|
Research - Divorce - Family breakdown harms children
Filed at 8:11 a.m. ET
LONDON (AP) -- Children growing up in single-parent
families are twice as likely as their counterparts to develop
serious psychiatric illnesses and addictions later in life,
according to an important new study.
Researchers have for years debated whether children
from broken homes bounce back or whether they are more likely
than kids whose parents stay together to develop serious emotional
problems.
Experts say the latest study, published this
week in The Lancet medical journal, is important mainly because
of its unprecedented scale and follow-up -- it tracked about
1 million children for a decade, into their mid-20s.
The question of why and how those children end
up with such problems remains unanswered. The study suggests
that financial hardship may play a role, but other experts
say the research also supports the view that quality of parenting
could be a factor.
The study used the Swedish national registries,
which cover almost the entire population and contain extensive
socio-economic and health information. Children were considered
to be living in a single-parent household if they were living
with the same single adult in both the 1985 and 1990 housing
census. That could have been the result of divorce, separation,
death of a parent, out of wedlock birth, guardianship or other
reasons.
About 60,000 were living with their mother and
about 5,500 with their father. There were 921,257 living with
both parents. The children were aged between 6 and 18 at the
start of the study, with half already in their teens.
The scientists found that children with single
parents were twice as likely as the others to develop a psychiatric
illness such as severe depression or schizophrenia, to kill
themselves or attempt suicide, and to develop an alcohol-related
disease.
Girls were three times more likely to become
drug addicts if they lived with a sole parent, and boys were
four times more likely.
The researchers concluded that financial hardship,
which they defined as renting rather than owning a home and
as being on welfare, made a big difference.
However, other experts questioned the financial
influence, saying Swedish single mothers are not poor when
compared with those in other countries, and suggested that
quality of parenting could also be a factor.
``It makes you think that what you're seeing
is just the most dysfunctional families having these problems,
rather than the low income. The money is really an indicator
of something else,'' said Sara McLanahan, a professor of sociology
and public affairs at Princeton University, who was not involved
in the study.
``If you really thought that it was the income
that makes the difference, you would think that Swedish lone
mothers would do a lot better than the British or those in
the U.S., but they look very similar,'' she said.
Other experts agreed.
In the last 20 to 30 years, poverty has been
greatly reduced everywhere in Europe, but psychiatric problems
in children have not, said Dr. Stephen Scott, a child health
and behavior researcher at the Institute of Psychiatry in
London, who also was not involved in the study.
He said that in previous studies, once researchers
have adjusted their results to eliminate the influence of
bad parenting, any increased risk of emotional problems shrinks
markedly. This, he said, indicates it is not so much single
parenthood but the quality of parenting that is at issue.
``The kind of people who end up as single parents
might not have done well by their kids, even if they hadn't
ended up alone. They tend to be more critical in their relationships,
more derogatory toward other people,'' Scott said, adding
that it is also harder to be a warm, non-critical parent when
you're bringing up a child alone.
However, he noted that there are plenty of children
from single-parent families who don't end up with serious
emotional problems.
There may also be a genetic element: More irritable
people are more likely to become separated, but they are also
more likely, whether they are separated or not, to have more
irritable children, Scott said.
``The whole field is highly debated. This is
another piece in that debate that makes several important
points -- firstly that there really is an increased risk in
young adulthood of pretty bad things. It also indicates it's
not all about the money, but may be about the people themselves,''
McLanahan said.
--------
On the Net:
The Lancet, http://www.thelancet.com
Conclusion
Our findings in almost a million children and
adolescents showed increased risks of psychiatric disease,
suicide or suicide attempt, injury and addiction in children
in single-parent households compared with those in two-parent
households. Boys in single-parent families had higher risks
than girls for psychiatric disease and drug-related disease,
and they also had a raised risk of all-cause mortality.
Investigators from early child-psychiatric studies
focused mainly on the process of divorce, suggested that the
effect of divorce on children could be understood in terms
of a crisis model, in which short-term effects related to
transition were common, but long-lasting effects were rare.
Long-term effects were usually dependent on other stress factors.13
Our findings, however, are consistent with those of more recent
studies,5,14-16 in which divorce and living in a single-parent
household were shown to have long-term effects.
Much of the raised risks recorded in children
living with only one parent in our analyses can be accounted
for by differences in socioeconomic circumstances, a finding
much the same as those in previous studies.1,5,14,25-26 Parental
economic distress, in general followed by inconsistent parental
discipline, was associated with behavioural problems such
as delinquency and drug misuse among children.27 Lipman28
used the same method in her analysis of Canadian data--ie,
regression analysis with adjustments for other factors that
could contribute to child outcome--and found that inclusion
of sociodemographic variables such as household income, lessened
the increase in risk. In our study, the main explanation for
the increase in risk was lack of household resources, as indicated
by receipt of social-welfare benefit and housing situation.
These factors seemed to serve as intermediate paths through
which single parenthood affects children's health and wellbeing.
Somewhat smaller contributions were made by the factors we
assumed to occur before the existing family situation (parental
age, socioeconomic group, residence, country of birth, addiction
and mental illness in parents). Of these factors, socioeconomic
group played the biggest part, while a very small part of
the raised risk can be accounted for by addiction and mental
illness, both of which were more frequent in single parents
than in those with a partner. Such factors have an important
effect on interaction patterns between parents and children,
and there could also be a genetic component involved.
Significant risk increases remained unaccounted
for even in our fully adjusted model. Factors such as parental
absence, lack of social support, and family conflict could
have been important in accounting for these increases. In
one-parent households the adult takes on many different roles,
including that of being the only breadwinner, which constrains
attention, help, and supervision of the child. The loss of
one parent as a role model in the home could also be important,
especially for boys who grow up with a single mother.29,30
Our results do not, however, lend support to the view that
the sex of the custodial parent or child affects the difference
in risk. The sons of single parents had worse outcomes than
girls only in psychiatric and drug-related disease.
