Clinical problems and counseling for single-parent families

Clinical problems and counseling for single-parent families

John R. Meurer

The shift from the traditional nuclear family (a mother, a father and their children) to diverse family forms has been dramatic in the United States. Currently, only 50 percent of children will reside with their biologic parents until their 18th birthday; therefore, many of the children seen by family physicians live in non-nuclear families. Family physicians should be aware of the unique problems faced by children and adults in these families and realize that their knowledge of family dynamics can be applied to these “new” families.[1]

Since 1970, the percentage of children living with single parents has more than doubled, from 12 to 27 percent, because of increases in the divorce rate and the number of unmarried parents. Single-parent families now include more than 18 million children and comprise the most common non-nuclear form of family. Black and Hispanic children are more likely than white children to live with one parent, and approximately two-thirds of black and Hispanic children who live with a single mother live below the poverty level.[2]

This essay discusses the typical problems and recommended management of two of the most common forms of single parent families: divorced parents and unmarried adolescent mothers.

Divorced Parents

Marital conflict and divorce are prevalent in our society, and patients frequently ask family physicians to assist them with marital difficulties. These problems often bring stress to the family and increased episodes of illness. For physicians who do not provide marriage counseling, an understanding of the basic techniques can be useful in referring couples for marital therapy.[3]

Women who divorce during middle age face age-specific stresses, including loss of long-held social position, the possibility of overdependence on young adult children, a shrinking remarriage pool, socially denigrated body changes and unfair labor market conditions.[4] In assisting these women, family physicians need to focus initially on the patient’s grief and mourning, and then emphasize behavior modification and improved coping skills, which may be accomplished with the aid of a therapist.

Events that accompany marital dissolution have been identified as correlates of adjustment in children.[5] Conflict between the parents after divorce, manifested as verbal and physical aggression, overt hostility and distrust, and the custodial parent’s emotional distress are jointly predictive of more problematic parent-child relationships and a greater need for emotional and behavioral adjustment in the child. As a group, children (especially boys) of parents going through a high-conflict divorce are two to four times more likely to have clinical emotional and behavioral disturbances, compared with national norms. Court-ordered joint physical custody and a frequent visitation arrangement in highconflict divorce tend to be associated with poorer outcomes in children, especially girls.[6]

Thus, a child’s ultimate adjustment to divorce depends on several factors, including (1) the level of interparental conflict that precedes and follows divorce, (2) the number of stressful life events that accompany and follow divorce, (3) the custodial parent’s psychologic adjustment and parenting skills, (4) the amount and quality of contact with the noncustodial parent and (5) the degree of economic hardship to which children are exposed. These factors can be used as guides to assess the probable impact of various legal and therapeutic interventions to improve the well-being of children with divorced parents.[7]

Following a divorce, children may experience sadness and depression, aggressive behavior, frequent illnesses, abdominal pain, headaches, difficulty in school, eating problems and sleeping disturbances. Children who experience parental divorce, compared with children in intact two-parent families, exhibit more conduct problems, more symptoms of psychologic maladjustment, lower academic achievement, more social difficulties and poorer self-concept. Similarly, adults who experienced parental divorce as children, compared with adults raised in continuously intact two-parent families, score lower on a variety of indicators of psychologic, interpersonal and socioeconomic well-being. However, the overall differences between offspring from divorced and intact families are small, with considerable diversity existing in children’s reactions to divorce.[7]

Knowledge about parental discord or divorce may initiate a clinical protocol to assess (1) the parents’ level of hostility, (2) indications of parental depression or other serious psychiatric disorder, (3) the child’s acute reaction, (4) the parents’ capacity to meet the child’s physical and emotional needs, (5) the visitation arrangements and the effect on the child of the continuing relationship with each parent and (6) periodic assessment of the child’s adjustment and psychosocial function among peers and in school.[8] Family physicians might counsel divorced parents to talk with their children honestly, repeatedly inquiring about their feelings and fears and constantly ensuring that the children know that they are not responsible for the separation.

Unmarried Adolescent Mothers

Each year, approximately 1 million adolescents become pregnant in the United States, and nearly half of them give birth and become parents.[9,10] Risk factors predictive of early sexual activity and subsequent pregnancy include poverty, poor academic ability and achievement, and a lack of educational goals.[11] The persistence of poverty, joblessness and lack of hope for the future are recurring themes in adolescent pregnancy, and these factors are increasingly being experienced by adolescents of all racial and ethnic backgrounds.[12]

Family physicians can help reverse the trend of increasing teenage pregnancy through patient education and identification of teenagers at high risk for early sexual activity. Contraceptive counseling for adolescents who are already sexually active and unwilling to abstain is essential.[13] Family physicians can also influence school and community leaders to ensure that all adolescents receive sound sex education in school programs and that family planning agencies are permitted to counsel teenagers and provide contraceptives.[14]

Pregnancy produces many adverse consequences for the adolescent female and her partner, for the children born to teenagers and for society as a whole. Pregnant adolescents are at greater risk than older mothers for nutritional deficiencies, anemia, pre-eclampsia and cephalopelvic disproportion, due partly to inadequate prenatal care. In addition, pregnancy increases the teenager’s risk of dropping out of school, leading to fewer career opportunities, chronic unemployment and societal dependence. Infants born to adolescents are at high risk for premature birth, low birth weight and infant death. They experience more illnesses, have more cognitive delays and perform less well in school than children with more mature parents. The children of adolescent parents are at risk themselves for early sexual activity and teenage pregnancy, thereby perpetuating the cycle.[9,10]

