Family Influences on Child Health Promotion
On completion of this chapter the reader will be able to:
• Discuss definitions of family.
• Describe three major family theories.
• Identify different family structures found in the United States.
• Discuss the effect of family size and configuration on personality development.
• Discuss the role transition experienced by new parents.
• Explain various parenting behaviors such as parenting styles, disciplinary patterns, and communication skills.
• Demonstrate an understanding of special parenting situations such as adoption, divorce, single parenting, parenting in reconstituted families, and dual-earner families.
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General Concepts
Definition of Family
The term family has been defined in many different ways according to the individual’s own frame of reference, values, or discipline. There is no universal definition of family; a family is what an individual considers it to be. Biology describes the family as fulfilling the biologic function of perpetuation of the species. Psychology emphasizes the interpersonal aspects of the family and its responsibility for personality development. Economics views the family as a productive unit providing for material needs. Sociology depicts the family as a social unit interacting with the larger society, creating the context within which cultural values and identity are formed. Others define family in terms of the relationships of the persons who make up the family unit. The most common type of relationships are consanguineous (blood relationships), affinal (marital relationships), and family of origin (family unit a person is born into).
Earlier definitions of family emphasized that family members were related by legal ties or genetic relationships and lived in the same household with specific roles. Later definitions have been broadened to reflect both structural and functional changes. A family can be defined as an institution in which individuals, related through biology or enduring commitments, and representing similar or different generations and genders, participate in roles involving mutual socialization, nurturance, and emotional commitment (Coehlo, Kaakinen, Hanson, and others, 2009).
Nursing care of infants and children is intimately involved with care of the child and the family. Family structure and dynamics can have an enduring influence on a child, affecting the child’s health and well-being (American Academy of Pediatrics, 2003). Consequently, nurses must be aware of the functions of the family, various types of family structures, and theories that provide a foundation for understanding the changes within a family and for directing family-oriented interventions.
Family Theories
A family theory can be used to describe families and how the family unit responds to events both within and outside the family. Each family theory makes assumptions about the family and has inherent strengths and limitations (Coehlo, Kaakinen, Hanson, and others, 2009). Most nurses use a combination of theories in their work with children and families. Commonly used theories are family systems theory, family stress theory, and developmental theory (Table 3-1).
TABLE 3-1
SUMMARY OF FAMILY THEORIES AND APPLICATIONS
ASSUMPTIONS | STRENGTHS | LIMITATIONS | APPLICATIONS |
Family Systems Theory | |||
A change in any one part of a family system affects all other parts of the family system (circular causality).Family systems are characterized by periods of rapid growth and change and periods of relative stability.Both too little change and too much change are dysfunctional for the family system; therefore, a balance between morphogenesis (change) and morphostasis (no change) is necessary.Family systems can initiate change, as well as react to it. | Applicable for family in normal everyday life, as well as for family dysfunction and pathologyUseful for families of varying structure and in various stages of the life cycle | More difficult to determine cause-and-effect relationships because of circular causality | Mate selection, courtship processes, family communication, boundary maintenance, power and control within family, parent–child relationships, teenage pregnancy and parenthood |
Family Stress Theory | |||
Stress is an inevitable part of family life, and any event, even if positive, can be stressful for the family.Family encounters both normative expected stressors and unexpected situational stressors over its life cycle.Stress has a cumulative effect on family.Families cope with and respond to stressors with a wide range of responses and effectiveness. | Potential to explain and predict family behavior in response to stressors and to develop effective interventions to promote family adaptationFocuses on positive contribution of resources, coping, and social support to adaptive outcomesCan be used by many disciplines in the health field | Relationships among all variables in the framework not yet adequately describedNot yet known if certain combinations of resources and coping strategies are applicable to all stressful events | Transition to parenthood and other normative transitions, single-parent families, families experiencing work-related stressors (dual-earner family, unemployment), acute or chronic childhood illness or disability, infertility, death of a child, divorce, teenage pregnancy and parenthood |
Developmental Theory | |||