When divorce is the cause of the family breakdown,
this process is usually preceded by family conflict, which
in many cases continues well beyond actual separation. Hostility
between the parents creates an aversive home environment in
which children become stressed, unhappy, and insecure. The
results of several studies1,7,24 have suggested that children
are better off in a single-parent family with a low level
of conflict than in an intact family with a high level of
conflict.
The main strengths of this register-based study
lie in its coverage of the whole population of a country and
the potential such analysis offers to adopt a longitudinal
approach with a low dropout rate. Use of deaths and hospital-discharge
records means that our health measure is not biased by self-reporting,
and can be expected to cover most serious morbidity outcomes.
However, a diagnosis on a hospital record does not include
any information about severity of disease or injury. If children
of single parents are more likely to be admitted for less
serious conditions, their relative risks will be overestimated.
Such an effect is possible, since the decision to admit a
child could be affected by the doctor's judgment of the parent
or parents' capability of taking care of their child at home.
Single parents could be more inclined to seek hospital care.
Analyses from the UK31 showed higher rates of consultations
of general practitioners for children in households with one
adult, which could reflect the insecurity of a single adult
with no opportunity to share responsibility for a sick child.
Whether such effects are applicable to the outcomes of our
study is questionable, with the exception of falls and cases
of poisoning. However, the risk of death from fall or poisoning
was, at least for boys, higher than that of being admitted
for the same reason.
In the registers we used, any child in a single-parent
household was recorded as living with just one parent, usually
the mother. We could not distinguish shared custody from other
forms of arrangements, despite the fact that shared custody
has become more frequent. To have knowledge about the non-custodial
parent's living-conditions would have been valuable, especially
for psychiatric illness and substance misuse. However, the
census gives information only about adults in the household
in which the child is registered. Psychiatric disease and
addiction in the parents of children in single-parent familes
is probably underestimated, and consequently, adjustments
for such factors cannot attenuate the risk increases in an
optimum way.
Another weakness is a lack of information about
when in childhood an eventual parental divorce took place,
which made it impossible to assess risks in relation to length
of time since parental separation. We defined long-term exposure
as having been living with the same single parent or the same
two parents for at least 5 years; however, we do not know
if the situation applies continuously over the whole period.
The personal financial disadvantages of being
a single parent vary greatly between different societies in
developed countries, with social policy an important determinant.32,33
From an international perspective, the socioeconomic situation
of a single parent in Sweden is quite favourable, mainly because
of the opportunities available for state-subsidised day-care
and financial support. In a comparison of self-perceived health
between single mothers and mothers with partners in Britain
and Sweden, the increased relative risk for single mothers
was the same in both countries, despite a more favourable
social policy in Sweden.32 However, different mechanisms seem
to be at work in the two countries. One hypothesis is that
single mothers in Sweden are affected more by less time than
by less money.32 Swedish family and employment policies do
not distinguish between single parents and working parents,
and do not recognise the special needs of the single parents
as the only family breadwinners and carer. If everyday life
is characterised by psychosocial stress and loss of control,
this surely will have an injurious effect on children's wellbeing.
Improving prerequisites for combining being a single parent
with working life is a challenging task.
Accordingly, preventive efforts aimed at the
risk behaviours of children and young people would be especially
desirable. Family circumstances can be improved in various
ways, so that children gain access to environments outside
the family--through social-policy measures, maternal and child
health care, and preschool, school, and leisure programmes.
Mortality, severe morbidity, and injury in children
living with single parents in Sweden: a population-based study
Gunilla Ringbäck Weitoft, Anders Hjern,
Bengt Haglund, Måns Rosén
http://www.thelancet.com/journal/journal.isa
--------------------------------------------------------------------------------
Centre for Epidemiology, National Board of Health
and Welfare, Stockholm, Sweden (G R Weitoft BA, A Hjern MD,
B Haglund DMSc, M Rosén PhD); Department of Public
Health and Clinical Medicine, Umeå University, Sweden
(G R Weitoft, M Rosén); Department of Clinical Sciences,
Huddinge University Hospital, Karolinska Institutet, Sweden
(A Hjern)
--------------------------------------------------------------------------------
Summary
Background Growing up with one parent has become
increasingly common, and seems to entail disadvantages in
terms of socioeconomic circumstances and health. We aimed
to investigate differences in mortality, severe morbidity,
and injury between children living in households with one
adult and those living in households with two adults.
Methods In this population-based study, we assessed
overall and cause-specific mortality between 1991 and 1998
and risk of admission between 1991 and 1999 for 65 085 children
with single parents and 921 257 children with two parents.
We estimated relative risks by Poisson regression, adjusted
for factors that might be presumed to select people into single
parenthood, and for other factors, mainly resulting from single
parenthood, that might have affected the relation between
type of parenting and risk.
Findings Children with single parents showed
increased risks of psychiatric disease, suicide or suicide
attempt, injury, and addiction. After adjustment for confounding
factors, such as socioeconomic status and parents' addiction
or mental disease, children in single-parent households had
increased risks compared with those in two-parent households
for psychiatric disease in childhood (relative risk for girls
2·1 [95% CI 1·9-2·3] and boys 2·5
[2·3-2·8]), suicide attempt (girls 2·0
[1·9-2·2], boys 2·3 [2·1-2·6]),
alcohol-related disease (girls 2·4 [2·2-2·7],
boys 2·2 [2·0-2·4]), and narcotics-related
disease (girls 3·2 [2·7-3·7], boys 4·0
[3·5-4·5]). Boys in single-parent families were
more likely to develop psychiatric disease and narcotics-related
disease than were girls, and they also had a raised risk of
all-cause mortality.
Conclusions Growing up in a single-parent family
has disadvantages to the health of the child. Lack of household
resources plays a major part in increased risks. However,
even when a wide range of demographic and socioeconomic circumstances
are included in multivariate models, children of single parents
still have increased risks of mortality, severe morbidity,
and injury.
