Joaquin Borrego, Jr., Tabitha Fleming, Elizabeth Ortiz‐Gonzalez, and Amber Morrow
Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
The health of a child can have a significant impact on the family. When a child has a medical illness (e.g., type 2 diabetes) or experiences a negative event (e.g., child maltreatment), the family, as well as other systems (e.g., communities), can be negatively impacted. The family is inevitably impacted whether it be an acute or chronic condition. This negative impact is especially significant for family members and others close to the child (e.g., friends, extended family members). Given this, it is imperative that inclusion of the family and other systems be taken into account when discussing children's health.
Some major public health concerns impacting children and families include, but not limited to, nutrition (an increase in obesity rates for both pediatric and adult populations, food insecurity for families living in poverty), chronic illness (e.g., asthma, cardiovascular disease, high blood pressure), pediatric and adult cancer, poor sleep hygiene, and child maltreatment (the child as victim and adult as the perpetrator). These, and other conditions, are very common in our society and are associated with additional health complications later in life.
A useful framework to help understand the complexity of child, family, and social relationships as they relate to health is the ecological framework. This conceptual framework is the work conducted by Urie Bronfenbrenner (1979) on the ecology of child development. Briefly, this conceptual model posits that the child and family operate in systems that are interrelated and reciprocal. Most immediate to the child is what is known as the microsystem. This system is the most immediate and includes those that are closely connected to the child such as siblings, parents, family, peers, and schools. Within this microsystem, there are subsystems that focus on relationships that the child has with peers, siblings, and the parents. The mesosystem involves the interactions and relationships that are developed between the different components of the microsystem. As examples, the mesosystem helps explain interactions and relationships formed between the family and the school, siblings and peers, etc. The exosystem involves the linkage between two settings that may directly or indirectly involve and impact the child. This can include extended family members, neighborhood, etc. The macrosystem is the most distant from the child but still has an influence on the child. Examples include social and cultural changes at a societal level that will inherently impact the child and family. A family's practices, values, beliefs, attitudes, and behaviors are shaped over time.
Bronfenbrenner's model has been applied to explain the complexities of the child and family within the context of health (Kazak, Alderfer, & Rader, 2017). The social ecology model helps identify the systems that are involved related to a child's health such as the family, hospitals, and school personnel (Kazak et al., 2017). As noted above, this is a useful conceptualization as it helps explain the intricate systems involved and the relationship between these systems. Examining these systems carefully can help identify contextual factors that may decrease the risk for continued health problems and increase resilience and adjustment for the child and family.
Children with medical illnesses can be very stressful for the family, especially siblings and parents or other caregivers. Illnesses in children can be stressful and even distressing for caregivers whether it be parents, guardians, or other caregivers such as a grandparent or close family friend (Cousino & Hazen, 2013). A child who is ill will miss school, and, depending on available family resources, some parents or guardians may need to miss work with or without pay. The literature from pediatric psychology suggests that a child with an illness can have a negative impact on siblings (Vermaes, van Susante, & van Bakel, 2012) and caregivers (Cousino & Hazen, 2013). There is also research to suggest that children with long, chronic illness experience difficulties across different domains in their life including academic and social problems (Pinquart & Teubert, 2012). In addition, children cannot manage their medical illness themselves, so they have to rely on family members for medical care. The level of parent or family involvement can range from being under‐involved in the management of the child's illness to over‐involvement such as overprotection of the child (Martire & Helgeson, 2017).
From an ecological framework, the child's negative health status has an impact within and across different systems. Within the family, a child's illness can impact his/her relationship with siblings and the parent–child relationship. These close family relationships have an impact on health (Chen, Brody, & Miller, 2017). In addition, the child's health status can also impact the relationship between parents or other caregivers. As noted above, a child with an illness can contribute to parenting stress, and, in turn, this can lead to discord in the marriage or the relationship. This discord can have a negative impact on relationship satisfaction. Parents and caregivers can become stressed and frustrated with the child or their partner in the relationship. A child missing significant amount of time from school or other events (e.g., sports‐related activities) can also have a negative impact on peer relationships.
Health disparities can be defined as quantifiable differences in incidence, prevalence, mortality, and health indicators in certain populations or groups (e.g., Latinos, African Americans; U.S. Surgeon General, 2001). Health disparities also include differences in access to healthcare in groups based on ethnicity/race, socioeconomic status (SES), and area of residence (Flores, 2010). This next section discusses factors that may contribute to health disparities.