Families develop and change over time in similar and consistent ways.Family and its members must perform certain time-specific tasks set by themselves and by persons in the broader society.Family role performance at one stage of family life cycle influences family’s behavioral options at next stage.Family tends to be in stage of disequilibrium when entering a new life-cycle stage and strives toward homeostasis within stages. | Provides a dynamic, rather than static, view of the familyAddresses both changes within the family and changes in the family as a social system over its life historyAnticipates potential stressors that normally accompany transitions to various stages and when problems may peak because of lack of resources | Traditional model more easily applied to two-parent families with childrenUse of age of oldest child and marital duration as marker of stage transition sometimes problematic (e.g., in stepfamilies, single-parent families) | Anticipatory guidance, educational strategies, and developing or strengthening family resources for management of transition to parenthood; family adjustment to children entering school, becoming adolescents, leaving home; management of “empty nest” years and retirement |
Family Systems Theory
Family systems theory is derived from general systems theory, a science of “wholeness” that is characterized by interaction among the components of the system and between the system and the environment (Bomar, 2004). General systems theory expanded scientific thought from a simplistic view of direct cause and effect (A causes B) to a more complex and interrelated theory (A influences B, but B also affects A). In family systems theory, the family is viewed as a system that continually interacts with its members and the environment. The emphasis is on the interactions among the members; a change in one family member creates a change in other members, which in turn results in a new change in the original member. Consequently, a problem or dysfunction does not lie in any one member but rather in the type of interactions used by the family. Because the interactions, not the individual members, are viewed as the source of the problem, the family becomes the patient and the focus of care. Examples of the application of family systems theory to clinical problems are nonorganic failure to thrive and child abuse. According to family systems theory, the problem does not rest solely with the parent or child but with the type of interactions between the parent and the child and the factors that affect their relationship.
Bowen’s family systems theory (Coehlo, Kaakinen, Hanson, and others, 2009) emphasizes that the key to healthy family function is the members’ ability to distinguish themselves from each other both emotionally and intellectually. The family unit has a high level of adaptability. When problems arise within the family, change occurs by altering the interaction or feedback messages that perpetuate disruptive behavior. Feedback refers to processes in the family that help identify strengths and needs and determine how well goals are accomplished. Positive feedback initiates change; negative feedback resists change (Goldenberg and Goldenberg, 2008). When the family system is disrupted, change can occur at any point in the system.
A major factor that influences a family’s adaptability is its boundary, an imaginary line that exists between the family and its environment (Coehlo, Kaakinen, Hanson, and others, 2009).
Family Stress Theory
Family stress theory explains how families react to stressful events and suggests factors that promote adaptation to stress (Coehlo, Kaakinen, Hanson, and others, 2009). Families encounter stressors (events that cause stress and have the potential to effect a change in the family social system), including those that are predictable (e.g., parenthood) and those that are unpredictable (e.g., illness, unemployment). These stressors are cumulative, involving simultaneous demands from work, family, and community life. Too many stressful events occurring within a relatively short period (usually 1 year) can overwhelm the family’s ability to cope and place it at risk for breakdown or physical and emotional health problems among its members. When the family experiences too many stressors for it to cope adequately, a state of crisis ensues. For adaptation to occur, a change in family structure or interaction is necessary.
The resiliency model of family stress, adjustment, and adaptation emphasizes that the stressful situation is not necessarily pathologic or detrimental to the family but demonstrates that the family needs to make fundamental structural or systemic changes to adapt to the situation (McCubbin and McCubbin, 1994).
Developmental Theory
Developmental theory is an outgrowth of several theories of development. Duvall (1977) described eight developmental tasks of the family throughout its life span (Box 3-1). The family is described as a small group, a semiclosed system of personalities that interacts with the larger cultural social system. As an interrelated system, the family does not have changes in one part without a series of changes in other parts.
Developmental theory addresses family change over time using Duvall’s family life cycle stages based on the predictable changes in the family’s structure, function, and roles with the age of the oldest child as the marker for stage transition. The arrival of the first child marks the transition from stage I to stage II. As the first child grows and develops, the family enters subsequent stages. In every stage, the family faces certain developmental tasks. At the same time, each family member must achieve individual developmental tasks as part of each family life cycle stage.
