Converging Trends in Family Research and Pediatrics: Recent Findings for the American Academy of Pediatrics Task Force on the Family
2003; American Academy of Pediatrics; Volume: 111; Issue: Supplement_2 Linguagem: Inglês
10.1542/peds.111.s2.1572
ISSN1098-4275
Autores Tópico(s)Child and Adolescent Psychosocial and Emotional Development
ResumoPediatricians and their colleagues in the social and behavioral sciences seek better understandings of how to keep children healthy. Some of the most basic and essential understandings of the processes of health and illness have emerged from the study of families. More than 25 years ago, Litman1 asserted that "the family constitutes perhaps the most important social context within which illness occurs and is resolved. It consequently serves as a primary unit in health and medical care." More recently, progressive health care professionals and organizations have moved toward family-centered care2,3 and family-focused care,4 reflecting philosophic, practical, and evidence-based commitments to the understanding of children's health outcomes as a function of family characteristics. This article reviews these recent trends in pediatrics and in the social and behavioral sciences to document the opportunities and challenges faced by pediatricians and other health care professionals as they pursue basic commitments to healthy children and successful families. These emergent mutual concerns of pediatricians and social and behavioral scientists generate many of the implications for training, practice, policy, and research promulgated by the accompanying report of the American Academy of Pediatrics (AAP) Task Force on the Family.5We begin with consideration of contemporary pediatrics' embrace of biopsychosocial analyses6 and the adoption of child development as a basic science7 as a means of diagnosing and treating within the "new morbidity."8 Family-centered care and family-focused care evolve simultaneously with these advances in pediatrics. In the social and behavioral sciences, research themes describing successful families, incorporating cultural diversity and sensitivity, and seeking avenues to contribute to societal needs converge such that child health is a unifying concern. The venues in which such mutual interests of pediatricians and social and behavioral scientists evolve will be described. The manner in which contemporary research on families can guide or enhance pediatric practice will be elaborated on with attention to health maintenance, primary care, chronic care, and community and policy applications.Empirical data and conceptual advances fuel the embrace of biopsychosocial frameworks as pediatricians strive to serve today's children. Serving today's children means serving today's families. In his address on child health in the year 2000, Haggerty8 revisits the discovery of the new morbidity 2 decades earlier as well as enduring epidemiologic data, such as the finding that up to 25% of pediatric office visits are associated with psychosomatic, social, or behavioral pathology.9 Newer morbidity adds to the challenges faced by pediatricians, for instance, as the care of children with human immunodeficiency virus10 or new transplantation procedures11 become part of policy and practice.From the other end of the developmental spectrum—adulthood—recent data have demonstrated higher levels of adult health risk behavior, morbidity, and mortality to be associated in a strong, graded manner with adverse childhood experiences.12 More than half of a sample of more than 8000 adult health maintenance organization patients reported exposure to some of 7 categories of adverse childhood experiences, such as household dysfunction, domestic violence, or living with substance-abusing or mentally ill adults. Individuals with experience in 4 or more categories of childhood adversity "had 4-fold to 12-fold increased risk for alcoholism, drug abuse, depression, and suicide attempt" as well as increased incidence of obesity, heart disease, cancer, lung disease, liver disease, and skeletal fracture. Thus, in addition to pediatricians encountering new and newer morbidities in childhood, they are at the front line for prevention efforts for significant adult morbidity and mortality.Numerous sources confirm the mission of pediatrics to treat illness and maintain health in the context of family. Most recently, the Public Health Policy Advisory Board, a new organization chaired by former US Department of Health and Human Services Secretary Louis Sullivan, MD, proffered as its foremost recommendation the need to "emphasize the central role of families and communities" in its report Health and the American Child: Risks, Trends, and Priorities for the Twenty-First Century.13 As early as 1988, the AAP Committee on Psychosocial Aspects of Child and Family Health lamented that the "powerful therapeutic potential of pediatricians' interactions with families is not always sufficiently realized. Effective cooperation between physician, family, and associated health professionals is needed to achieve optimal function and adaptation for child and family, both biologically and socially."14 Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, a key set of practice standards, explicitly asserted that "health supervision goals include enhancing families' strengths, addressing families' problems, promoting resilience, building parental competence, and helping families share in responsibility for preventing illness or disability and promoting health."15 Recent years have seen amplification and clarification of the pediatrician's mission and obligation in a variety of statements and articles, such as "Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs,"16 "The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women,"17 "Children in Diverse Family Constellations,"18 and "Pediatric Care for Children Whose Parents Are Gay or Lesbian."19 The book, The Family Is the Patient: Using Family Interviews in Children's Medical Care,20 emphasized family