Lancet 2003; 361: 289-95
See Commentary
Introduction
Children do not themselves choose the circumstances
of their childhood and adolescence, and childhood family background
still seems to be an important predictor of a person's life-chances
as an adult.1-5 In the second half of the 20th century, growing
up with one parent is increasingly common for children in
developed countries. In 1999, a quarter of all Swedish 17-year-olds
had experienced their parents' separation.6 Several investigators7
have assessed the implications of parental divorce and single
parenthood on children's educational achievement, conduct,
psychological adjustment, social competence, and health.7
Despite these contributions, conclusions about the health
and wellbeing of the child have been controversial. Findings
generally suggest that divorce, which is the main cause of
family breakdown, has adverse consequences in the short term.8-10
However, Edwards11 suggested that most children recover from
divorce with few long-term consequences, whereas Krantz12
and Wallerstein13 concluded that children whose parents have
divorced are at increased risk of inadequate psychological
adjustment.
In a large meta-analysis,7 parental divorce
had little effect on the wellbeing of the children. But the
authors concluded that researchers in general are looking
for effects in the wrong place--ie, short-term emotional and
social problems could be less serious than long-term consequences
in terms of adult attainment and quality of life. In Sweden
and Finland, the breaking-up of a family and a single-parent
background had negative effects on mental and general health
of the children, and was associated with deaths in young adults.1,14-16
Previous research has usually been based on
small samples, and has mainly considered conditions reported
by parents or teachers, or by children or adolescents themselves.
We postulated that the generally poorer household resources
of single parents affect their children's health.
Materials and methods
Participants
We used Swedish national registers, which contain
information about many aspects of individuals in a population,
to assess the effects of single parenthood on health problems
and psychosocial disturbances in Swedish children, adolescents,
and young adults. Every Swedish resident is allocated a unique
personal identification number, so we could link individuals'
data between different data sources.
We identified children in Sweden living in households
with the same single adult (parent or guardian) in both 1985
and 1990, and children who were living with the same two adults
of different sex at these times from Swedish Population and
Housing censuses. Children were categorised irrespective of
whether their parent or guardian were biological parents.
A household was defined as a person or group of people registered
in the same dwelling, which made it possible to link different
members of any household. The woman had to be aged 18-49 years
and the men 18-59 years at the time of the child's birth.
Children were aged 6-18 years at the start of follow-up (in
1991); by the end of 1999, the youngest child was 14 years
old and the oldest 26 years old (birth cohort 1973-1985).
We excluded 169 613 (15%) of the 986 342 children identified
because they did not meet our criteria for the family situation.
Procedures
Since our main aim was to assess the net effects
of single parenthood and to increase understanding of the
possible mechanisms through which parenting status and health
are related, we obtained relevant information from several
data sources. From the census of 1990, we obtained information
about the age of child and parents (at delivery of the child),
and various parental characteristics (such as country of birth,
socioeconomic group affiliation, housing situation, residency,
number of children aged 17 years or younger living in the
household). Socioeconomic groups were classified in accordance
with a classification mainly based on occupation, but also
takes into account position at work and industrial sector.
For households with two adults, we chose the higher of the
socioeconomic group statuses of the adults to characterise
the household; for country of birth and parental age, we gave
preference to information about the mother.
We obtained information about social welfare
and unemployment benefits from Sweden's Total Enumeration
Income Survey of 1990. Data from these surveys are entered
into a register, maintained by Statistics Sweden, which contains
information about the incomes and personal taxes of all Swedish
residents. We had access to yearly totals, and households
that obtained any allowance were classified as either receiving
benefits or not.
We also gathered information about alcohol or
drug-abuse and psychiatric disease by the adults in the household
from the Swedish Hospital Discharge Register (for the years
1987-99), which contains data for all discharges from Swedish
hospitals through the Swedish National Board of Health and
Welfare.
We assessed mortality in children from 1991-98
and severe morbidity (indicating psychosocial disturbance
or injury) over the period 1991-99 using data from the National
Cause of Death Register and the National Hospital Discharge
Register, respectively. Diagnoses in the records from the
Swedish Hospital Discharge Register are mainly based on the
judgment of the doctor, standard diagnostic assessments are
rarely used. We classified the outcomes in accordance with
International Classification of Diseases (ICD) 9 (1991-1996)
and ICD 10 (1997-99) (table 1).
--------------------------------------------------------------------------------
Outcome
Age at outcome
Data sources
ICD9 1991-96
ICD10 1997-98 (99)*
(years)
Total mortality
6-25
Mortality data
All diagnoses
··
Child and adolescent psychiatric care (except for diagnoses
indicating addiction)
6-19
Inpatient data
Adult psychiatric care (except for diagnoses indicating addiction)
20-26
Inpatient data
290-319 (except for diagnoses 291, 292, 303-305.0)
F00-F99 (except for diagnoses F10-16, F18-19)
Suicide/suicide attempt
13-26
Inpatient data
13-25
Mortality data
E950-59, E980-89
X60-84, Y10-34
Traffic injury
6-26
Inpatient data
6-25
Mortality data
E800-49
V01-V99
Intentional violence
6-26
Inpatient data
6-25
Mortality data
E960-68
X85-Y09
Fall and poisoning
6-26
Inpatient data
6-25
Mortality data
E850-59, E880-88
X40-49, W00-19
Alcohol-related diagnosis
13-26
Inpatient data
291, 303, 305.0, 357.5, 425.5, 535.3, 571.0-571.3, E860, E980+980
E24.4, F10.1-F10.9, G31.2, G62.1, G72.1, I42.6, K29.2, K70,
K86.0, O35.4, P04.3, Q86.0, T51, Y90.1-Y90.9, Y91.1-Y91.9,
Z50.2, Z71.4
13-25
Mortality data†
Narcotics-related diagnosis
13-26
Inpatient data
292‡, 304, 965.0, 968.5, 969.6, 969.7
F11.1-F11.9, F12.1-F12.9, F13.1-F13.9, F14.1-F14.9, F15.1-F15.9,
F16.1-F16.9, F18.1-F18.9,F19.1-F19.9, O35.5, P04.4, T40.0-T40.3,
T40.5-T40.9, T43.6, Z50.3, Z71.5
13-25
Mortality data†
*Mortality is analysed for 1991-98 and inpatient data for
1991-99. †Alcohol-related and narcotics-related mortality
are presented together (addiction). ‡Not included in
mortality diagnoses.