Developmental theory can be applied to nursing practice. For example, the nurse can assess how well new parents are accomplishing the individual and family developmental tasks associated with transition to parenthood. New applications should emerge as more is learned about developmental stages for nonnuclear and nontraditional families.
Family Nursing Interventions
In working with children, the nurse must include family members in their care plan. Research confirms parents’ desire and expectation to participate in their child’s care (Power and Franck, 2008). To discover family dynamics, strengths, and weaknesses, a thorough family assessment is necessary (see Chapter 6). The nurse’s choice of interventions depends on the theoretic family model that is used (Box 3-2). For example, in family systems theory, the focus is on the interaction of family members within the larger environment (Goldenberg and Goldenberg, 2008). In this case, using group dynamics to involve all members in the intervention process and being a skillful communicator are essential. Systems theory also presents excellent opportunities for anticipatory guidance. Because each family member reacts to every stress experienced by that system, nurses can intervene to help the family prepare for and cope with changes. In family stress theory, the nurse uses crisis intervention strategies to help family members cope with the challenging event. In developmental theory, the nurse provides anticipatory guidance to prepare members for transition to the next family stage. Nurses who think family involvement plays a key role in the care of a child are more likely to include families in the child’s daily care (Fisher, Lindhorst, Matthews, and others, 2008).
Family Structure and Function
Family Structure
The family structure, or family composition, consists of individuals, each with a socially recognized status and position, who interact with one another on a regular, recurring basis in socially sanctioned ways (Coehlo, Kaakinen, Hanson, and others, 2009). When members are gained or lost through events such as marriage, divorce, birth, death, abandonment, or incarceration, the family composition is altered, and roles must be redefined or redistributed.
Nurses must be able to meet the needs of children from many diverse family structures and home situations. A family’s particular structure affects the direction of nursing care. The U.S. Census Bureau uses four definitions for families: the traditional nuclear family, the nuclear family, the blended family or household, and the extended family or household.
Traditional Nuclear Family
A traditional nuclear family consists of a married couple and their biologic children. Children in this type of family live with both biologic parents and, if siblings are present, only full brothers and sisters (i.e., siblings who share the same two biologic parents). No other persons are present in the household (i.e., no steprelatives, foster or adopted children, half siblings, other relatives, or nonrelatives).
Nuclear Family
The nuclear family is composed of two parents and their children. The parent–child relationship may be biologic, step, adoptive, or foster. Sibling ties may be biologic, step, half, or adoptive. The parents are not necessarily married. No other relatives or nonrelatives are present in the household.
Blended Family
A blended family or household, also called a reconstituted family, includes at least one stepparent, stepsibling, or half sibling. A stepparent is the spouse of a child’s biologic parent but is not the child’s biologic parent. Stepsiblings do not share a common biologic parent; the biologic parent of one child is the stepparent of the other. Half siblings share only one biologic parent.
Extended Family
An extended family or household includes at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. Parent–child and sibling relationships may be biologic, step, adoptive, or foster.
In many nations and among many ethnic and cultural groups, households with extended families are common. Within the extended family, grandparents often find themselves rearing their grandchildren (Fig. 3-1). Young parents are often considered too young or too inexperienced to make decisions independently. Often, the older relative holds the authority and makes decisions in consultation with the young parents. Sharing residence with relatives also assists with the management of scarce resources and provides child care for working families. A resource for extended families is the Grandparent Information Center.*
Single-Parent Family
In the United States, an estimated 23.8 million children lived in single-parent families (Annie E. Casey Foundation, 2011). The contemporary single-parent family has emerged partially as a consequence of the women’s rights movement and also as a result of more women (and men) establishing separate households because of divorce, death, desertion, or single parenthood. In addition, a more liberal attitude in the courts has made it possible for single people, both men and women, to adopt children. Although mothers usually head single-parent families, it is becoming more common for fathers to be awarded custody of dependent children in divorce settlements. With women’s increased psychologic and financial independence and the increased acceptability of single parents in society, more unmarried women are deliberately choosing mother–child families. Frequently, these mothers and children are absorbed into the extended family. The challenges of single-parent families are discussed on p. 39.