interviewing in children's medical care. Another book, Health and Welfare for Families in the 21st Century,21 documented social and political forces in family health and health promotion. Pediatricians and behavioral and social scientists have collaborated to describe and integrate the scientific and empirical bases for this appropriately enlarging focus of pediatric policy and practice.22,23 Contemporaneous with these developments in pediatrics have been significant trends in the social and behavioral sciences, which are increasingly ready for further integration and application in pediatrics.The fields of family research broadened and deepened in recent years with 2 separate but related trends, especially relevant for the interests and needs of pediatricians as they pursue enhanced health for children. One trend involves attention to describing and understanding "successful families," an important advance over earlier preoccupations with dysfunctional or pathologic families. A second trend involves attention to family diversity, cultural diversity, and generation of understandings basic to the delivery of culturally sensitive or culturally competent services by health care professionals.Family researchers have had a longstanding interest in the associations between a variety of family structure and process variables and outcomes in terms of family members' health. Traditionally, there has been more interest in relatively narrow mental health outcomes, though contemporary studies are more apt to assess health in a multidimensional biopsychosocial framework considering physical and mental health variables. Also traditionally, there has been a bias toward study of the family as "the breeding ground for somatic complaints."24 Despite these traditional emphases, even as early as 1976, there was interest in some of the more positive or salutary aspects of family structure and process, as captured in Pratt's25 notion of the energized family and in an emerging family strengths movement in social science and family therapy.26,27 More recently, researchers as well as clinicians have demonstrated the value of documenting and examining successful families,28–30 resilient families,31,32 and good child outcomes.33,34The interest in positive features of family process and structure was not pursued only to counteract the problematic emphasis on psychopathologic processes and illness outcomes. Rather, broadening the research focus to include dimensions of strength, success, and resilience was pursued to achieve a more comprehensive, accurate, and ecologically valid view of family influences on health, a view with greater utility for professionals interested in promoting health and good outcomes for children.35 To date, most of the intervention research has fallen short of the conceptual demands of a social-ecologic framework, despite the growing awareness and policy demands for consideration of family contexts.36 In a review of 40 randomized clinical trial intervention studies using child's physical health concerns as outcomes, only 31 were explicitly theory driven, and only 7 enacted a social-ecologic model, as indicated by including family members in the intervention itself.36Those researchers who strove for a more balanced articulation of strengths and weaknesses have generated some of the most useful data and understandings that manifest in contemporary notions of at-risk families with factors of risk, protection, and resilience. For instance, although poverty is widely acknowledged to be a powerful, even pervasive, negative influence on families and a correlate or cause of numerous negative health outcomes for children,37 researchers using multifactorial and ecologic frameworks have been able to identify significant opportunities for building on strengths to promote children's health and well-being. The critical reviews by Black et al36,37 of interventions targeting children in low-income urban settings demonstrated how these more sophisticated frameworks can guide policy and practice in ways likely to improve important health outcomes. Poverty as a final common denominator38 is also better understood when anthropologic research weighs in on such multifactorial and multidisciplinary challenges. For instance, the 9-year longitudinal study of children in a rural Caribbean village by Flinn and England39 found that family environment was a more important predictor than socioeconomic condition in accounting for relationships between psychosocial stress and illness, concluding that the stress and immunosuppression associated with family processes may mediate links between poverty and health.Processes by which children in adverse circumstances evade predicted negative impacts and emerge healthy or successful in later life are characterized by the notion of resilience. Among the basic features of healthy or successful families are resilience and the capacity to adapt.29 Resilient families are those who "withstand and rebound from disruptive life challenges."32 Positive health outcomes for children may be more likely in resilient families in which particular belief systems, organizational processes, and communication processes described by family researchers suggest guidelines and principles for practice.31,32 Resilience researchers have marshaled the conceptual and empirical justifications for this progressive orientation toward individual and family functioning.40Although the discussion that follows will emphasize application of recent research on successful or resilient families, it is important to note that retaining the concepts of risky families will be important as well. For instance, Repetti et al41 adapted a cascade of risk framework in their analysis of the associations between family structure and processes and children's health to conclude that: Our analyses then will need to consider family processes, such as conflict, anger, aggression, emotional neglect, and ineffective discipline, as elements in poor health outcomes for children. At least as