The Pediatrician's Role in Family Support Programs

CHANGES IN FAMILIES

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 32% by 1995.¹ Since 1960, the divorce rate has more than doubled,^2–4 and it is estimated that 25% of children growing up in this decade will experience the consequences of divorce.⁵ Although remarriage rates are high, more than a third of remarried couples are divorced again.⁶ As a consequence, approximately 8% fewer children are living with 2 parents (74.8% in 1989 vs 83.1% in 1971),^7,8 and only 61% live with both biological parents.⁹ Another change in family life is that approximately 65% of all mothers with preschool-aged children are in the labor force, reflecting a twofold increase since 1970.¹⁰ A decline in the purchasing power of family income, the lack of comparable wages for women, and significant rates of homelessness have all added to the stress on families. Social disparities have also contributed to the growing percentage of children who live in poverty. Adolescents present the pediatrician with particular challenges for assessment and counseling. High-risk families, including adolescent parents (single or married) also require increased attention for problem prevention and assistance. Finally, residential mobility has separated many families from the natural support systems provided by their extended families. This may leave parents feeling socially isolated and prevents the intergenerational transmission of cultural and community-specific advice and support.

These social changes have strained the ability of families to provide for their children's needs. Economic and social inequalities have led to increasingly impoverished neighborhoods, more working families living in or near poverty, and weakening of community ties. As a result, the health, development, and well-being of children have been jeopardized. Rising rates of child abuse and neglect, and high rates of adolescent problems such as teenage pregnancy, drug use, dropping out of school, delinquency, homicide, and suicide reflect the weakened capacity of many communities to meet the needs of children and families.

TYPES OF COMMUNITY SUPPORT PROGRAMS

Social institutions have begun to offer various family support services to help parents carry out essential functions on behalf of their children. 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 and Temporary Assistance for Needy Families.

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 provider groups. Topics may include information on child development, personal growth and family relationships, peer support groups, parent-child activities, home visits, drop-in programs, early developmental screening, outreach, community referral and follow-up, job skills training, and/or adult education, especially language and literacy education.¹¹Services should be provided to all families regardless of their economic or ethnic background. Families participate in such programs because of 1) a need or desire for specific services; 2) difficulties encountered in using existing services, such as expense, logistics, or red tape; and 3) the simple need to belong to a group of people with similar concerns.¹² The programs operate on the premise that no family is entirely self-sufficient and most can benefit from some external support.^13,14 Pediatricians should search for, become familiar with, and refer families to high-quality family support services in their communities.

Many pediatricians are already familiar with some types of family support programs such as home visitor programs for families with newborn infants, family preservation programs for abused and/or neglected children at risk for foster care placement, parent education groups, play groups for preschool children, drop-in centers for parents of young children, comprehensive early childhood education programs (eg, Early Head Start, Head Start), early screening and referral programs, crisis care programs, parent support groups, early reading and parental literacy, early intervention programs for children with special needs (eg, Individuals with Disabilities Education Act, Part C), and others.

PRINCIPLES OF FAMILY SUPPORT PROGRAMS

High-quality programs operate on the following principles:

• 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 links with community resources.

• Social support for parents with young children serves to prevent behavioral problems, enrich the child's development, and help parents develop the maturity required to raise children.

• The kinds of support provided should be determined by the needs and interests of the parents. Although participation should be voluntary, it should be encouraged in high-risk situations, including abuse and neglect. Suspected or substantiated abuse and neglect warrant mandatory reporting and services as appropriate.

• Support offered by friends, neighbors, and community-based resources is as vital as access to professional support services.

• The support given should enhance the strengths found within the family unit among family members.

• The aim of support is to strengthen the family unit and the community while preventing alienation and family dysfunction.

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 low-income families, is well-documented.¹⁵ All families need knowledge, skills, and support to raise their children and to foster normal growth, development, and learning. Supportive programs, however, cannot substitute for unsupportive relationships. Ultimately, even the best professional programs cannot substitute for community, nor can social services replace kindness and caring expressed within the family and by primary caregivers. The American Academy of Pediatrics 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.