the parents. However, most child care in the United States is not of high quality.12 The children with the most risk factors, such as those with teen parents, poverty, and social isolation, are also those least likely to be placed in highquality settings. Advocacy for national policies supporting quality child care is somthing pediatricians can do to promote children's well-being. The individual parent should be offered counseling regarding what features to consider when choosing child care and their importance to the child. The latter is also a more immediately obtainable goal than the former. Pediatricians should be sensitive to issues that can emerge between parents and child care providers such as jealousy, competition, and conflict over child-rearing practices. This facilitates smooth resolution of these for the child's sake. This can reduce conflict for the parent in pursuing his or her own parenting style and prevent multiple changes of child care providers with disruption of relationships and stress for ¿he child.
There is a group of parents for whom staying at home to care for their child would be an option, but social pressures push them toward outside employment. We can encourage a choice to stay home by pointing out the value of their care, especially in the first 3 years, and by helping them examine the forces affecting their decision, by providing resource lists of parent groups or daytime activities that will connect them to peers, and by establishing parent support groups in the office where parents staying at home can meet
FORMATTING YOUR PRACTICE TO SERVE FAMILIES
Given the variety of family constellations, a choice of appointment times is ideal to make it possible for all caregivers to attend visits. Weekend and evening hours may be reserved in longer blocks of time to allow family counseling for parenting issues. At least one large consultation room that can seat several adults is essential to an atmosphere for family discussion. Staff may also need to be trained to welcome a variety of family members into visits rather than greeting them with a gasp. However, the most important factor for selectively helping diverse families with parenting is the pediatrician's attitude toward this challenging but rewarding aspect of care.
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5. Sherry SN. Helping t'amili« adapt to adoption. Coruemporarj Pediatrics. 1986;li:96-lll.
6. Gershom T. Lesbian and gay families: Stresses and strengths. In: Tanner JL ed. Children, Families, and Streu, Ripari of the Z5A ROJS Roundtabie on Criticai Approaches to Common Pediatrie ProHtms. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 1995:132-142.
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8. Saba CW. Immigration, acculturation, and stress: A family-systems approach. In: Tanner JL ed. Children, Families, and Siren, Report of Ae 25th Ross Roundtabíe on Critical Approach« to Common Pediatrie ProHemi. Columbus. Ohio: Ross Products EWvision, Abbott Laboratories; 1995:116-129.
9. Mac Kune-Karer B, Taylor EH. Toward multiculturaliry. Pediatr Clin North Am. 1995;42:21 -30.
10. Dunst CJ, Trivette CM. Assessment of social support in early intervention programs. In Handbook of Early Childhood Intervention. Meisels S, Shonhoff J, eds. Cambridge, England: Cambridge University Press; 1990.
11. American Telephone and Telegraph Co.
12. Phillips D, ed. Quality in Child Care: What Does Research TeU Us? Washington, DC: National Association tor the Education erf Young Children.
Altering Practices to Demonstrate Openness to Different Family Types