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Keith Kleinman MD, in Harriet Lane Handbook, 2021

B Structuring Family Meetings

1.

Make sure that all necessary individuals are present and understand the purpose of the meeting.

2.

Make sure that all clinicians are in agreement about the patient's condition and the recommendations.

3.

Identify the individual who will facilitate the meeting.

4.

Choose a private location with minimal distraction.

5.

Always have water and tissues available.

6.

Begin by introducing all participants and the purpose of the meeting.

7.

Assess what the family knows and expects with respect to the patient's condition.

8.

Describe the clinical situation, providing the big picture and then asking family members if they would like or are ready for more details.

9.

Encourage each member of the family to express concerns and questions.

10.

Explore the patient's and family's values and how they influence decision making.

11.

Propose goals for the patient's care that reflect the stated values.

12.

Provide a concrete follow-up plan.

Family structure, cohesion and positive parenting

Family structure has been investigated in relation to adolescent substance use, and research has demonstrated that children from two-parent homes are less likely to use alcohol and other drugs than children from single-parent homes (Epstein et al., 2001). However, the predictive power of family structure is dependent on other protective factors, that is, family structure alone does not predict adolescent alcohol use.

Parents, regardless of family structure, can indirectly influence adolescent substance use by advising against experimentation, imposing punishment for experimentation, influencing their adolescent's substance use beliefs, and affecting peer selection (Johnson and Johnson, 2000). Positive parent-child attachment and effective parenting processes, including parent-teen communication, appear to have important protective influences on youth substance use (Brook Hawkins Spoth DeWit Duncan Stice Stice Stice Welte Peterson a,b). Family cohesion, or the extent to which family members support, help, and are involved with each other, for example, has been found to reduce initial levels of adolescent et al., 1990; substance use and to delay increases in use over time ( et al., 1992; et al., 1996 2000; Wills and Cleary, 1996). A positive relationship alone, however, is not enough. Evidence indicates, for example, that extremes of parental support and control increase the risk for alcohol use ( et al., 1995; et al., 1997, substance use ( et al., 1993; Ellickson and Hayes, 1991). et al., 1993). Strong parental norms against teenage drinking and appropriate parental control and monitoring reduce the risk of initiation in early adolescence, and this interactional pattern has demonstrated consistency over time, such that secular declines in parental disapproval coincide with increases in adolescent et al., 1993; et al., 1999). Finally, general family management strategies have been related to adolescent alcohol use ( et al., 1994) and disapproval of alcohol use by parents has been associated with less alcohol use later in adolescence (

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Tom Lissauer MB, BChir, FRCPCH, in Illustrated Textbook of Paediatrics, 2022

Family structure

Although the 'two biological parent family' remains the norm, there are many variations in family structure. In the UK, the family structure has changed markedly over the last 20 years ( Fig. 1.2).

Lone-parent households - 22% of children in the UK now live in a lone-parent household (86% of which are headed by a female parent). Whilst many lone parents are excellent parents, being a lone parent is associated with an increased risk of social adversities: a higher level of unemployment, poor housing and financial hardship, with nearly half (47%) of the children living in poverty. These disadvantages may in turn mean lone parents require greater support in providing for their children, e.g. the provision of a healthy diet, take-up of preventive services such as immunization and developmental screening, vigilance about safety, and coping with an acutely sick child at home. This may in part explain why children raised in a lone-parent family are at higher risk of poor educational and health outcomes, including mental health.

Reconstituted families - The increase in the number of parents who change partners and the accompanying rise in reconstituted families (1 in 10 children live in a step-family) mean that children are having to cope with a range of new and complex parental and sibling relationships. This can lead to greater risk of emotional, behavioural and social difficulties.

Looked-after children - The term 'looked-after children' is generally used to mean those children who are looked after by the State. Most of these children will be in foster care, either living with a kinship (family) carer or with a non-family foster carer. A small number live in children's homes or other supported living accommodation. Children enter care for a number of reasons including physical, sexual or emotional abuse or neglect, or being an unaccompanied asylum-seeking minor. In 2016/17, there were over 96,000 children in care in the UK. They have significantly greater health needs than children and young people from comparable socio-economic backgrounds who have not been 'looked after'. Past experiences, including an often chaotic start in life, removal from family, placement location and transitions mean that these children are often at risk of having poor access to health services, both universal andspecialist. For example, they are less likely to have been immunized. They fall short even of their statutory health checks - such as dental and annual medical assessments - with nearly 15% of children missing out. There is increasing evidence that children who experience these 'adverse childhood experiences' (ACEs) are more likely to have physical and mental health problems throughout their life (Table 1.1).