Table 1: Classification of outcomes
--------------------------------------------------------------------------------
Statistical analysis
Mortality risks and severe morbidity, indicated
by records of hospital discharges, were analysed and reported
separately, with person-months at risk used as a basis for
assessment. For our assessment of mortality, we calculated
the number of months that individuals were alive during follow-up;
and, for other outcomes based on hospital data, the months
until the first relevant discharge or death. In general, we
used only the primary diagnosis at first discharge (1991-99)
or underlying cause of death (1991-98) as an outcome. However,
in the cases of alcohol and drug addiction, we also considered
contributory diagnoses. Relative risks with 95% CIs were used
as estimates of effects, with children in households with
two adults as the reference group. Multivariate analyses were
done with Poisson regression (SAS, version 8.0).
We entered the ages of the children and parents
(preferably the mother) at the time of delivery of the child
as continuous independent second-degree polynomial variables.
All other variables were classified when entered into the
models. Boys and girls were assessed together, with interaction
between sex and type of parenting, but results are presented
separately for the sexes. First, we investigated the effects
on morbidity of adjustment for each variable separately. After
these preliminary analyses, we excluded unemployment benefit
from all models because this factor did not affect any of
the relations studied.
In the multivariate analyses, we distinguished
between variables referring to conditions before the operation
of the independent variable (confounders) and those that operated
contemporaneously between family position and the health outcome
in question (mediators) (figure). For example, adjustment
for different measures of income might control for circumstances
resulting from living in a single-parent household. Such a
procedure can be used to understand a relation, although it
is not suitable for dismissing a spurious association17 and
these adjustments can also have relevance to the timing of
interventions relevant to prevention of ill-health. Although
making such distinctions in real life is difficult, we assessed
variables such as age of child and parents, and parental characteristics
such as socioeconomic group affiliation, living in a big city,
country of birth, alcohol or drug abuse, or psychiatric disease,
as confounders. Women with low educational status, which is
highly correlated with socioeconomic status (as measured by
occupation), have a higher risk of being a single mother through
separation than do mothers with high education.18 We also
believe that the style of living in a big city leads to an
increase in the number of single parents, rather than that
becoming a single parent leads to urban migration. Ill-health
in parents can be accounted for by the stress of divorce and
the fact of being alone. However, when we use severe morbidity
with in-patient care as a measure of ill-health, such difficulties
are even more related to the prerequisites for either entering
into or staying in a relationship.19-23 Thus, ill-health in
parents was treated as a confounder in our analyses.
A conceptual framework for investigation of the effect of
single parenthood on morbidity and injury of the child
By contrast, receiving social benefit and renting
or owning a home were seen as measures of household resources
and treated as mediators. Many findings18,24 have suggested
that the poor financial situation in which single parents
often find themselves is a consequence of being sole providers
for their family. Income selection processes--ie, that economic
difficulties often arise before eventual separation--do not
seem to have the same effect.24 Number of children was also
classified as a mediator.
In the multivariate analyses, we adjusted for
the different groups of variables described above. For the
first model, adjustment was made only for age of child. The
second model included the confounders, whereas the third encompassed
the variables treated as mediators. Finally, both confounders
and mediators were added to make up a fourth model.
Role of the funding source
The sponsor of the study had no role in study
design, data collection, data analysis, data interpretation,
or in the writing of the report.
Results
We investigated 65 085 children living with
the same single parent in both 1985 and 1990 (5433 registered
with their father and 59 652 with their mother) and 921 257
children living with the same two parents in both years.
The socioeconomic situation of children in families
with only one adult was different from that of children in
families with two adults. More single parents than couples
were unskilled manual workers, low-grade non-manual workers,
and people without occupation, whereas couples were more likely
than single parents to be high-grade or medium-grade non-manual
workers (table 2). Children in single-parent families were
more likely to live in large towns than were children in two-parent
families, and it was slightly more common for their mother
(or father if the mother was absent) to be born outside Sweden.
The number of parents on social welfare in 1990 was seven
times greater in the single-parent group than in the two-parent-group,
and five times as many single parents as couples rented rather
than owned their homes (table 2). Twice as many single parents
as couples received unemployment benefit (table 2). Admissions
for psychiatric disease or addiction to alcohol were recorded
in 60% more single parents than parents with partners. Note
that values for couples are expressed for the household--ie,
two people contribute to the probability of disease, compared
with households with a single parent.