Poverty can have a long‐term deleterious impact on a child's psychological, emotional, physical, and behavioral development (Bradley & Corwyn, 2002; Yoshikawa, Aber, & Beardsee, 2012). In addition, years of research have identified profound health disparities associated with poverty (Gallo & Matthews, 2003). Particularly, families with means may provide their children with access to health services, education, and social connections that might not be available or less available to lower SES families (Lescano & Rahill, 2017). Research shows that there is a relationship between SES (an exosystemic factor) and health as SES can impact health outcomes even before birth. Growing evidence suggests that children from low SES families are at risk of suffering from neurodevelopmental abnormalities in utero, premature birth, and low birth weight (Bradley & Corwyn, 2002).
Unfortunately, low SES families are less likely to consistently follow an immunization schedule and have adequate access to healthcare and proper nutrition (Bradley & Corwyn, 2002). Nutrition has been identified as an important link between SES and psychological and physical well‐being. Additionally, poor nutrition during childhood can negatively impact cognitive and behavioral development and contribute to an increase in morbidity in children. As previously mentioned, SES can contribute to biological and physiological changes in utero, during infancy, and during childhood. These disturbances create vulnerabilities that result in an overall decrease in health status and health problems that continue or manifest in adulthood. However, the degree of impact caused by low SES varies depending on how many years the child has spent in poverty and how young the child is when the family is living in poverty (Bradley & Corwyn).
Lower SES families often have limited access to medical care, which often translates into deficient prenatal care during pregnancy and inadequate preventive care during childhood. Children from low SES families often do not have adequate immunizations, may not receive appropriate medical care when experiencing acute or chronic diseases, or may only take their children to the doctor when the disease is at an advanced stage (Bradley & Corwyn, 2002). Many of these families do not have financial means to purchase insurances and tend to rely on emergency rooms more or might avoid visiting the doctor altogether.
A disproportionate amount of families living at or below national poverty levels in the United States are ethnic and racial minorities. According to 2016 data, 22% of Black/African Americans and 19.4% of Hispanics (all races) live in poverty (U.S. Census Bureau, 2017). In contrast, 10.1% of those who identify as Asian and 8.8% of individuals who identify as White, not Hispanic, live in poverty (U.S. Census Bureau, 2017). Social disparities, low educational attainment, low income, and deficient housing contribute to the inequalities experienced by ethnic minority families (Sanders‐Phillips, Settles‐Reaves, Walker, & Brownlow, 2009). Furthermore, even when adjusting for factors such as income and insurance coverage, ethnic minorities in the United States receive medical services that are of lower quality than European Americans (U.S. Surgeon General, 2001).
It is estimated that by 2020, ethnic minority children will outnumber European American children in the United States (U.S. Census Bureau, 2014). However, even when ethnic minority children are close to representing the numerical majority of the child population, profound disparities in access to healthcare remain. Research suggests that ethnic minorities are less likely to seek medical care (U.S. Surgeon General, 2001). This phenomenon can be explained by differences in beliefs and attitudes toward healthcare. Ethnic minority parents may not trust medical providers, and they may place a different emphasis on health. For example, Latino and African American parents often indicate that their doctors do not understand their children's needs (Flores, 2010). However, the intersectionality between ethnic minority status, low SES, and limited insurance coverage is a key factor that contributes to the underutilization of health services.
Racial disparities are evident when examining mortality rates in the United States. For example, childhood mortality rates tend to be significantly higher for African American children compared with European American children (Flores, 2010). African American children have the lowest immunization rates and present with high rates of obesity. The risk for obesity continues throughout adolescence, with African American female adolescents reporting a higher prevalence of obesity and needing but not getting medical care (Flores). Important disparities can be found in obesity rates, physical activity, and nutrition in Latino children as well. Research shows that Latino children have the highest rate of obesity when compared with other ethnic/racial groups (Flores).