Asylum seekers - These are people who have come to the UK to apply for protection as refugees. They are often placed in temporary housing and moved repeatedly into areas unfamiliar to them. In addition to the uncertainty as to whether or not they will be allowed to stay in the country, they face problems as a result of language barrier, poverty, fragmentation of families and racism. Many have lost family members and are uncertain about the safety of friends and family. All of these can have a serious impact on both physical and mental health. Children have particular difficulties as the frequent moves can disrupt continuity of care. It also disrupts childhood friendships, education, and family support networks. As with looked-after children, they are more likely to have been exposed to multiple adverse childhood experiences, which have an inevitable impact on a child's wellbeing and put them at risk of poor health outcomes.

Social Work.

Family structure and support are crucial to a successful outcome, no matter the form of intervention or communication. A social worker is able to assess the extent to which the family is actively involved with their child and can determine whether there are life stressors external to communication issues that could affect outcome. There is no concern when the family communicates with a child effectively, is actively involved in the child's therapeutic and educational program, and effectively copes with parental stress. Mild to moderate concern is warranted when some family members communicate with the child effectively, the family is not intact but still communicates and supports the child's needs, there is moderate parental stress, and appointments are occasionally canceled or broken during the evaluation process or by history. If a family does not communicate with the child effectively and is not intact, with issues that override the child's needs, and there is severe parental stress and a past history of noncompliance with medical regimens, the social worker may have great concern. There is no concern when a child's behavior is typical for age and there is effective parental control of behavior. In the event of sporadic parental control of a child's behavior or inconsistent engagement in therapy sessions, mild to moderate concern is warranted. Severely hyperactive, aggressive, or defiant behavior, poor parental control of the child's behavior, or consistent disengagement in therapy sessions constitutes major concern.

Parental expectations of the child's outcome with the implant are an important factor to consider in cochlear implant candidacy. Parents must realize that the cochlear implant will not fix the child's hearing and that the implanted child will remain deaf. The parents must realize that progress with the cochlear implant is not sudden and that extensive therapy is required. Parents must realize that their deaf children may always need support from assistive communication services and other deaf individuals. However, parents should expect that with consistent use, follow-up, and therapy, the child will have more access to sound and spoken language. With parents who realize that a cochlear implant will not restore normal hearing and have a rehabilitation or habilitation plan, the rating is no concern. Mild to moderate concern is justified when the parents believe that their child will move to a mainstream setting, with no support services, whose expectations are inflexible, and have no plan for rehabilitation. A cochlear implant team will have great concern if parents inflexibly believe that the cochlear implant will restore normal hearing. If the child is old enough to be able to understand that he or she is being evaluated for cochlear implantation, the child's expectations must also be similarly considered.

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Karen J. Marcdante MD, in Nelson Essentials of Pediatrics, 2019

Adoption

Adoption is a legal and social process that provides full family membership to a child who is not the adult parent's biological offspring. Most adoptions in the United States involve U.S. parents adopting U.S. children, but shifting cultural trends have increased the diversity in the ways in which adoptions occur; the process can involve biologically related and unrelated children, stepchildren, adoption through private and public agencies, domestic and international adoptions, and independent and informal adoptions. Based on data from the U.S. Department of Health and Human Services, the number of adoptions that are finalized each year has remained relatively stable (between 50,000 and 53,500) over the last decade. Approximately 2% of children in the United States are adopted. In 2009-2011, 13% of adopted children under 18 were internationally adopted. Over that same period, there were 438,000 transracially adopted children under the age of 18 (over a third of whom were foreign born), or 28% of all adopted children under 18. Increasing numbers of same-gender couples or single-LGB adults are raising children via adoption. Each type of adoption raises unique issues for families and health care providers. Data suggests that adopted children live in households that have higher incomes, a lower percentage in poverty, and a higher percentage with a parent with at least a bachelor's degree than stepchildren or biological children. Open adoptions in which the biological parents and birth parents agree to interact are occurring with increased frequency and create new issues for the adoption triad (biological parent, adoptive parent, and child).

Pediatricians are in an ideal position to help adoptive parents obtain and evaluate medical information, consider the unique medical needs of the adopted child, and provide a source of advice and counseling from the preadoption period through adolescence. A preadoption visit may allow discussion of medical information that the prospective parents have received about the child and identify important missing information such as the medical history of the biological family and the educational and social history of the biological parents. The preadoption period is the time that families are most likely to be able to obtain this information. Depending on the preadoption history, there may be risks of infections, in utero substance exposure, poor nutrition, or inadequate infant care that should be discussed with adoptive parents.