important will be consideration of the association of successful family variables, such as good communication, social connectedness, positive parenting, and religious or spiritual orientation, as factors in health and illness.These considerations of trends in behavioral and social science converge in important ways with the trends in pediatrics outlined earlier. Family researchers and pediatricians have mutual interest in understanding successful families and healthy children. Health and health promotion are key concerns; illness and health-risk behavior, especially as encompassed by the new morbidity, are shared foci. As an example, consider the problem of substance abuse, a developmental biopsychosocial morbidity of serious consequence. Data reviewed by Repetti et al41 supported their cascade model of risky families: Another example of the converging mutual interests of pediatricians with social and behavioral scientists is evident in confirming the integrity of the "Health Charter" found in Bright Futures,15 a well-regarded guide for progressive and effective pediatric practice. It states: "Every child and adolescent deserves a nurturing family and supportive relationships with other significant persons who provide security, positive role models, warmth, love, and unconditional acceptance. A child's health begins with the health of his parents."This premise accrued important empirical support in a recent report titled Setting an Example: The Health, Medical Care, and Health-Related Behavior of American Parents.42 These analyses of survey data from the National Center for Health Statistics revealed that 30% of mothers and 40% of fathers engage in at least 1 health risk behavior (smoking, drinking, being overweight, exercising insufficiently, driving after drinking). Less than half of all parents surveyed engaged in at least 3 of 5 good health habits (using a seat belt, eating breakfast, participating in sports or exercise, getting enough sleep, rarely snacking). Married parents who reported having stress in their lives were less likely to practice positive behaviors and more likely to engage in negative behaviors. Only 55% of fathers and 74% of mothers reported having a medical check-up within the last 2 years. The "report concludes by calling on parents to set a better example of healthy behavior for their children. It also calls on the public health community to find more effective strategies for encouraging parents to engage in healthful behaviors. Parents have the strongest motivation of any group of adults to change their behavior and preserve their health: they have children to raise." Thus, social and behavioral science joins Bright Futures in setting an agenda for health care professionals.The challenges in such an agenda cannot be underestimated, given recent findings reported by Minkovitz et al43 Their survey of 30 pediatric practices participating in the Healthy Steps for Young Children program, a national demonstration project committed to improving the quality of children's health care by enhancing child development and family-involvement components, found that only one third of physicians conduct family risk assessments basic to enhanced care delivery.One more example illustrates the mutual concerns of pediatricians and family researchers and introduces a set of caveats that complicate the task of enhancing communication between researchers and practitioners. In his thoughtful manifesto for child health care professionals on the front line, Rushton44 provided perspectives on the challenges of divorce and single-parent families: Thus, Rushton had important expectations of the research on successful families. In addition, he was aware that a naive view that simple notions of family structure that might contrast "normal" families and divorced families or might attribute deficits in a simple causal relationship without adequate consideration of complex family processes will not ultimately serve the children in our care.Before reviewing the recent research on successful families that might serve pediatricians and the children in their care, it is important to consider some of the limitations and cautions to be exercised in constructing applications of the social and behavioral science to pediatric practice and policy. As suggested earlier, the mutual concerns of family researchers and pediatricians are already generating helpful conceptualizations and practices. Perhaps we know enough about family strengths and weaknesses and how best to care for children such that further basic research is not necessary or may even be counterproductive in terms of resource allocation or access to quality services.45,46 Certainly, in the decade since the first appearance of the consensus document on characteristics of successful families,29 important clarifications and elaborations have been generated by social and behavioral scientists and used in formulating policy and practice in pediatrics.Among the challenges faced in the application process are a variety of generic limitations of research and a few concerns specific to family research. For instance, practitioners are most often appropriately concerned with the individual patient in their care at the moment; calling on scientific data summarized and interpreted on the basis of groups and statistical probabilities can be irrelevant or misleading. Most relationships demonstrated by the social and behavioral research under consideration derive from correlational analyses. Inappropriately or prematurely inferring or substantiating causal relationships and then applying these to a single case is fraught with dangers, inaccuracies, and ethical problems. When families or "family values" are the subject of investigation, philosophic and ideologic biases may be implicit and explicit in even the most objective scientific research. Among the most compelling distinctions relevant to examination of the impact of family process on child heath is that of family discord independent of or in association with marital