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PEDIATRICS Vol. 106 No. 5 November 2000, p. e68
From the * Social, Genetic and Developmental Psychiatry Research Centre, Institute of Psychiatry, King's College, London, United Kingdom; and the Institute of Child Health, University of Bristol, Bristol, United Kingdom.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
References
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Objective. To investigate whether family type and psychosocial risks indexed by family type were systematically associated with differences in health outcomes in children.
Design and Subjects. The study is based on a longitudinal, prospective study of a large (n = ~10 000) community sample of families, the Avon Longitudinal Study of Pregnancy and Childhood.
Main Outcome Measures. Frequency of accidents, illnesses, and medical interventions.
Results. At 2 years of age, children in single-parent and stepfamilies were disproportionately likely to experience accidents and receive medical treatment for physical illnesses. In addition, children in single-parent families and stepfamilies were more likely to be hospitalized or receive attention from a hospital doctor for an injury or illness. Exposure to psychosocial risks also were elevated in single-parent families and stepfamilies, compared with intact or nonstepfamilies, and these factors primarily accounted for the connection between family type and children's physical health.
Conclusions. The consequences of family transitions on children's health extend beyond traditional mental health and behavioral outcomes and include accident proneness, illness, and receipt of medical attention. The mediating processes are not entirely attributable to social class differences connected to family type and may instead be associated with a range of psychosocial risks that are more frequently found in single-parent families and stepfamilies, compared with intact or nonstepfamilies. Prevention and intervention efforts directed toward children at risk for poor behavioral and mental health adjustment secondary to family disruption should consider children's physical health and health-related behaviors. Key words: family type, childhood, accidents, injuries, illnesses.
Membership in a single-parent family or stepfamily is
associated with increased levels of significant behavioral, emotional, and academic problems in children.1,2 The mechanisms
underlying this connection are likely to involve, among other factors,
financial adversity, increased stress directly related to family
transitions, and increased exposure to additional psychosocial
risks.3,4 Compared with the extensive research base
connecting family type (ie, membership in a 2-parent biological family,
stepfamily, or single-parent family) and children's psychological
adjustment, little is known about the physical health consequences of
membership in diverse family types. One study5 found that
children in both single-parent families and stepfamilies were more
likely to experience hospitalization or an injury attributable to
accident than were children living with both biological parents. A
smaller study found that children in single-parent families visited the
general practitioner more and experienced more psychosomatic health
problems.6 A further study7 found a
connection between marital disruption and children's health but was
not able to distinguish between alternative explanations for this
effect. By suggesting a link between family type and significant health
outcomes in children, the above studies raise important questions
concerning the public health implications of the high rates of divorce
and remarriage.
Several questions remain regarding the connection between membership in
a single-parent or stepfamily and children's physical well-being.
First, it is not clear from previous research if family type and
attendant psychosocial risks act in a nonspecific or general manner.
Second, there is a need to identify the underlying risk processes.
Several key psychosocial risks are disproportionately distributed
among step- and single-parent families and may mediate the connection
between family type and health.3,4,8-10 It is, therefore,
important to demonstrate that the family type effect on health is not
entirely accounted for by, for example, social class differences among
family types.
Additionally, individuals who have experienced a parental divorce in
childhood, teenage pregnancy, left home early, or prematurely terminated education are more likely to select into a single-parent family or stepfamily and to experience increased levels of current social adversity.11 It may be that these life-course
developmental risks are implicated in childhood accidents and injuries.
Thus, one study12 found that teenage parents with a
previous history of behavioral problems in childhood had (subsequently
born) children who were more likely to have poor health outcomes at 5 years of age.
Using data from the Avon Longitudinal Study of Pregnancy and Childhood
(ALSPAC),13 the current study examines the connection
between membership in a single-parent and stepfamily and rates of
accidents, injuries, and illnesses in 2-year-olds. We test the
hypothesis that this association is mediated by concurrent psychosocial
stresses and maternal life-course risks including those that predate
the child's birth.
Study Population
The ALSPAC is a longitudinal, prospective study of women, their
partners, and an index child. The study design included all pregnant
women living in the health district of Avon, England, who were to
deliver their infant between April 1, 1991 and December 31, 1992.13 It was estimated that 85% to 90% of the eligible
population took part. The average age of the women at pregnancy was 28 years and ranged from 14 to 46; <5% were younger than 20 years of age
and <1% were older than 40 years of age. Approximately 45% of the women were expecting their first child; 6% of the women had 3 or more
children. The families initially selected to take part in the study
resemble those in Britain as a whole, based on a comparison with census
data.14
At several points in the pregnancy and the child's early years women
completed questionnaires on a wide range of issues concerning medical
health, development, and social factors. Data from the current study
are based on a questionnaire concerning family constellation and
exposure to psychosocial risks, administered when the children were 21 months old, and on a subsequent questionnaire on accidents and
illnesses administered when the children were 24 months old. In
addition, data on the parents' childhood history and life-course patterns before the birth of the child were collected from a previous questionnaire administered in pregnancy.