--------------------------------------------------------------------------------
Children with single parent (n=65 085)
Children with two parents (n=921 257)
n (%)
Deaths
Death rate*
n (%)
Deaths
Death rate*
Sex of child
Girl
31669 (49%)
56
22·1
448291 (49%)
608
17·0
Boy
33416 (51%)
131
49·1
472966 (51%)
1117
29·6
Age of child in 1990 (years)
5-12
34352 (53%)
52
18·9
552536 (60%)
679
15·4
13-17
30733 (47%)
135
55·0
368721 (40%)
1046
35·5
Household characteristics
Number of children
1
31307 (48%)
92
36·8
185263 (20%)
454
30·7
2-3
31797 (49%)
90
35·4
661396 (72%)
1097
20·7
4
1981 (3%)
5
31·6
74598 (8%)
174
29·2
Socioeconomic group in 1990
Unskilled manual workers
17994 (28%)
42
29·2
110326 (12%)
278
31·5
Skilled manual workers
7394 (11%)
24
40·6
143151 (16%)
287
25·1
Low-grade non-manual workers
11705 (18%)
32
34·2
122086 (13%)
197
20·2
High and medium-grade non-manual workers
15 937 (24%)
45
35·3
420426 (46%)
712
21·2
Self-employed
1361 (2%)
3
27·6
108097 (12%)
207
24·0
Others†
10694 (16%)
41
48·0
17171 (2%)
44
32·1
Country of birth
Sweden
55432 (85%)
155
35·0
830513 (90%)
1515
22·8
Other Nordic countries
5236 (8%)
22
52·6
44403 (5%)
112
31·6
Other European countries
2845 (4%)
7
30·8
25553 (3%)
47
23·0
Rest of world
1572 (2%)
3
23·9
20788 (2%)
51
30·7
Place of residence
Big town
28671 (44%)
86
37·5
270966 (29%)
492
22·7
Intermediate town
20822 (32%)
47
28·2
320796 (35%)
550
21·4
Small town
15592 (24%)
54
43·4
329495 (36%)
683
25·9
Housing
Owns
21187 (33%)
63
37·2
790079 (86%)
1438
22·8
Rents
42276 (65%)
119
35·2
119580 (13%)
262
27·4
Other
1622 (2%)
5
38·6
11598 (1%)
25
27·0
Received social welfare in 1990
Yes
13672 (21%)
46
42·1
26563 (3%)
77
36·3
No
51413 (79%)
141
34·3
894694 (97%)
1648
23·0
Received unemployment benefit in 1990
Yes
6015 (9%)
16
33·3
40214 (4%)
84
26·1
No
59070 (91%)
171
36·2
881043 (96%)
1641
23·3
Parental psychiatric diagnosis 1987-99
Yes
3621 (6%)
20
69·2
32217 (3%)
114
44·3
No
61464 (94%)
167
34·0
889040 (97%)
1611
22·7
Parental alcohol-related diagnosis 1987-99
Yes
1524 (2%)
3
24·6
13206 (1%)
44
41·7
No
63561 (98%)
184
36·2
908051 (99%)
1681
23·2
Parental drug-related diagnosis 1987-99
Yes
547 (1%)
2
45·8
2352 (<1%)
10
53·3
No
64538 (99%)
185
35·9
918905 (100%)
1715
23·3
*Deaths per 100 000 person-years. †Including people
without an occupation.
Table 2: Sociodemographic indicators and crude mortality data
by type of parenting
--------------------------------------------------------------------------------
1912 children in Sweden died during the 8-year
study period. The crude mortality rate (number of deaths per
100 000 person-years at risk) suggested that children with
single parents had a higher risk of death than those with
two parents, with only a few exceptions (table 2). Among children
with parental alcohol-related or drug-related disease, the
risk of death was lower in those with single parents (death
rate 24·6 per 100 000 person-years) than in those with
two parents (41·7). This was also the case among children
from outside Europe (death rates 23·9 and 30·7,
respectively). The excess death rate in children with single
parents was more pronounced in those aged 13-17 years (55·0
for single parents and 35·5 for two parents) than in
those aged 5-12 years (18·9 compared with 15·4)
(table 2). After adjustment for age, the risk of dying was
more than 50% greater in boys in single-parent families than
in those boys living with both parents (table 3). The risk
of death did not differ between girls with single parents
and those with two parents (table 3). However, girls with
single parents were more than twice as likely to commit suicide
and more than three times as likely to die from an addiction
to drugs or alcohol than were girls with two parents (table
3). Boys of single parents were more than five times more
likely to die from an addiction to drugs or alcohol, more
than three times as likely to die from a fall or poisoning,
and four times more likely to die from external violence (but
this measure was based on very few deaths; table 3). The number
of deaths from traffic injuries did not differ between children
with single parents and those with two parents (table 3).
--------------------------------------------------------------------------------
Girls
Boys
Single parent
Two parents
Relative risk (95% CI)*
Single parent
Two parents
Relative risk (95% CI)*
Cause of death
Total mortality
56
608
1·21 (0·92-1·59)
131
1117
1·54 (1·29-1·85)
Suicide
19
96
2·43 (1·48-3·97)
32
217
1·83 (1·26-2·65)
Traffic injury
8
155
0·67 (0·33-1·36)
29
336
1·12 (0·77-1·64)
Violence
2
10
2·54 (0·56-11·6)
6
19
4·04 (1·61-10·13)
Fall and poisoning
1
4
1·40 (0·18-11·03)
9
16
3·68 (1·75-7·73)
Addiction
4
13
3·73 (1·22-11·44)
16
37
5·31 (2·95-9·55)
*Adjusted for age of child.
Table 3: Relative risks for various mortality outcomes 1991-98
for children living with single parents compared with children
with two parents
--------------------------------------------------------------------------------
Both boys and girls in single-parent households
had raised risks of all outcomes over the 9-year period compared
with those in two-parent households (table 4) when morbidity
was measured with hospital data. The largest risks for boys
and girls were for diagnoses indicating misuse of drugs, with
risks of suicide and violence also very high (table 4). We
recorded only small increases in risks for traffic injuries,
and falls and cases of poisoning. Young people in single-parent
households had a greater risk of psychiatric disease during
both childhood and early adulthood than did those with two
parents, with the increase in risk greater during childhood
than in young adulthood for both boys and girls (table 4).
