Family Influences on Child Health Promotion

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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).

Considerable controversy has surrounded the newer concepts of family, such as communal families, single-parent families, and homosexual families. To accommodate these and other varieties of family styles, the descriptive term household is frequently used.

Nursing Alert

The nurse’s knowledge and the sensitivity with which he or she assesses a household will determine the types of interventions that are appropriate to support family members.

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 pathology Useful 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 adaptation Focuses on positive contribution of resources, coping, and social support to adaptive outcomes Can be used by many disciplines in the health field	Relationships among all variables in the framework not yet adequately described Not 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 family Addresses both changes within the family and changes in the family as a social system over its life history Anticipates 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 children Use 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 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.

The family is viewed as a whole that is different from the sum of the individual members. For example, a household of parents and one child consists of not only three individuals but also four interactive units. These units include three dyads (the marital relationship, the mother–child relationship, and the father–child relationship) and a triangle (the mother–father–child relationship). In this ecologic model, the family system functions within a larger system, with the family dyads in the center of a circle surrounded by the extended family, the subculture, and the culture, with the larger society at the periphery.

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).

Families have varying degrees of openness and closure in these boundaries. For example, whereas one family has the capacity to reach out for help, another considers help threatening. Knowledge of boundaries is critical when teaching or counseling families. Families with open boundaries may demonstrate a greater receptivity to interventions, but families demonstrating closed boundaries often require increased sensitivity and skill on the part of the nurse to gain their trust and acceptance. The nurse who uses family systems theory should assess the family’s ability to accept new ideas, information, resources, and opportunities and to plan strategies.

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.

Box 3-1

Duvall’s Developmental Stages of the Family

Stage I—Marriage and an Independent Home: The Joining of Families

Reestablish couple identity.

Realign relationships with extended family.

Make decisions regarding parenthood.

Stage II—Families with Infants

Integrate infants into the family unit.

Accommodate to new parenting and grandparenting roles.

Maintain the marital bond.

Stage III—Families with Preschoolers

Socialize children.

Parents and children adjust to separation.

Stage IV—Families with Schoolchildren

Children develop peer relationships.

Parents adjust to their children’s peer and school influences.

Stage V—Families with Teenagers

Adolescents develop increasing autonomy.

Parents refocus on midlife marital and career issues.

Parents begin a shift toward concern for the older generation.

Stage VI—Families as Launching Centers

Parents and young adults establish independent identities.

Parents renegotiate marital relationship.

Stage VII—Middle-Aged Families

Reinvest in couple identity with concurrent development of independent interests.

Realign relationships to include in-laws and grandchildren.

Deal with disabilities and the death of the older generation.

Stage VIII—Aging Families

Shift from a work role to leisure and semiretirement or full retirement.

Maintain couple and individual functioning while adapting to the aging process.

Prepare for own death and dealing with the loss of spouse, or siblings, and other peers.

Modified from Wright LM, Leahey M: Nurses and families: a guide to family assessment and intervention, Philadelphia, 1984, FA Davis.

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

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.*

FIG 3-1 Children benefit from interaction with grandparents, who sometimes assume the parenting role.

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.

When children are brought up in GLBT families, the relationships seem as natural to them as heterosexual parents do to their offspring. In other cases, however, disclosure of parental homosexuality (“coming out”) to children can be a concern for families. A number of factors must be considered before disclosing this information to children. Parents should be comfortable with their own sexual orientation and should discuss it with their children as they become old enough to understand relationships. Discussions should be planned and take place in a quiet setting where interruptions are unlikely.

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.

Case Study—Family Functioning

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.

Box 3-3

Qualities of Strong Families

• A belief and sense of commitment toward promoting the well-being and growth of individual family members, as well as the family unit

• Appreciation for the small and large things that individual family members do well and encouragement to do better

• Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event

• A sense of purpose that permeates the reasons and basis for “going on” in both bad and good times

• A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs

• The ability to communicate with one another in a way that emphasizes positive interactions

• A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior

• A varied repertoire of coping strategies that promotes positive functioning in dealing with both normative and nonnormative life events

• The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources

• The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and problems as an opportunity to learn and grow

• Flexibility and adaptability in the roles necessary to procure resources to meet needs

• A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future

From Dunst C, Trivette C, Deal A: Enabling and empowering families: principles and guidelines for practice, Cambridge, Mass, 1988, Brookline Books.

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.