When the adopted child is first seen, screening for medical disorders beyond the typical age-appropriate screening tests should be considered. If the child has not had the standard newborn screening tests, the pediatrician may need to obtain these tests. Documented immunizations should be reviewed and, if needed, a plan developed to complete the needed immunizations (seeChapter 94). Children may be at high risk for infection based on the biological mother's social history or the country from which the child was adopted, including infection with human immunodeficiency virus, hepatitis B, cytomegalovirus, tuberculosis, syphilis, and parasites. A complete blood count may be needed to screen for iron deficiency.

SUMMARY

Changes in the family structure represent nodal points that can have a significant impact on a child. Most of these events, such as the birth of a sibling or the death of a parent or grandparent, are likely to have predictable consequences, allowing the physician to anticipate the typical reactions and offer timely guidance. Nevertheless, the particular structure of a given family and its available resources become a better predictor of whether the parents (and consequently the child) will be able to navigate these rocky shoals. An understanding of the family life cycle, the developmental stage of the child, the family's emotional and economic resources, and the symptoms of childhood problems guides the physician in assessing which families are coping, and which may need monitoring and intervention. As in other areas of developmental-behavioral pediatrics, the identification of child and family counseling services facilitates timely referral when needed.

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URL: https://www.sciencedirect.com/science/article/pii/B9781416033707000146

16.6.3 Family definition

Although the ethnography on family structures has tended to focus on predominantly white, cisgender, middle-class, educated gay or lesbian couples, national data indicates gay and lesbian parents of racial or ethnic minority groups are more likely to report raising or having had children than their White counterparts. With regard to parenting (i.e., from previous different-sex relationships or adoption), no differences have been observed in childhood outcomes. Nevertheless, sexual- and gender-minority couples continue to face social, legal, and financial barriers in accessing reproductive services and navigating the adoption process. They are more likely to have household incomes near the poverty threshold. In addition, they may be subject to alienation from families of origin and/or lack legal recognition, which can have further impact on mental health during the transition to parenthood. The absence of traditional gender roles that commonly exists in these families has also been shown to provoke questions of family legitimacy.

Family definition for sexual- and gender-minority people may challenge typical ideas of family structure. Often, biological or legal relationships may not be essential. For example, "chosen families" consist of kin with similar backgrounds and/or identities without biological relation. By finding connection through shared identity, families such as these may be viewed as more supportive than families of origin. Whereas "chosen families" exist for all sexual- and gender-minority individuals, family networks have emerged in racial and ethnic minority groups with potentially broader purpose. Research within these communities has found "gay families" and "houses" provide support against the charge of both hetero/cissexism and racism. "Houses" tend to have a performance component, notably within the ballroom community, while "gay families" do not have the same focus. Houses originated in Harlem, New York during the 1920s and 1930s but now include other major US cities. They are often helmed by an appointed house Mother and/or Father who provides support and guidance, and members compete or "walk" in drag and other performance competitions.

The process of family definition holds long-term implications. Elderly sexual- and gender-minority adults today are more likely to live alone and less likely to have children to care for them and may therefore require "chosen families" for support later in life. Family structure may be of particular importance for this population. Elderly sexual- and gender-minority adults must contend with the cumulative effects of stigma, much of which predates the LGBT rights movement, and the vast majority of elderly LGBT individuals report experiencing at least one episode of victimization during their lifetimes.

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Family Conciliation

The social evolution of family structures could partly explain the increase in personal telephone use. We may speak of various factors: (1) the emergence of single-parent or patchwork families: particularly reliant on external phone connections due to characteristics of their structure; (2), internal democratization of the family which accentuates individual autonomy and is susceptible of favoring diffusion of a less collective, more personal, form of telephonic communications; (3) the demand for individual communications devices given that children remain living with their parents for longer in some countries. The increasing incorporation of women into the workforce might be considered a fourth factor. Even though cell phones have not changed any social conventions, women tend to use it to cope with family responsibilities across a space-time gap, bringing their private world of domestic responsibilities to their public, occupation-related world, and vice versa.

All these changes in family morphology are reflected in affective and social bonds. Cell phones have made it possible for teenagers to construct a kind of virtual brotherhood. Moreover, cell phones promote individual thinking and networks of external support and propitiate virtual proximity (in the double sense of the word virtual). Connections mediated by cell phones only deal with the issue generating the call, leaving the parties involved free of any emotional commitment beyond the topic dealt with in the conversation or message. Present society demands fast and efficient connections. In this respect, distance is not an obstacle for connecting, but being connected is likewise not an obstacle for maintaining distances. Being connected is more economical than really relating. Thus, we may speak of new family constellations and emotional processes deriving in a society, still under construction, which gives rise to new ways of communicating to maintain family unity and the sense of belonging which both adolescents and adults need.