Data on accidents, illnesses, and hospitalizations were available on
10 431 families. The drop in sample across time points is comparable
to other large-scale questionnaire-based studies.15 The
sample size for each analysis is based on the maximum sample available.
Sample size differs across bivariate and multivariate analyses because
of missing data.
Family Type
Families were classified into 5 types based on household
composition: intact/nonstepfamily, stepfather family, stepmother family, blended stepfamily, and single-parent family. Stepmother families and blended stepfamilies were combined in analyses because of
small sample size and limited power to detect differences.
Children's Health Outcomes
Information on 3 types of accidents was collected: burns/scalds,
falls, and swallowing objects. For each of these accident types, both
the frequency of occurrence since the child was 15 months of age and
whether the accident required medical attention (taking the child to
the hospital or doctor) were assessed. A total frequency of all
accidents was also computed. Parents reported whether the child had
ever experienced any accident that resulted in a scar or disability.
Illnesses requiring medication were assessed according to both common
illnesses and over-the-counter medicines (cough medicine, throat
medicine, paracetamol) and somewhat less common or potentially more
severe illnesses that more frequently require medical attention and
prescription medication (antibiotics, medication for diarrhea). Parents
reported whether the child required the above medications for a
specific illness on 0, 1, or 2 or more occurrences since the child was
15 months of age. To distinguish those risks that identified children
with somewhat more severe illness, we analyzed the data according to a
dichotomy between 0 to 1 and 2 or more occurrences. Finally, parents
reported whether the child had seen a specialist clinic or hospital
doctor since the child was 15 months of age.
Social and Demographic Control Variables
Parent self-reported financial difficulties (ability to pay for
specific family needs and wants) were included as an index of financial
stress and adversity; high financial stress was defined as scoring in
the top quartile. In addition, a crowding variable was based on a
cutoff of >1 person/room. In addition, the highest achieved level of
education was coded on a 4-point scale, with the lowest score
indicating minimal educational qualifications and the highest level
indicating university degree. Financial difficulties, crowding, and
maternal education were included as indicators of social class. Partner
education or occupation was not included because such data did not
exist for women in single-parent families; maternal occupation was not
included as an indicator of social class because a substantial number
of women were not in part-time or full-time work.
Psychosocial Risks
Concurrent risks for accidents and injury include the activity
scale from a child temperament inventory16; children above
the 75% percentile were judged to be at possible risk for poor
outcomes. Recent stressful life events were assessed according to a
measure of 42 stressful life events.17 The total number of
stressful life events endorsed is used; a cutoff score at the 75th
percentile identified highly stressed families. Maternal depression was
assessed using the Edinburgh Postnatal Depression Scale, based on a
clinical cutoff indicating potential clinical
depression.18,19
Maternal life history risks were defined as having experienced parental
divorce, leaving the parental home early (before 18 years of age), and
teenage pregnancy. Previous research identifies these 3 risks as
indexing a high-risk life-course pattern that is strongly predictive of
adult adjustment.20
Statistical Analysis
Data are presented in 4 sections. First, we report the incidence
of accidents, illnesses, and receiving hospital/doctor visits for the
period assessed. Second, we examine the bivariate association between
family type and children's health. Third, we examine whether the
association between family type and child outcome is maintained after
controlling for social class indicators and demographic control
factors. Finally, we present the joint effects of family type, social
class, and control factors and developmental and concurrent risks on
children's health outcomes.
Relations between family type and physical health outcomes and
psychosocial risk variables are based on categorical methods. Logistic
regressions, from which we report the odds ratio (OR), were used to
test whether the prediction of health outcomes from family type was
accounted for by specific psychosocial risks. Because of the interest
in the effect of severe rather than low to moderate level of risk
variables, continuous variables were dichotomized at the 75th
percentile.
Of the sample children, 7.6% (n = 785) had
experienced a burn or scalding since 15 months of age; <1%
experienced >1. Of those children who were burned, ~13% received
hospitalization or a doctor visit. Twenty-four percent
(n = 2471) of the children had experienced a major fall
since 15 months of age; <7% experienced >1 major fall. Of those
children who did experience a major fall, 27% required hospitalization
or a doctor visit. Finally, 5% of the children in the sample swallowed
a potentially dangerous object since 15 months of age; a repeated
swallowing occurred in <1% of the cases. Of those children who did
swallow a potentially dangerous object, hospitalization or a doctor
visit occurred in 35% of the cases. Overall, 26% of the sample
experienced at least one of the above types of accidents; 15% had 2 or
more. In addition, 8% (n = 819) of the children in the
sample had ever received a long-term injury resulting from an accident
and 8% (n = 782) had ever been left with a scar from
an accident. In total, 19% of the children had been to a specialist
clinic or hospital doctor since 15 months of age.
