Book Review

Growing Up with a Single Parent: What hurts, what helps

N Engl J Med 1995; 332:966-968April 6, 1995

Article

Growing Up with a Single Parent: What hurts, what helps
By Sara McLanahan and Garry Sandefur. 196 pp. Cambridge, Mass., Harvard University Press, 1994. $19.95. ISBN: 0-674-36407-4

Since the 1992 presidential election, family values have been a hot political topic, and properly so. Families matter. Unfortunately, much of the public discussion has been characterized by a distressing ignorance about, and a remarkable indifference to, empirical data, which is one reason why Growing Up with a Single Parent is so valuable. Because family structure is a prime determinant of health for both children and adults, this clearly written and remarkably jargon-free monograph is highly recommended to all practicing physicians. McLanahan and Sandefur summarize the facts about single parenthood and its consequences; they outline social policies that might set things right. Whether or not readers choose to support the actions recommended (I do), the data the authors have assembled define the issues that must be addressed.

Public figures depict the typical American household as though it consisted of married couples and their children; in fact, such families make up only 26 percent of American households. According to the Bureau of the Census, nonmarital cohabitation, separation, and divorce have become more common, as has remarriage. Children living with only one parent (24 percent) or with “melded” sibships of children from several families (15 percent) are increasing in number; half of all children in the United States lived or will live with one parent before reaching adulthood. Most one-parent families (86 percent) are headed by mothers. Contrary to widespread belief, most single-parent families (63 percent) are white, not black, though the rate of single parenthood is higher among blacks. For the most part, single parenthood arises from separation or divorce, not consensual union and out-of-wedlock births. Most single parents are in their 20s and 30s, not in their teens.

Does the expansion of welfare benefits account for single motherhood? That myth can be sustained only by selectively ignoring facts when they do not match expectations. Welfare benefits and single parenthood did increase in parallel in the 1960s and 1970s. During the past 20 years, however, welfare benefits have declined in real dollar value by 26 percent, whereas single parenthood has continued to increase. Is the phenomenon of out-of-wedlock births uniquely American? Rates in the United Kingdom, Canada, and France are about the same as those in the United States; rates in Sweden and Denmark are more than 50 percent higher. The structure of the family is changing rapidly throughout the Western world.

What is unique is that births to unwed teenagers have been increasing in the United States at the same time that they have been decreasing in Sweden. In Sweden, infants born out of wedlock commonly enter families of two parents in their 20s living in a consensual union; in the United States such infants most often have only a mother to care for them, a mother living in poverty, to boot. Among industrialized nations, the United States has the highest rate of teenage pregnancy and the highest rate of teenage childbirth despite the highest rate of teenage abortion. The reason is not that we have the highest rates of adolescent nonmarital cohabitation; rates in Sweden are actually higher. Sweden has systematically provided adolescents with education about human sexuality and access to contraception for many years; in contrast, both education and access to contraception have been restricted in the United States for fear of encouraging promiscuity. Americans operate on the flawed premise that if we do not tell children about sex, they will not find out about it.

Need we worry about the increase in single-parent families, or do they simply represent alternative lifestyles without consequence for child development? The data assembled by McLanahan and Sandefur demonstrate unequivocally that children need two parents. It is not that single mothers cannot raise children who become successful adults; most do. But the risk of a poor outcome is much higher for children in single-parent families than for those in two-parent families. Six nationally representative data sets demonstrate that children growing up in single-parent households, whether the parents were never married or have separated or divorced, have twice the risk of repeating a grade in school, having behavioral problems, dropping out of high school, and being out of work, and girls have twice the risk of becoming teenage mothers. Adjusting for social class reduces these risks by about half; nonetheless, even when income is taken into account, children from single-parent families fare worse than those from two-parent families.

What accounts for these untoward outcomes? Separation and divorce are obvious stressors for children. In the United States the split family loses about 40 percent of its income; once divorce occurs, the likelihood that a child will be living in poverty doubles. Even when they work full time, most single mothers in the United States remain near or below the poverty line, because their wages are so low. They are vulnerable to layoffs, high expenses for child care deplete their meager earnings, and they lose Medicaid benefits if they work.