Family physicians can be an important source of help to adolescents by discussing the scope and consequences of pregnancy. Such care begins with effective communication, using strategies aimed at building rapport, assuring confidentiality, avoiding judgmental stances and tailoring information to cognitive maturity. The physician should facilitate balanced decision making regarding pregnancy resolution options, including abortion, adoption and childrearing. The family physician must discuss topics related to injury prevention, the use of prenatal care and the formulation of long-term plans. Methods for exploring family relationships are also helpful, because these ties are key influences on subsequent decisions and behaviors. Physicians who can effectively address these topics can help teenagers make informed decisions and improve their prospects for the future.[15]

Family physicians should also become familiar with community resources for pregnant adolescents. Comprehensive prenatal and parenting programs that focus specifically on the health, educational and social needs of this vulnerable group may alleviate some of the negative consequences of adolescent pregnancy, improve pregnancy outcomes and help the teenager achieve self-sufficiency.[16]

The components of effective programs for pregnant teenagers include:

* Case management and coordination of resources (e.g., outreach, counseling, assistance and follow-up).

* Decision counseling about pregnancy resolution options, with appropriate referral for abortion or adoption.

* Prenatal care, with services geared toward high-risk adolescents and educational programs in nutrition, health, labor and delivery.

* Social support and continuity of medical care.

* Education in parenting skills and child development.

* Enhancement of career options through continued education and training.

* Prevention of subsequent unintended pregnancy.[17]

Finally, when caring for an adolescent who has children, ongoing support and advice on parenting skills are needed in the context of the family structure. Many children of adolescent mothers live in multigenerational families with a grandmother serving as the primary childrearer. One study found that in poor black families with very young mothers, grandmothers who lived in the home with the young mother demonstrated a higher quality of parenting than did grandmothers who did not reside in the home. However, older teenage mothers were more likely to provide positive parenting when they did not reside with the grandmother.[18] In another study, grandmothers rearing the children of drug-addicted parents found parenting their grandchildren an emotionally rewarding experience, but also incurred psychologic, physical and economic problems in performing their roles.[19] Family physicians must be aware that these grandparents may downplay their own health problems and symptoms.[20]

In summary, whether caring for divorced parents or an unmarried adolescent mother, advice from the family physician may help these patients to better cope with single parenthood.

The authors thank Vickie Beson for help in the preparation of the manuscript.


[1.] Doherty WJ, Baird MA. Family therapy and family medicine: toward the primary care of families. New York: Guilford, 1983. [2.] Child Health USA ’94. Washington, D.C.: Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Maternal and Child Health Bureau, 1995:13;DHHS publication no. HRSA-MCH-95-1. [3.] Starling BP, Martin AC. Improving marital relationships: strategies for the family physician. J Am Board Fam Pract 1992;5:511-6. [4.] Bogolub EB. Women and mid-life divorce: some practice issues. Soc Work 1991;36:428-33. [5.] Shaw DS. The effects of divorce on children’s adjustment. Review and implications. Behav Modif 1991;15:456-85 [6.] Johnston JR. High-conflict divorce. Future Child 1994;4:165-82. [7.] Amato PR. Life-span adjustment of children to their parents’ divorce. Future Child 1994;4:143-64. [8.] Committee on Psychosocial Aspects of Child and Family Health of the American Academy of Pediatrics. Pediatrician’s role in helping children and families deal with separation and divorce. Pediatrics 1994;94:119-21. [9.] Adolescent health: Background and effectiveness of selected prevention and treatment services. Washington D.C.: U.S. Government Printing Office, 1991. [10.] Hayes CD. Risking the future: adolescent sexuality, pregnancy and childbearing. Washington D.C.: National Academy Press, 1987. [11.] Santelli JS, Beilenson R Risk factors for adolescent sexual behavior, fertility, and sexually transmitted diseases. J Sch Health 1992;62:271-9. [12.] Desmond AM. Adolescent pregnancy in the United States: not a minority issue. Health Care Women Int 1994;15:325-31. [13.] Ringdahl EN. The role of the family physician in preventing teenage pregnancy. Am Fam Physician 1992;45:2215-20. [14.] Fielding JE, Williams CA. Adolescent pregnancy in the United States: a review and recommendations for clinicians and research needs. Am J Prev Med 1991;7:47-52. [15.] Bluestein D, Starling ME. Helping pregnant teenagers. West J Med 1994;161:140-3. [16.] Nord CW, Moore KA, Morrison DR, Brown B Myers DE. Consequences of teenage parenting. J Sch Health 1992;62:310-8. [17.] Stevens-Simon C, Beach RK. School-based prenatal and postpartum care: strategies for meeting the medical and educational needs of pregnant and parenting students. J Sch Health 1992;62:304-9. [18.] Chase-Lansdale PL, Brooks-Gunn J, Zamsky ES. Young African-American multigenerational families in poverty: quality of mothering and grandmothering. Child Dev 1994;65(2):373-93. [19.] Burton LM. Black grandparents rearing children of drug-addicted parents: stressors, outcomes, and social service needs. Gerontologist 1992; 32:744-51. [20.] Minkler M, Roe KM, Price M. The physical and emotional health of grandmothers raising children in the crack cocaine epidemic. Gerontologist 1992;32:752-61.

Dr. John Meurer is a pediatrician and is assistant professor in pediatrics and health policy at the Medical College of Wisconsin. Dr. Linda Meurer, a family physician, is assistant professor of family and community medicine at the Medical College of Wisconsin. Dr. Holloway is professor and vice chairman of family and community medicine and chief of the Division of Academic Programs at the Medical College of Wisconsin. He is a marriage and family therapist.

COPYRIGHT 1996 American Academy of Family Physicians

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