Since the children in the sample were 15 months of age, 22% had been
given antibiotics on 2 or more occasions; an additional 25% of the
children had been given antibiotics on one occasion. Medication for
diarrhea was given to 8% of the sample; 2% received medication on 2 or more occasions. Cough medicine was given to 53% of the sample; 26%
on 2 or more occasions. Seventy-eight percent of the children in the
sample received paracetamol on 2 or more occasions; an additional 14%
received such medication only once. Throat medicine was given to 3% of
the sample; only 1% received throat medication more than once.
Table 1 presents the connection between
family type membership and health outcomes. For each outcome, the first
row presents the percent of affected children in each family type; this
is complemented in the second row with the OR from logistic regression
analysis using children living with 2 biological parents as the index
(control) group. Children in single-parent families were significantly
more likely to experience a burn/scald (with or without medical
attention), 2 or more accidents, a long-term disability, or scar from
an accident, compared with children in intact or nonstepfamilies. In
addition, children in single-parent families were more likely to
require antibiotics, medicine for diarrhea, and to have seen a
specialist in the past 15 months. In most cases, the percentage (and
OR) of risk in single-parent families was greater than that in
stepmother/blended stepfamilies; the rate in stepfather families was
rarely substantially larger than that found for intact or
nonstepfamilies. There was one negative finding: children in
stepfamilies and single-parent families were significantly less likely
to receive paracetamol/Calpol than children in intact or
nonstepfamilies.
TABLE 1
METHODS
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Abstract
Methods
Results
Discussion
References
RESULTS
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Abstract
Methods
Results
Discussion
References
Association Between Family Type and Accidents and
Illnesses
Further logistic regression analyses indicated that the effect of family type on health outcomes was, in most cases, significant after controlling for the 3 social class indicators and child sex. Of the 8 health outcome measures that were significantly positively associated with family type in Table 1 (in most cases with single-parent family membership), 3 (long-term injury after any previous accident, scarred by any previous accident, antibiotics) were no longer significantly associated with family type membership after accounting for overcrowding, lack of economic resources, educational attainment, and child sex (not tabled).
The final set of analyses examined the joint effect of family type, social and demographic risks, and concurrent and developmental life-course risks on children's health outcomes. The results from multiple logistic regression analyses are presented in Tables 2 and 3. Analyses are presented for those health outcomes that were positively associated with membership in a single-parent or stepfamily in bivariate analyses. The ORs for membership in single-parent and stepfamily in the analyses in Tables 2 and 3 are almost universally lower than are those in Table 1. This reduction in the ORs reflects the degree to which the social, demographic, concurrent, and developmental life-course risks mediate the connection between family type and children's health outcomes. Importantly, family type is not significantly associated with health outcome measures when other key variables are considered. The single exception to this was seeing a specialist clinic or hospital doctor since 15 months of age. The effect of membership in a single-parent family was substantially reduced once the covariates were introduced (change in OR from 3.32 to 1.39), but it remained significant at P < .05. The results in Tables 2 and 3 also indicate that concurrent risks (most consistently maternal depression and stressful life events) and maternal life history risks (most consistently giving birth before age 20 and leaving home before 18 years of age) exerted a consistent and generalized effect on children's health outcomes at 2 years of age.
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DISCUSSION |
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Abstract
Methods
Results
Discussion
References
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In a large community sample of families in England, an association was obtained between membership in a single-parent family or stepfamily and physical health, defined as accidents, hospitalizations, and receiving medicinal attention for illness. The effect of family type was not, in most instances, accounted for by social class and financial status differences among single-parent families, stepfamilies, and nonstepfamilies. Instead, the family type effect was nearly entirely explained by social and maternal life-course risks that disproportionately affect single-parent families and, to a lesser degree, stepfamilies. The findings add to a small but important set of studies implicating family type and psychosocial risks in children's health outcomes. We discuss interpretations of the findings before turning to the health implications.
Epidemiologic and public health research highlights a robust connection between social factors and physical health.10 Following this approach, several studies have now identified specific environmental and child factors associated with an increased likelihood of injury in young children21 (but see reference 22). Several of the most commonly identified risk factors in previous research were identified in this study, including being male, membership in a single-parent or stepfamily,5 high levels of parent-reported childhood activity,23,24 maternal mental health problems,25 and a history of teenage parenthood.26 What is relatively novel about this report is the consideration of the joint effects of psychosocial risk factors, while controlling for multiple indicators of social class and the assessment of both accidents and illnesses in a large community sample followed prospectively since pregnancy.