Binuclear Family
The term binuclear family refers to parents continuing the parenting role while terminating the spousal unit. The degree of cooperation between households and the time the child spends with each can vary. In joint custody, the court assigns divorcing parents equal rights and responsibilities concerning the minor child or children. These alternate family forms are efforts to view divorce as a process of reorganization and redefinition of a family rather than as a family dissolution. Joint custody and coparenting are discussed further on p. 39.
Polygamous Family
Although it is not legally sanctioned in the United States, the conjugal unit is sometimes extended by the addition of spouses in polygamous matings. Polygamy refers to either multiple wives (polygyny) or, rarely, multiple husbands (polyandry). Many societies practice polygyny that is further designated as sororal, in which the wives are sisters, or nonsororal, in which the wives are unrelated. Sororal polygyny is widespread throughout the world. Most often, mothers and their children share a husband and father, respectively, with each mother and her children living in the same or separate households.
Communal Family
The communal family emerged from disenchantment with most contemporary life choices. Although communal families may have divergent beliefs, practices, and organization, the basic impetus for formation is often dissatisfaction with the nuclear family structure, social systems, and goals of the larger community. Relatively uncommon today, communal groups share common ownership of property. In cooperatives, property ownership is private, but certain goods and services are shared and exchanged without monetary consideration. There is strong reliance on group members and material interdependence. Both provide collective security for nonproductive members, share homemaking and childrearing functions, and help overcome the problem of interpersonal isolation or loneliness.
Gay, Lesbian, Bisexual, and Transgender Families
A same-sex, homosexual, or gay/lesbian/bisexual/transgender (GLBT) family is one in which there is a legal or common-law tie between two persons of the same sex who have children (Blackwell, 2007). There are a growing number of families with same-sex parents in the United States, with an estimated one fourth of all same-sex couples raising children (Pawelski, Perrin, Foy, and others, 2006). Although some children in GLBT households are biologic from a former marriage or relationship, children may be present in other circumstances. They may be foster or adoptive parents, lesbian mothers may conceive through artificial fertilization, or a gay male couple may become parents through use of a surrogate mother.
Nurses need to be nonjudgmental and to learn to accept differences rather than demonstrate prejudice that can have a detrimental effect on the nurse–child–family relationship (Blackwell, 2007). Moreover, the more nurses know about the child’s family and lifestyle, the more they can help the parents and the child.
Family Strengths and Functioning Style
Family function refers to the interactions of family members, especially the quality of those relationships and interactions (Bomar, 2004). Researchers are interested in family characteristics that help families function effectively. Knowledge of these factors guides the nurse throughout the nursing process and helps the nurse to predict ways that families may cope and respond to a stressful event, provide individualized support that builds on family strengths and unique functioning style, and assist family members in obtaining resources.
Family strengths and unique functioning styles (Box 3-3) are significant resources that nurses can use to meet family needs. Building on qualities that make a family work well and strengthening family resources make the family unit even stronger. All families have strengths as well as vulnerabilities.
Family Roles and Relationships
Each individual has a position, or status, in the family structure and plays culturally and socially defined roles in interactions within the family. Each family also has its own traditions and values and sets its own standards for interaction within and outside the group. Each determines the experiences the children should have, those they are to be shielded from, and how each of these experiences meets the needs of family members. When family ties are strong, social control is highly effective, and most members conform to their roles willingly and with commitment. Conflicts arise when people do not fulfill their roles in ways that meet other family members’ expectations, either because they are unaware of the expectations or because they choose not to meet them.
Parental Roles
In all family groups, the socially recognized status of father and mother exists with socially sanctioned roles that prescribe appropriate sexual behavior and childrearing responsibilities. The guides for behavior in these roles serve to control sexual conflict in society and provide for prolonged care of children. The degree to which parents are committed and the way they play their roles are influenced by a number of variables and by the parents’ unique socialization experience.