--------------------------------------------------------------------------------
Number of cases (incidence*)
Model 1 (relative risk, 95% CI)
Model 2 (relative risk, 95% CI)
Model 3 (relative risk, 95% CI)
Model 4 (relative risk, 95% CI)
Single parents
Two parents
Psychiatric disease in children and adolescents
Girls
718 (361)
4166 (138)
2·46 (2·27-2·66)
2·08 (1·91-2·26)
1·85 (1·69-2·02)
1·77 (1·62-1·94)
Boys
516 (244)
2466 (77)
2·97 (2·70-3·27)
2·52 (2·28-2·78)
2·24 (2·02-2·48)
2·15 (1·94-2·39)
Psychiatric disease in young adults
Girls
309 (373)
2048 (205)
1·82 (1·61-2·05)
1·58 (1·40-1·79)
1·46 (1·28-1·66)
1·42 (1·25-1·62)
Boys
241 (279)
1317 (125)
2·24 (1·95-2·56)
1·96 (1·70-2·25)
1·65 (1·54-1·76)
1·65 (1·54-1·77)
Suicide
Girls
709 (304)
3773 (122)
2·44 (2·25-2·64)
2·04 (1·87-2·22)
1·84 (1·68-2·02)
1·78 (1·62-1·96)
Boys
326 (132)
1524 (47)
2·79 (2·47-3·14)
2·33 (2·06-2·64)
2·12 (1·86-2·40)
2·05 (1·80-2·33)
Traffic injuries
Girls
608 (216)
7272 (182)
1·16 (1·07-1·27)
1·13 (1·04-1·23)
1·23 (1·13-1·34)
1·18 (1·08-1·29)
Boys
996 (337)
12124 (289)
1·14 (1·07-1·22)
1·11 (1·04-1·18)
1·21 (1·12-1·29)
1·15 (1·07-1·23)
Intentional violence
Girls
83 (29)
400 (10)
2·63 (2·08-3·33)
2·02 (1·59-2·57)
1·86 (1·46-2·38)
1·69 (1·32-2·16)
Boys
401 (134)
2442 (58)
2·10 (1·89-2·33)
1·62 (1·45-1·81)
1·50 (1·33-1·69)
1·35 (1·20-1·53)
Fall and poisoning
Girls
1000 (357)
12085 (304)
1·20 (1·13-1·28)
1·18 (1·10-1·26)
1·21 (1·13-1·30)
1·18 (1·10-1·26)
Boys
1552 (530)
20212 (486)
1·12 (1·06-1·17)
1·09 (1·04-1·15)
1·12 (1·06-1·19)
1·09 (1·03-1·16)
Alcohol-related disorder
Girls
365 (156)
1623 (52)
2·96 (2·64-3·31)
2·42 (2·15-2·72)
2·23 (1·97-2·53)
2·09 (1·84-2·37)
Boys
430 (66)
2138 (174)
2·66 (2·40-2·95)
2·18 (1·95-2·43)
2·02 (1·80-2·26)
1·88 (1·67-2·12)
Drugs-related disorder
Girls
213 (90)
586 (19)
4·53 (3·87-5·30)
3·17 (2·70-3·74)
2·54 (2·14-3·01)
2·38 (2·00-2·84)
Boys
362 (25)
809 (146)
5·63 (4·97-6·37)
3·97 (3·48-4·53)
3·21 (2·79-3·70)
3·01 (2·60-3·48)
Model 1-=adjusted for age of child. Model 2=adjusted for age
of child and parental confounders (age, socioeconomic group,
living in a big city and country of birth, psychiatric disease,
alcohol and drug addiction). Model 3=adjusted for age of child
and parental mediators (social benefit, number of children,
and housing situation). Model 4=adjusted for age of child,
parental confounders, and mediators. *Incidence per 100 000
person-years (crude).
Table 4: Multivariate models for severe psychiatric diseases
and injuries 1991-99 for children in single-parent families
compared with those in two-parent families
--------------------------------------------------------------------------------
The raised risks for most outcomes in children
with single parents lessened when the variables treated as
confounders or mediators, especially mediators, were added
to the initial model (table 4, models II-III). The adjustments
substantially decreased the risks for all outcomes except
traffic injuries and falls and cases of poisoning. The mediators
(receipt of social benefit, renting or owning a house, number
of children) accounted for 42% of the difference in risk of
attempting suicide between girls in single-parent families
compared with those in two-parent families and for 37% of
this risk in boys--calculated by ([relative risk in model
1-1]-[relative risk in model 2-1])/(relative risk in model
1-1). The confounders (age of child and parents, socioeconomic
group, living in a big city, country of birth, psychiatric
disease, alcohol or drug diagnosis in adults) accounted for
28% of the difference in risk of attempting suicide for girls
and for 26% of this risk in boys. Confounders and mediators
taken together accounted for 46% of the difference in suicide
attempts in girls and for 41% of the difference in boys. Of
the variables treated as confounders, socioeconomic group
affiliation was the most important factor in accounting for
differences between children with single and those with two
parents. Country of birth and residency had only a small effect
on the relation, mainly for drug-related disease. Psychiatric
disease and addiction in the parents accounted for an even
smaller part of the differences (data not shown).
The largest explained fractions, encompassing
all factors included in the models, were for violence and
addiction to narcotics (at around 60% for both boys and girls).
However, for all outcomes, significant increases in risk remained
unaccounted for even in the fully adjusted model.
The effects of living in a single-parent household
on risk of death did not differ significantly between boys
and girls. CIs for the interaction were wide, and all included
1·0 for all causes of death studied (after adjustments
were made for the variables adjusted for in model 2). Furthermore,
when discharges for suicide attempt, traffic injury, intentional
violence, fall and poisoning, and alcohol-related disease
were analysed, we recorded no significant differences between
the sexes. However, compared with girls, boys in single-parent
households had higher risks of drug-related disease (interaction
term 1·25, 95% CI 1·02-1·53) and of psychiatric
disease during childhood (1·21, 1·07-1·37)
and adulthood (1·24, 1·03-1·48).
The sex of the custodial parent, however, did
not significantly modify the relation between single parenthood
and severe morbidity or injury in either boys or girls (data
not shown).
To supplement risk comparisons as a measure
of potential improvement we calculated the number of admissions
and deaths that would have been avoided if children living
with single parents had faced the same risk as those living
with two parents. In such hypothetical circumstances, 608
(10%) suicide attempts, 497 (11%) cases of alcohol-related
disease, and 454 (23%) cases of drug-related disease would
not have occurred. Only 52 deaths (3%) would have been avoided.
If, instead, we base our calculations on household socioeconomic
affiliation, thereby assuming that all children have the risk
of ill-health faced by children of middle and upper white-collar
workers, we showed that 168 (9%) deaths would have been avoided,
as would 900 (14%) suicide attempts, 547 (12%) cases of alcohol-related
disease, and 473 (24%) cases of drug-related disease. Based
on these figures, family situation has the same importance
as socioeconomic affiliation as a predictor of cases of addiction
and suicide attempts in adolescents.
Contributors
G R Weitoft was responsible for study design,
analyses, and writing of the report. B Haglund, A Hjern, and
M Rosén contributed to discussions about study design
and data analyses. A Hjern also contributed to the writing
of the report.
Conflict of interest statement
None declared.