Overall, the effects of family type and, more specifically, the psychosocial risks indexed by family type on children's health outcomes seem to be generalized rather than specific; however, there was variation in the effects of family type and specific and more proximal risk factors. Where no or minimal psychosocial prediction was obtained, it seems likely that the outcome was not predicted because it was relatively normal and, therefore, not linked to risk status (eg, falls, very minor illnesses such as cough) or was extremely infrequent and, therefore, difficult to predict (swallowing objects).
The sample size and study design provided important leverage to determine which psychosocial risks that covary with single-parent and stepfamilies account for the added risk. Teenage pregnancy and early home leaving were consistently associated with children's health outcomes. The reasons why these risks, which were experienced long before the child's birth, would predict the health of children several years later require further consideration. The findings suggest that there are aspects of the mother that directly or indirectly carry risk for children's health. Direct risks may arise from activity level or other behavioral risks, which may have a genetic component.27 Indirect routes include the possibility that the parent, who may have a history of risk-taking, provides a high-risk family environment for the child, which may include poor parental monitoring and supervision.
In contrast, children born to mothers with life-course trajectories characterized by less than optimal patterns of relationship formation, childbearing, and educational attainment are likely to experience adverse social conditions that, in turn, compromise children's health. There is, for example, evidence for a link between family stress and compromised immuno-functioning in adults and to a lesser degree in children.28 Regardless of the factors that increase exposure to adverse social circumstances, the source of social adversity did not arise from crowding, financial strain, and low education, because these variables were also included in the analysis.
The finding that higher education was associated with higher rates of some negative health outcomes (eg, 2 or more accidents) was unanticipated and contrasts with previous work.29 The finding may reflect more accurate reporting of some health outcomes in higher compared with lower socioeconomic groups or may reflect a real difference attributed to an unspecified cause. The uncertainty about the nature of this effect provides a reminder of the limitations of self-reported data. There may be biases in reporting because of poor or distorted recall of information, and this may distort the true estimates of effect. However, the limitations of self-reported data must be set against the benefits of data from large-scale population samples.
One key implication of this study is that family stress and associated risks are a public health matter rather than simply a matter for the mental health, social service, and education sectors. Because of the limitation of not knowing the context of the specific injuries and illnesses examined in this report, we would caution against too literal extrapolation from these findings to health costs. Nevertheless, intervention and prevention efforts geared to children whose parent(s) experience a divorce or remarriage should also consider health outcomes such as accidents and illnesses. Positive impact at that level may well have a health-promoting effect by reducing the need for medical intervention, including general practitioner and hospital visits. Finally, it is important to note that the outcome measures were in terms of both treatment and morbidity. Findings concerning these 2 types of health outcomes are not synonymous30,31 and may lead to somewhat different conclusions.
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ACKNOWLEDGMENTS |
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This study was supported by Wellcome Trust, Department of Health, Department of the Environment, and the Medical Research Council among many others.
We are extremely grateful to all of the mothers who took part and to the midwives for their cooperation and help in recruitment.
The whole ALSPAC study team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers, and managers who continue to make the study possible. The ALSPAC study is part of the World Health Organization-initiated European Longitudinal Study of Pregnancy and Childhood.
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FOOTNOTES |
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Received for publication Sep 7, 1999; accepted Jun 13, 2000.
Reprint requests to (T.G.O.) Institute of Psychiatry, 111 Denmark Hill, London, UK SE5 8AF. E-mail: spjwtoc{at}iop.kcl.ac.uk
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ABBREVIATIONS |
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ALSPAC, Avon Longitudinal Study of Pregnancy and Childhood; OR, odds ratio.
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REFERENCES |
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This article has been cited by other articles:
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  D. C. Schwebel and C. M. Brezausek Chronic Maternal Depression and Children's Injury Risk J. Pediatr. Psychol., May 12, 2008; (2008) jsn046v1. [Abstract] [Full Text] [PDF]
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 B. D. Johnston Understanding shared injury risk on the family farm. Arch Pediatr Adolesc Med, November 1, 2006; 160(11): 1180 - 1181. [Full Text] [PDF]
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R. Rowe, B. Maughan, and R. Goodman Childhood Psychiatric Disorder and Unintentional Injury: Findings from a National Cohort Study J. Pediatr. Psychol., March 1, 2004; 29(2): 119 - 130. [Abstract] [Full Text] [PDF]
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