status or family structure.47 Research on the effects of divorce may be especially prone to some of these biases, confounds, and fallacies.48,49The intersection of health research and family research is especially vulnerable. For example, Cotten50 documented the problems inherent in research on marital status and mental health because of the commonly restricted comparison of married versus nonmarried groups in many studies. Her analyses that broke out from the nonmarried group subsamples of separated or divorced, widowed, and never married generated some highly differentiated patterns of relationships between these marital statuses and distress as well as utility of psychosocial resources, such as support from friends and family or self-esteem. Even in this recent effort substantiating the need for more precise levels of the marital status index, it is striking that parent versus nonparent status is not incorporated. This omission is especially problematic given that important health correlates of parent status have been documented.51 More specifically, health outcomes for adolescents with diabetes can be differentiated in contrasts of single-parent, blended, and intact family structures.52 In addition, multiple sources or multiple informants in research on family processes are important given demonstrations of discordance between children and their caretakers on a variety of perceptions of health indices.53 With these cautions in mind, it remains useful to review recent research with successful families as a framework and then to consider a variety of venues of pediatric practice that might call on such findings.As noted earlier, a catalog of family processes associated with positive outcomes has been generated in recent years by family researchers. A growing body of research is documenting relationships between such family processes and child health in ways relevant to current pediatric practice, training, and policies. Examples of such research will be reviewed here, followed by consideration of existing pediatric venues most likely to use and generate such understandings. Next, examples of such integrations of family research findings in pediatrics will be described. Although one may rely on the original catalog of successful family variables generated by a gathering of family researchers a decade ago,29 it is important to recognize that there is considerable conceptual and methodologic overlap of constructs within the catalog, as well as a set of several constructs generated since that time or in studies beyond the scope of the original review. Thus, the catalog is neither comprehensive nor definitive but is certainly useful to organize current data and understanding. For the presentation that follows, we will refer to the dimensions or characteristics offered by Krysan et al29 and constructs and variables studied in the literature on family coping and positive parenting. These researchers have mapped a view of child health outcomes associated with processes in successful families that include communication, encouragement of individuals, expression of appreciation, commitment to family, religious or spiritual orientation, social connectedness, ability to adapt, resilience, clear roles, and family time together.Many manifestations of successful family functioning are observable in communication processes and dynamics within the family. Parent-child and marital communication processes have been studied. Walsh32 documented communication clarity, open emotional expression, and collaborative problem-solving as elements of resilience associated with recovery from illness and adaptation to chronic illness or disability. In a community-based sample of 225 families with an adolescent, similar communication skills and styles reflecting conflict resolution, problem-solving, and open, reciprocal emotional expression were among the factors positively associated with better health; health assessment was based on a self-reported child's health composite indexed along numerous dimensions, including somatic symptoms, health perceptions and evaluation, abstinence from alcohol, general well-being, and traditional mental health items on depression and anxiety.54 Clearly, specific relationships of a particular communication style to a specific health outcome have not been substantiated by studies such as this. However, salutogenic elements of empirically derived family typologies have been documented and suggest that more effective or successful families have better child health as part of their success.At a more molecular or biologic level, the nature of these relationships also have been elucidated by longitudinal research demonstrating that parent-child communication patterns described as parental coaching of emotional expression are associated with improved vagal functioning in response to stress at 5 years of age.55 Such family communication styles or child-rearing practices that teach about emotions and their regulation are predictive of the child's emotion regulation 3 years later and significantly associated with the child's physical health at 8 years of age.Communication dimensions were seen in a more directly clinical situation in a study of 101 adolescents (mean age: 15.5 years) who had recurrent headaches. When compared with healthy controls, these children were less likely to frequently express their emotions in daily family life.56 Because the sample of children with headaches had a disproportionate number of single-parent families, Osterhaus suggested 2 hypotheses relevant to the structural dimensions of communication to be addressed by future research: is reduced emotional expressivity a function of having 1 rather than 2 parents in the home; and/or might the stresses associated with life in a single-parent home generate a greater load of particular types of emotion (eg, worry, sadness), which may be expressed in different ways? Such empirical questions open the way to identifying communication patterns or skills that could characterize