Acknowledgments
We thank Jon Kimber for excellent work with
correcting our English. The study was funded by the National
Board of Health and Welfare in Sweden.
References
1 Lundberg O. The impact of childhood living
conditions on illness and mortality in adulthood. Soc Sci
Med 1993; 36: 1047-52. [PubMed]
2 Power C, Matthews S. Origins of health inequalities
in a national population sample. Lancet 1997; 350: 1584-89.
[Text]
3 Vågerö D, Leon D. Effect of social
class in childhood and adulthood on adult mortality. Lancet
1994; 343: 1224-25. [PubMed]
4 Pensola T, Valkonen T. Mortality differences
by parental social class from childhood to adulthood. J Epidemiol
Community Health 2000; 54: 525-29. [PubMed]
5 Östberg V. Social structure and children's
life chances: an analysis of child mortality in Sweden. PhD
thesis. Stockholm: Swedish Institute for Social Research;
1996.
6 Barn och deras familjer 1999. Children and
their families 1999: demographic reports. Stockholm: Statistics
Sweden, 2000.
7 Amato P, Keith B. Parental divorce and well-being
of children: a meta-analysis. Psychol Bull 1991; 110: 26-46.
[PubMed]
8 Wallerstein JS, Kelly JB. Children and divorce:
a review. Soc Work 1979; 24: 468-75. [PubMed]
9 Wadsworth J, Burnell I, Taylor B, Butler N.
Family type and accidents in preschool children. J Epidemiol
Community Health 1983; 37: 100-04. [PubMed]
10 Hetherington E, Cox M, Cox R. Effect of divorce
on parents and children. In: Lamb M. Non-traditional families:
parenting and child development. London: Hillsdale New Jersey:
Lawrence Erlbaum, 1982: 233-88.
11 Edwards J. Changing family structure and
youthful well-being: assessing the future. J Fam Issues 1987;
8: 355-72. [PubMed]
12 Krantz S. The impact of divorce on children.
In: Dornbusch S, Strober M. Feminism, children and the new
families. New York: Guilford Press, 1988: 249-73.
13 Wallerstein JS. The long-term effects of
divorce on children: a review. J Am Acad Child Adolesc Psychiatry
1991; 30: 349-60. [PubMed]
14 Hansagi H, Brandt L, Andreásson S.
Parental divorce: psychosocial well-being, mental health and
mortality during youth and young adulthood: a longitudinal
study of Swedish conscripts. Eur J Public Health 2000; 10:
86-92. [PubMed]
15 Mäkikyrö T, Sauvola A, Moring J,
et al. Hospital-treated psychiatric disorders in adults with
a single-parent and two-parent family background: a 28-year
follow-up of the 1966 northern Finland cohort. Fam Process
1998; 37: 335-44. [PubMed]
16 Sauvola A, Räsänen P, Joukamaa
M, Jokelainen J, Järvelin M-R, Isohanni MK. Mortality
of young adults in relation to single-parent family background.
Eur J Publ Health 2001; 11: 284-86. [PubMed]
17 Macintyre S. The effects of family position
and status on health. Soc Sci Med 1992; 35: 453-64. [PubMed]
18 Nyman H. An economic analysis of lone motherhood
in Sweden. PhD thesis. Göteborg: Department of Economics,
Göteborg University, 1998.
19 Hope S, Power C, Rodgers B. Does financial
hardship account for elevated psychological distress in lone
mothers? Soc Sci Med 1999; 49: 1637-49. [PubMed]
20 Ringbäck Weitoft G, Haglund B, Rosén
M. Mortality among lone mothers in Sweden. Lancet 2000; 355:
1215-19. [Text]
21 Ringbäck Weitoft G, Haglund B, Hjern
A, Rosén M. Mortality severe morbidity and injury among
long-term lone mothers in Sweden. Int J Epidemiol 2002; 31:
573-80. [PubMed]
22 Benzeval M. Self-reported health status of
lone parents. Soc Sci Med 1998; 46: 1337-53. [PubMed]
23 Mastekaasa A. Psychological well-being and
marital dissolution: selection effects? J Fam Issues 1994;
15: 208-28. [PubMed]
24 Gähler M. Life after divorce. Economical
and psychological well-being among Swedish adults and children
following family dissolution. PhD thesis. Stockholm: Swedish
Institute for Social Research, 1998.
25 Judge K, Benzeval M. Health inequalities:
new concerns about the children of single mothers. BMJ 1993;
306: 677-80. [PubMed]
26 Blum H, Boyle M, Offord DR. Single-parent
families: child psychiatric disorder and school performance.
J Am Acad Child Adolesc Psychiatry 1988; 27: 214-19. [PubMed]
27 Voydanoff P. Economic distress and family
relations: a review of the eighties. J Marriage Fam 1990;
52: 1099-115. [PubMed]
28 Lipman EL, Boyle MH, Dooley MD, Offord DR.
Child well-being in single-mother families. J Am Acad Child
Adolesc Psychiatry 2002; 41: 75-82. [PubMed]
29 Neighbors B, Forehand R, Armistead L. Is
parental divorce a critical stressor for young adolescents?
Grade point average as a case in point. Adolescence 1992;
27: 639-46. [PubMed]
30 Zaslow MJ. Sex differences in children's
response to parental divorce: research methodology and postdivorce
family forms. Am J Orthopsychiatry 1988; 58: 355-78. [PubMed]
31 Fleming D, Charlton JRH. Morbidity and healthcare
utilisation of children in households with one adult: comparative
observational study. BMJ 1998; 316: 1572-76. [PubMed]
32 Whitehead M, Burström B, Diderichsen
F. Social policies and the pathways to inequalities in health:
a comparative analysis of lone mothers in Britain and Sweden.
Soc Sci Med 2000; 50: 255-70. [PubMed]
33 Hobson B, Takahashi M. The parent-worker
model: lone mothers in Sweden. In: Lewis J. Lone mothers in
European welfare regimes. London and Philadelphia: Jessica
Kingsley Publishers, 1997: 121-39.