Psychologists and medical professionals alike are recognizing the importance and influence that culture has on different aspects of an individuals' life. Culture can shape attitudes, behaviors, practices, and values, to name a few. Culture can also influence how health distress is expressed in families, how families adjust, and how family relationships can impact health (Campos & Kim, 2017; Clay, 2017). In addition, culture has an influence on how individuals view the concept of the family. As an example, for some, the concept of who family and who is a caregiver only involves immediate family members (e.g., parents and siblings), and for others, the concept of family or caregiver is not restricted to the immediate family. As an example, in African American culture, it may be that a long‐standing neighbor or friend is known as family and is not distinguished between other immediate family relatives. This is important to consider as it highlights the flexibility within which the different systems function for the child. From a cultural lens perspective, these systems are best conceptualized as flexible in parameters from one family to another.
Research suggests that lack of health insurance is a barrier to accessing quality healthcare (U.S. Surgeon General, 2001). This is particularly relevant for ethnic minority populations as being uninsured is a barrier for Latinos and African Americans attempting to access quality healthcare. For example, African American families are more likely to be uninsured and/or sporadically insured. Uninsured families typically experience delays and problems in accessing healthcare. Latino and African American children have an increased likelihood of not having access to a usual source of care or primary care physician (Flores, 2010). Moreover, Latino and African American children are less likely to be referred to see a medical specialist. Research indicates that higher hospitalization rates for ambulatory care and emergency department visits for African American children and African American and Latino children have a higher rate of avoidable hospital admissions (Flores). Overall, African American and Latino children experience disparities in the use of healthcare including less visits to the doctor (spending a year or more since the last physician visit) and less calls to the doctor's office.
Other disparities in access that warrant attention include difficulties in communication. Research shows that Latino families are more likely to report difficulties with doctor–patient communication with their provider (Flores, 2010). This may be due to a language barrier between the family being more proficient and comfortable speaking Spanish and medical personnel not being proficient in Spanish. Children of Spanish‐speaking parents are often placed in a position to interpret for their parents or provide their own information. Developmentally, depending on the child's age, the child may not be able to provide accurate information, may be embarrassed to convey personal information, or may provide distorted information to medical personnel. This can also be the case for any family whose preferred language is not English.
Some ethnic minority children are exposed from a young age to prejudicial attitudes and racial discrimination, and contact with discrimination may contribute to feelings of hopelessness and lead to a poor self‐concept (Sanders‐Phillips et al., 2009). Moreover, an awareness of minority status, which is typically achieved in adolescence, might lead to an internalized devalued group membership and identity. Adversity and negative social experiences experienced by ethnic minority children may have a long‐standing effect in physiological functioning. Moreover, research shows that chronic exposure to racial discrimination correlates with biological and psychological changes that may persist and might impact health outcomes in childhood. Fortunately, the family and other systems such as churches and schools are in a position to help children cope with prejudice and racism through teaching cultural pride and racial socialization. Research suggests that having a sense of ethnic/racial identity may reduce the risk against developing of internalizing behavior problems (Smith & Trimble, 2016).
As with protective and risk factors associated with psychological disorders, a host of these factors are also correlated with medical disorders and negative health‐related outcomes (Mash & Barkley, 2014). A risk factor can be defined as “a characteristic at the biological, psychological, family, community, or cultural level that precedes and is associated with a higher likelihood of problem outcomes,” while a protective factor can be defined as “a characteristic at the biological, psychological, family, or community (including peers and culture) level that is associated with a lower likelihood of problem outcomes or that reduces the negative impact of a risk factor on problem outcomes” (National Research Council and Institute of Medicine, 2009, pp. xxvii–xxviii). Across the lifespan, protective and risk factors tend to vary according to developmental stage beginning in early childhood all the way through middle childhood, adolescence, and adulthood. However, some protective or risk factors are present in several stages over the course of development. These factors play different roles in shaping a child, and, in turn the family, thus it is important to be cognizant of each and their role in the child's health as well as in the outcomes associated.
In early childhood, secure attachment is crucial for healthy development that has implications later in life for emotion regulation, family relationships, and prosocial behavior (National Research Council and Institute of Medicine, 2009). Through building a foundation of consistent and positive and parent–child interactions, a secure relationship can be formed and solidified early, promoting healthy child development. A positive home environment can also contribute to development of executive functioning skills (e.g., problem‐solving skills, language acquisition), encourage early childhood and lifelong positive psychological, emotional, and behavioral health (National Research Council and Institute of Medicine, 2009).