successful single-parent families as well as successful 2-parent families.Family time together is a dimension of successful families related to communication and often measured in terms of families' rituals, including family mealtime. Though Baranowski57 remained concerned about methodologic problems in the relevant research, there do appear to be cognitive and dietary-practice benefits for children when families have mealtime together.Among the most substantially documented relationships between a characteristic of successful families and health outcomes is social connectedness or social support. This dimension is evident and relevant within the family (eg, quality of relationships between and among family members) and in the family's connection to instrumental and emotional resources outside the family. The importance of social support for health is evident from the beginning of life, as documented in a review by Dunkel-Schetter et al58 of more than 200 studies of the determinants of adverse birth outcomes; social support from the infant's father and/or other family members predicts higher birth weight, among other positive birth outcomes. The mechanisms by which social support impacts health remain the subject of ongoing research, though evidence indicates that the changes in cardiovascular, endocrine, and immune functions associated with social support justify incorporation of social support interventions in prevention and treatment of health problems.59 Scores of studies across the life span document reduced health risks as well as lower morbidity and mortality in conditions of adequate to high social support.60 Only a few of these studies examined child health outcomes explicitly, so it is important to consider the positive impact of parental health on child health, as noted earlier, along with more direct child health indicators. Marriage, itself a key form of social connectedness, is well documented as a health protector in that "married individuals are more likely to comply with medical regimens, abstain from smoking, drink moderately, avoid risk-taking behavior, and lead stable, secure, and scheduled lifestyles."61 Children with married parents, then, have an advantage of such models for shaping their own health behavior.42 The protective impact of marriage appears to be stronger for men than for women, though how this might change with recent changes in women's roles and work outside the home, for instance, remains to be seen.61,62If marriage has direct and indirect positive impacts on children's health, what then of divorce, an example perhaps of disconnectedness or an unsuccessful family? As noted earlier, research on the impact of divorce on children remains controversial, and the findings to date are subject to varying interpretations and numerous qualifications.49 Relatively little of this research has examined the long-term impact of divorce on children's health. Our best information on this question comes from the classic Terman Life Cycle Study, which documented a higher risk of premature mortality for boys from divorced families throughout the life span63; the somewhat higher risk for girls was not statistically significant. This study began in 1921 and followed a large homogeneous group of 1528 bright, white, middle-class Californian children through 1991. At study entry, the children were approximately 11 years old. Approximately 13% of the sample (160 children) experienced the divorce of their parents before reaching 21 years of age. Of these, 48% (76 individuals) died between 1950 and 1991. The factors mediating this increased risk for men include a greater likelihood to have their own marriages end in divorce, lower educational level, and lower degree of involvement in service activities. For women, those who experienced parental divorce during childhood were more likely to experience their own divorce in adulthood and more likely to smoke, 2 factors predicting higher mortality risk. Small sample size precluded definitive explanations of the higher risks, though evidence suggested that "psychosocial difficulties associated with parental divorce may lead individuals down a destructive path that ultimately results in higher mortality risk." The authors appropriately pointed out that although their analyses were based on comparisons of divorced with nondivorced families, this rather crude index was probably a proxy measure for family conflict. If more refined measures of communication styles or conflict types and levels had been available in the Terman Study archives, they would have expected even stronger relationships with morbidity and mortality. Married families with high conflict would likely have shown greater risk than would divorced families with low conflict levels. On the one hand, the homogeneity of the sample and its decades-old data sources limited generalizability; on the other hand, the demonstration of this effect in a longitudinal sample relatively free of known risk elevators, such as poverty or limited access to medical care, underlined the salience of the findings.Factors of poverty and limited access to health care figured more prominently in other recent studies that document social connectedness as a successful family dimension. For instance, with recent concerns about underimmunization among Latino children living in poor urban areas, Anderson et al64 surveyed 688 mothers in Los Angeles to find that those with 1 or more close family members present were more likely to have a child with adequate immunization status. Interestingly, the findings of this study also showed that the better-immunized children were with less acculturated mothers, suggesting that the continuity of the closer family or social structure of the mostly Mexican culture may be a protective factor.One additional example of the salience of social connectedness for optimal health comes from the National Longitudinal Study on Adolescent Health (Add Health).65 Drawing from cross-secti
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