After parents separate, children have much less time with their fathers. (One third see their children once a week, and another third not at all.) Children of separated parents are twice as likely as children in intact families to have to move and change schools, losing friends in the process. Remarriage is common, and many children must adapt to stepparents and stepsiblings; one third of second marriages end in divorce, leading to further stress. The long-term outcome depends on the circumstances of the custodial parent after the separation and on the quality of the relationship with each parent.

Given that the breakup of families and single parenthood are associated with misery and an increased risk of adverse outcomes in adulthood for the children who grow up in such families, what measures can promote the stability of families and protect children? The trends in family dissolution date far back in time and are occurring in industrialized countries throughout the world, so can we realistically hope to reverse them? McLanahan and Sandefur, though appropriately cautious, point out,

To the extent that marital disruption and nonmarital childbearing are caused by a lack of support for poor fathers or poor two-parent families . . . and to the extent that they are caused by an overemphasis on individualistic values and a failure to enforce parental responsibility, it is possible that the trends in family behavior may level off or decline in the future.

Three principles underlie the authors' recommendations: first, steps must be taken immediately to reduce the economic insecurity of children growing up in single-parent families; second, both parents should assume responsibility for the cost of raising their children; and third, family-support programs must be universal to reinforce the recognition that the problems faced by single parents, though more urgent, are the same problems faced by all parents. Universality (making all families eligible for benefits in the same way that all older people are entitled to Medicare) avoids the problem of programs that help single-parent families but also convey the message that young men and women have to live apart to be eligible for support.

Social policy should be redesigned to help two-parent families stay together by subsidizing health care, child care, and housing; at present, poor two-parent families receive less help from the government than do well-off or single-parent families. Nearly all middle- and upper-income families receive tax-subsidized medical insurance through work; single-mother families living in poverty are eligible for Medicaid. Poor two-parent families fall through the safety net.

We need to do more to help single-parent families; at present, we do much less than other Western countries. Single mothers already contribute to the support of their children. Over 70 percent of single mothers work at least part of the year, and 25 percent work full time year-round. Both political parties agree that employment offers single mothers a better future than does welfare. But employment requires the availability of decent jobs in the first place, the skills to perform those jobs, and good day care and after-school programs so that children are not placed at risk. Most married mothers prefer to work outside the home; there is no reason to think that single mothers are any different. Employment will increase a mother's earning power as well as her self-esteem. The child of a mother in the labor force will have an advantage when it comes to finding a job and planning his or her own future. What is missing is a national full-employment program; neither withdrawing welfare benefits for single mothers nor providing job training will solve the problem if there are no jobs to be had.

Responsibility for children should be borne by both parents. Nonresident fathers should be expected to share their income with their children; child-support awards should be vigorously enforced. Financial security for mothers and children could be ensured with a guaranteed minimal child-support benefit paid directly by the government and recouped from fathers as far as possible. Unlike welfare, a guaranteed child-support benefit would not depend on the mother's income (and therefore would not be reduced if the mother worked).

McLanahan and Sandefur do not discuss a national policy I would strongly advocate: public-school education about family planning and access to contraception, as in Sweden. The fact that 60 percent of pregnancies in the United States are unintended (and not merely those among unmarried teenagers) is a simple index of how much room there is for enabling men and women to make their own decisions about having children. Unwanted pregnancies contribute to the breakup of families and are associated with an increased risk of poverty.

The authors conclude by stating an ethical viewpoint to which I propose we all subscribe: “Growing up with a single parent is not something that happens to other people and other people's children; it is something that happens to us and to our children's children.” Not only should Growing Up with a Single Parent be on every doctor's bookshelf, it also ought to be read and contemplated. It offers no easy answers and makes it clear why easy answers will not suffice. The book makes it equally clear that single-parenthood has major social consequences.

Leon Eisenberg, M.D.
Harvard Medical School, Boston, MA 02115