In middle childhood, it is increasingly important for children to successfully achieve appropriate developmental milestones such as academic achievement, following rules for appropriate behavior and positive peer relations. As noted earlier, academic and social problems can develop for children with chronic illnesses. A child's ability to master academic skills, along with making friends with peers, can contribute to protecting against poor health or overall negative outcomes. Additionally, the concept of resilience is a key component eliciting positive developmental outcomes in this stage of development (National Research Council and Institute of Medicine, 2009). The resilient ability to persevere despite adversity protects children in middle childhood from potentially problematic outcomes.
In adolescence, essential protective factors leading to positive development and child health include engagement in positive physical health habits, intellectual development, physiological and emotional development, and social development (National Research Council and Institute of Medicine, 2009). On an individualized level, adolescents who exhibit high sense of self‐worth, emotional regulation, and good coping and problem‐solving skills are more equip to avoid or minimize the impact of negative outcomes (National Research Council and Institute of Medicine, 2009). From a family and school perspective, protective factors in adolescence also include receiving extended family support and engaging in positive peer relationships. Further, different systems can each play a role in helping reduce health‐compromising behaviors and increasing health‐promoting behaviors in youth (Wilson, Coulon, & Huffman, 2017).
These protective factors associated with outcomes of children across the development are important to consider in contrast with the risk factors also associated. Across the lifespan, there are many risk factors associated with negative health outcomes that can be detrimental regardless of developmental stage. Such risk factors including child maltreatment, family dysfunction (e.g., poor family communication, avoidance of negative emotions) community and school risk factors (e.g., violence), and poverty can contribute to a host of problematic outcomes in children of all ages (National Research Council and Institute of Medicine, 2009).
Further, family dysfunction and disruption including divorce, a poor parent–child relationship, insecure attachment, and parental psychopathology can also elevate risk for negative outcomes in children across all developmental stages (National Research Council and Institute of Medicine, 2009). Additionally, community and school risk factors including victimization, bullying, academic failure, and association with deviant peers contribute to potential negative health outcomes in children (National Research Council and Institute of Medicine, 2009).
The health of the child and family has such an important and profound impact on each other. This reciprocal system, in turn, impacts other systems in the child's life such as development of peer relationships and academic performance in schools. We have a sufficient scientific knowledge base regarding prevention and early intervention programs that can assist in raising children with prosocial skills and having close family relationships (Biglan, 2015). In addition, we can now point to numerous social determinants of health that can have a negative impact on the child and family (Black, 2017). Having close family relationships can ameliorate some of the negative impact that acute and chronic medical conditions can have on the child, family, and other systems such as peers, schools, and communities. Practitioners and researchers alike are encouraged to closely examine the quality of the parent–child relationship as well as the quality of the sibling relationship and the caregiver's relationship. In addition to examining family cohesion, the degree to which the child and family have a positive and supportive social network should be taken into account. This can include the child's peer relationships and the family's network extended family members and friends through work, the child's school, and the community. At a broader level, schools and the healthcare system need to be examined in the context of child and family health.
Joaquin Borrego, Jr., PhD, is an associate professor in the Department of Psychological Sciences at Texas Tech University. He is a member of the clinical psychology doctoral program and directs the Parent‐Child Interaction Therapy (PCIT) research lab. His research interests include parent–child relationships, discipline practices, culture, and prevention and early intervention of child physical abuse. He moved to Department of Psychology, Pacific University, Forest Grove, Oregon, USA, in summer 2018, after this chapter was initially written.
Tabitha Fleming, MA, is a doctoral student in the Texas Tech University Clinical Psychology doctoral program and a member of the Parent‐Child Interaction Therapy (PCIT) research lab. Her research interests include parent management, parental discipline practices, and prevention of child maltreatment.
Elizabeth Ortiz‐Gonzalez, MA, is a doctoral student in the Texas Tech University Clinical Psychology doctoral program and a member of the Parent‐Child Interaction Therapy (PCIT) research lab. Her research interests include parenting practices with ethnic minority families, particularly Latino families.
Amber Morrow, BA, is a doctoral student in the Texas Tech University Clinical Psychology doctoral program and a member of the Parent‐Child Interaction Therapy (PCIT) research lab. Her research interests include discipline practices and the prevention of the use of physical punishment and child maltreatment.