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B. The Status of Elders

During the 17th and 18th centuries, most families and communities were dominated by religious and social principles endorsing male hierarchy, with economic dependence and reciprocal obligation between the generations. Frailty and decline in old age were considered to be natural and inevitable, part of man's punishment for original sin. However, this belief was coupled with the hope for redemption and a blessed afterlife. Survival into old age, infrequent as it was, signified a "distinguishing favor" from God. Aging was felt to be an integral component of life's journey, its final stage. Among Puritans, the male pilgrim faced the evils of the spiritual road quite alone, and the physical decay of aging was feared. For Puritan women, however, the traditional medieval pattern persisted. The ideal woman, a pilgrim on life's spiritual journey, accepted physical decline with grace and equanimity, using life experiences and nurturing relationships for spiritual progress. Thus, these "natural stages of life" provided religious meaning and social standing for aging men and women [11].

About the time of the American Revolution, a similar revolution in age relations occurred. Old age began to decline in status, and a new youth culture arose. From 1770 to 1820, the cultural shift away from an esteemed old age was reflected in language, dress, customs, and art. In meeting halls, front row seats were no longer reserved for the elderly. Fashion came to favor a more youthful look; white wigs were dropped in favor of toupees, and clothing ceased to flatter the older frame. Although people had once commonly pretended to be older than they actually were, claimed ages in the census drifted downward from this time on. Children were less frequently named after grandparents, and contempt for the old began to be expressed in terms like "old fogey," "codger," and "geezer." Around 1790, for the first time, retirement from public office at 60 or 70 became mandatory in many states. The ideal of age equality overthrew the "tyranny of age," and the exaltation of the old began to be replaced by the cult of youth [5].

Analysis of early American family structure reveals power relations between fathers and sons and the limits of the sons' autonomy determined by marriage, landholding, and inheritance. By the end of the 18th century however, patriarchal control was weakened in part by a land shortage, which led to the dispersal of sons and outmigration [ 12]. By common law, widows inherited one third of household goods and controlled one third of the real estate, usually generating sufficient maintenance income. Until the 20th century, property laws held greater protection for women's property obtained through parental inheritance or by gift. Authority vested in husbands and fathers thus left a woman with lesser control over property she had helped build in the course of a marriage. For additional security then, women exerted their collective moral and social authority within family and kin networks, developing places to turn for alternative support.

"A woman who faced early death from childbirth counted on her sisters to protect her children from mistreatment ... [and] elderly widows counted on their daughters and daughters-in-law to nurse them in reciprocity for prior care" [13].

Elderly women after the American Revolution sought to remain pious and to be useful by serving as models of moral integrity for the new nation. The female virtues accorded aged women of the day emphasized piety, submissiveness, domesticity, and service to others. Aged matriarchs were valued primarily in having set good examples for younger women by living the virtuous Christian life. Because motherhood was felt to be the most important female occupation among younger women, older women were thus revered for having been good mothers [14]. Elderly women were further esteemed for Christ-like submission, bearing the pain and suffering of old age with quiet and patient resignation. Physical decline as one grew old was considered part of one's spiritual atonement at the end of life. "Emphasizing sickness and dependency highlighted the elderly's proximity to death and was meant to spur efforts to prepare for future judgment" [15]. In addition, older women were able to maintain continuity and connection among family and friends in their declining years. The lives of aging men, however, were more narrowly defined. A fall from power and loss of public status were often the primary markers of this stage in the life course of older men. Elderly men were thus seen as weaker, without authority, and more feminine. Although little documented, it is likely that most men never achieved significant public status in their lifetimes. Given the male yardstick of power and social achievement, their gendered experience in old age perhaps suffers in comparison to that of elderly women [16]. This issue is poignantly revisited in the 20th century in Arthur Miller's Death of a Salesman:

"Willy Loman never made a lot of money. His name was never in the paper... . He's not to be allowed to fall into his grave like an old dog. Attention, attention must be finally paid to such a person" [17].