Parental role definitions have changed as a result of the changing economy and increased opportunities for women (Bomar, 2004). As women’s role has changed, the complementary role of men has also changed. Many fathers are more active in childrearing and household tasks. As the redefinition of sex roles continues in American families, role conflicts may arise in many families because of a cultural lag of the persisting traditional role definitions.
Role Learning
Family Size and Configuration
Parenting practices differ between small and large families. Small families place more emphasis on the individual development of the children. Parenting is intensive rather than extensive, and there is constant pressure to measure up to family expectations. Children’s development and achievement are measured against those of other children in the neighborhood and social class. In small families, children have more democratic participation than in larger families. Adolescents in small families identify more strongly with their parents and rely more on them for advice. They have well-developed, autonomous inner controls as contrasted with adolescents from larger families, who rely more on adult authority.
Children in a large family are able to adjust to a variety of changes and crises. There is more emphasis on the group and less on the individual (Fig. 3-2). Cooperation is essential, often because of economic necessity. The large number of people sharing a limited amount of space requires a greater degree of organization, administration, and authoritarian control. A dominant family member (a parent or older child) wields control. The number of children reduces the intimate, one-to-one contact between the parent and any individual child. Consequently, children turn to each other for what they cannot get from their parents. The reduced parent–child contact encourages individual children to adopt specialized roles to gain recognition in the family.
Older siblings in large families often administer discipline. Siblings are usually attuned to what constitutes misbehavior. Sibling disapproval or ostracism is frequently a more meaningful disciplinary measure than parental interventions. In situations such as the death or illness of a parent, an older sibling often assumes responsibility for the family at considerable personal sacrifice. Large families generate a sense of security in the children that is fostered by sibling support and cooperation. However, adolescents from large families are more peer oriented than family oriented.
Sibling Interactions
Spacing of Children
Age differences between siblings affect the childhood environment but to a lesser extent than does the gender of the sibling. The arrival of a sibling is difficult for toddlers and preschool children, especially between the ages of 2 and 3 years. At this age, they are still very attached to their parents and do not understand the concept of sharing. An older child is able to understand the situation and is less likely to see the newcomer as a threat, although the child does feel the loss of the only-child status (Coehlo, Kaakinen, Hanson, and others, 2009). In general, the narrower the spacing between siblings, the more the children influence one another, especially in emotional characteristics. The wider the spacing, the greater the influence of the parents.
Traditionally, sibling relationships were viewed from a Freudian perspective that emphasized the concept of sibling rivalry. Researchers have viewed siblings through developmental or ecologic frameworks that focus on interactions within family systems (Friedman, Bowden, and Jones, 2003). The results of these broader perspectives provide a picture of rich and varied sibling interactions (Fig. 3-3).
Sibling Functions
The sibling relationship’s most unique feature is its duration. The longest relationship one will share with another human being is the sibling relationship, which lasts through a lifetime (often 50 to 80 years), compared with the child–parent relationship of approximately 30 to 50 years. Siblings spend long periods together and get to know each other at their best and worst.
Siblings exert power, exchange services, and express feelings in reciprocal ways that are often not revealed in the presence of the parents. They see themselves in their brothers and sisters, experience life vicariously through their siblings’ behavior, and begin to expand on their own possibilities. Siblings can also be touchstones for what the other would not like to be, and they use each other as yardsticks for comparison. They provide a sounding board for each other and offer a safe forum for experimenting with new behaviors and roles. Brothers and sisters provide each other with tangible services (e.g., lending money, clothing, toys, or sports equipment; teaching a skill), help each other with childhood problems, provide support in dealing with parents or others outside the family, and provide introductions to new friendship groups. Children learn to negotiate and bargain, and sometimes to manipulate, from their siblings. Their interactions with each other provide opportunities for conflict and conflict resolution. They protect one another from parental-executive abuse of power and can form a coalition to deal with the issues of authority, power, and emotional support. Negotiating with parents is stronger when siblings act together rather than singly.
Tattling can be an important lever in sibling interactions. On the other hand, siblings often have a conspiracy of silence, leaving the parents feeling isolated and excluded. A willingness to maintain each other’s privacy often forges a powerful bond of loyalty that distinguishes the relationship between siblings from that between friends.

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