Home
The Journal
Current Issue
Editorial and review
Volume 361, Number 9354 25 January 2003
Commentary
http://www.thelancet.com/journal/vol361/iss9354/full/llan.361.9354.editorial_and_review.24281.1
The health disadvantage of lone mothers in industrialised
countries has raised questions about the health of the children
who live with them.1-5 Few studies, however, have analysed
the health of children living with lone, compared with two
parents, with sufficient sociodemographic data to adjust for
key confounding and mediating factors. The paper in today's
Lancet by Gunilla Ringbäck Weitoft and colleagues is,
therefore, important, not least because it is longitudinal,
achieves almost complete population coverage, and links national
registers to attach extensive socioeconomic data to health
outcomes. The investigators followed up the mortality, severe
morbidity, and hospital inpatient use of nearly a million
Swedish children over 9 years.
The main findings are that, after controlling
for confounders, Swedish children of lone parents have more
than double the risk of psychiatric disease, suicide or attempted
suicide, and alcohol-related disease; and more than three
times the risk of drug-related disease compared with their
counterparts in two-parent households. Boys in lone-parent
families also had increased risk of all-cause mortality.
The question is what causes this health disadvantage?
The investigators test various explanatory hypotheses and
conclude that lack of household resources, as measured by
receipt of social benefit and renting rather than owning a
home, has a major role in accounting for these increased risks.
The findings still leave major questions about
why and how. What are the causal pathways, for instance, by
which inequalities in household resources could translate
into differential risk to health for lone-parent versus two-parent
households? And are these pathways necessarily the same in
different countries? The possibility of different social pathways
to ill-health in contrasting policy contexts has recently
been raised by the findings of cross-country comparisons.
Take, for example, the hypothesised pathway that financial
hardship of lone parents causes heightened anxiety, depression,
and social isolation, which in turn leads not only to psychiatric
disease but also to strategies for coping with hardship which
include excess use of tobacco and other health-damaging substances.
Evidence to support these psychological and social mechanisms
has been found in relation to lone mothers in the UK.6-9
Most Swedish lone-parent households, however,
cannot be considered to be in financial hardship in the same
sense that their UK counterparts are, even in relative terms.
In a study comparing Britain and Sweden, less than 10% of
Swedish lone-mothers were poor (measured as below 50% of median
income, standardised for family size). Most were working,
but even among those who were not, only a few were classed
as poor by this measure.1,4 The Swedish welfare system largely
protected lone mothers from poverty and unemployment, in stark
contrast with the UK situation, in which most lone mothers
were still poor, even with the help of welfare benefits. Under
these conditions, poverty and worklessness, in subsequent
analyses, explained much of the health disadvantage of lone
mothers compared with couple mothers in Britain but little
or nothing of the equivalent health gap in Sweden.4 The search
continues for what it is about the economic and social experiences
of lone parents in Sweden that is ultimately damaging to their
own health and that of their children.
What such studies highlight more generally is
the need for a deeper understanding of the policy context
in the various societies under study, and the need to question
the meaning of what is being measured. Part of the issue may
be that the necessarily crude indicators used to measure complex
sociological processes may have different meanings in different
places. Whilst in the UK and USA, receipt of welfare benefits
is often taken as a marker of poverty, what is this variable
capturing in Sweden in Ringbäck Weitoft and colleagues'
study? The same question applies to the housing-tenure indicator
of renting versus owning a home. In some contexts, housing
tenure indicates more than the level of income alone, encompassing
notions of degree of control over available resources and
perceptions of longer-term security.10,11 Future studies need
to take these lines of investigation forward, to increase
understanding of the subtleties of the multiple pathways to
health disadvantage in specific societies. Such work is imperative
to find effective policies, matched to prevailing circumstances,
to address these inequalities.
*Margaret Whitehead, Paula Holland
--------------------------------------------------------------------------------
Department of Public Health, University of Liverpool,
Liverpool L69 3GB, UK (e-mail:mmw@liverpool.ac.uk)
1 Burström B, Diderichsen F, Shouls S,
Whitehead M. Lone mothers in Sweden: trends in health and
socio-economic circumstances, 1979-1995 . J Epidemiol Community
Health 1999; 53: 750-56. [PubMed]
2 Whitehead M, Drever F. Narrowing inequalities
in health? Analysis of trends in mortality among the babies
of lone mothers. BMJ 1999; 318: 908-14. [PubMed]
3 Ringbäck Weitoft G, Haglund B, Rosen
M. Mortality among lone mothers in Sweden: a population study.
Lancet 2000; 355: 1215-19. [Text]
4 Whitehead M, Burström B, Diderichsen
F. Social policies and the pathways to inequalities in health:
a comparative analysis of lone mothers in Britain and Sweden.
Soc Sci Med 2000, 50: 255-70.
5 Lahelma E, Arber S, Kivelä K, Roos E.
Multiple roles and health among British and Finnish women:
the influence of socio-economic circumstances. Soc Sci Med
2002; 54: 727-40. [PubMed]
6 Brown G, Moran P. Single mothers, poverty
and depression. Psychol Med 1997; 27: 21-33. [PubMed]
7 Hope S, Power C, Rodgers B. Does financial
hardship account for elevated psychological distress in lone
mothers? Soc Sci Med 1999; 49: 1637-49. [PubMed]
8 Graham H. Being poor: perceptions and coping
strategies of lone mothers. In: Brannen J, Wilson G, eds.
Give and take in families: studies on resource distribution.
London: Allen and Unwin, 1987: 56-74.
9 Graham H. Women's smoking and family health.
Soc Sci Med 1987; 25: 47-56. [PubMed]
10 Macintyre S, Ellaway A, Der G, Ford G, Hunt
K. Are housing tenure and car access simply measures of income
or self-esteem? A Scottish study. J Epidemiol Community Health
1998; 52: 657-64. [PubMed]
11 Hiscock R, Kearns A, Macintyre S, Ellaway
A. Ontological security and psychosocial benefits from the
home: qualitative evidence on issues of tenure. Housing Theory
Soc 2001; 18: 50-66. [PubMed]
|