The Victorian era of the 19th century promoted the virtues of independence, success, and healthy living. The ideal self-made man practiced a strict regimen of self-denial and industriousness. The ideal Victorian woman followed a regimen of domestic and spiritual activities, relegated to the "woman's sphere." Longevity was no longer viewed as a gift from God but was rather felt to be a reward for proper behavior, hygiene, and self-discipline. Indeed a rising belief in human perfectibility led to popular health reform and a public movement that assumed all people were naturally healthy and that disease was caused by violation of fixed scientific laws [11]. However, around 1850, average life expectancy was a mere 39.5 years, and infant mortality claimed 22% of live births. Nearly half of all deaths occurred before age 15; less than 15% occurred after age 60 [18]. Pursuit of perfect health and longevity promised that good habits would lead to an old age characterized by good health and self-reliance. However, these beliefs had a darker implication. Physical decline and dependency in an elder meant a lack of discipline and implied that one's life had been immoral. Pain and suffering in old age now invoked feelings of shame and a sense of failure [11].

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3.2.1 The Nuclear Family: Separate or Part of the Extended Family?

The key element in studying different types of family structure and its relationships with psychological development of the children, its economic base, and its culture is the nuclear family. In 1949, Murdock made an important distinction regarding the relationship of the nuclear family to the extended family: "The nuclear family is a universal human social grouping. Either as the sole prevailing form of the family or as the basic unit from which more complex familial forms are compounded, it exists as a distinct and strongly functional group in every known society."

Murdock made an important point: The nuclear family is prevalent in all societies, not necessarily as an autonomous unit but because the extended family is essentially a constellation of nuclear families across at least three generations. Parsons' theory that the adaptation of the family unit to the industrial revolution required a nuclear family structure resulting in its isolation from its traditional extended family and kinship network, leading to psychological isolation and anomie, has had a strong influence on psychological and sociological theorizing about the nuclear family. However, studies of social networks in North America and northern Europe have shown that the hypothesized isolation of the nuclear family is a myth. Nuclear families, even in these industrial countries, have networks with grandparents, brothers and sisters, and other kin. The question is the degree of contact and communication with these kin, even in nations of northern and southern Europe.

A second issue relates to the different cycles of family, from the moment of marriage to the death of the parents or grandparents. The classic three-generation extended family has a lifetime of perhaps 20-30 years. The death of the grandparent, the patriarch of an extended family, results in one cycle closing and the beginning of a new cycle with two or three nuclear families, the married and unmarried sons and daughters. These are nuclear families in transition. Some will form new extended families, others may not have children, some will not marry, and others (e.g., the second son in the stem family) will not have the economic base to form a new stem family. That is, even in cultures with a dominant extended family system, there are always nuclear families.

A third issue is the determination of a nuclear family. This is related to place of common residence or the "household" of the nuclear family. Demographic studies of the family usually employ the term household in determining the number of people residing in the residence and their roles. However, there is a paradox between the concepts household and family as employed in demographic studies. Household refers to counting the number of persons in a house. If there are two generations, parents and the children, they are identified as a nuclear family. However, this may lead to erroneous conclusions about the percentage of nuclear families in a country. For example, in a European demographic study, Germany and Austria had lower percentages of nuclear families than Greece. This appears to be strange because Greece is known to be a country with a strong extended family system. However, demographic statistics provide only "surface" information, which is difficult to interpret without data about attitudes, values, and interactions between family members. Nuclear households in Greece, as in many other countries throughout the world, are very near to the grandparents-in the apartment next door, on the next floor, or in the neighborhood-and the visits and telephone calls between kin are very frequent. Thus, although nuclear in terms of common residence, the families are in fact extended in terms of their relationships and interactions.

In addition, there is the psychological component of those who one considers to be family. Social representation of his or her family may consist of a mosaic of parents, brothers and sisters, grandparents, uncles, and aunts and cousins on both sides, together with different degrees of emotional attachments to each one, different types of interactions, bonds, memories, etc. Each person has a genealogical tree consisting of a constellation of overlapping kinship groups-through the mother, father, mother-in-law, father-in-law, but also through the sister-in-law, brother-in-law, cousin-in-law, etc. The overlapping circles of nuclear families in this constellation of kin relationships are almost endless. Both the psychological dimension of family-one's social representation-and the culturally specified definition of which kin relationships are important determine which kin affiliations are important to the individual ("my favorite aunt") or the family ("our older brother's" family) and which are important in the clan (the "Zaman" extended family) or community (the "Johnsons" nuclear family). Thus, it is not so important "who lives in the box" but, rather, the types of affiliations and psychological ties with the constellation of different family members or kin in the person's conception of his or her family, whether it is an "independent" nuclear family in Germany or an "extended family" in Nigeria.

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Keith Kleinman MD, in Harriet Lane Handbook, 2021 1. Make sure that all necessary individuals are present and understand the purpose of the meeting. 2. Make sure that all clinicians are in agreement about the patient's condition and the recommendations. 3. Identify the individual who will facilitate the meeting. 4.

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