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discuss the importance of family case study

Defining Family: A Case Study Activity

  • Emily Ruehs-Navarro
  • Sarah Friedman

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Learning Goals and Assessments

Learning Goal(s):

  • Goal 1: Students will be able to challenge normative definitions of the family.
  • Goal 2: Identify the various institutions and social groups that define families currently and evaluate how family groups are impacted by these definitions.
  • Goal 3: Reflect on the importance of defining families and the barriers faced by social groups who do not meet societal definitions of family

Goal Assessment(s):

  • Assessment 1: Through discussion of case studies, students will identify social groups that consider themselves family, yet do not fall into many definitions..
  • Assessment 2: Students will create a list of scenarios in which the definition of family is important. They will then identify which institutions have the power to create the definition in each scenario.
  • Assessment 3: Through small group and class conversations, students will identify how social groups in the case study do or do not have access to resources based on normative definitions of families.

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Family Relationships and Well-Being

Patricia a thomas.

1 Department of Sociology and Center on Aging and the Life Course, Purdue University, West Lafayette, Indiana

2 Department of Sociology, Michigan State University, East Lansing

Debra Umberson

3 Department of Sociology and Population Research Center, University of Texas at Austin

Family relationships are enduring and consequential for well-being across the life course. We discuss several types of family relationships—marital, intergenerational, and sibling ties—that have an important influence on well-being. We highlight the quality of family relationships as well as diversity of family relationships in explaining their impact on well-being across the adult life course. We discuss directions for future research, such as better understanding the complexities of these relationships with greater attention to diverse family structures, unexpected benefits of relationship strain, and unique intersections of social statuses.

Translational Significance

It is important for future research and health promotion policies to take into account complexities in family relationships, paying attention to family context, diversity of family structures, relationship quality, and intersections of social statuses in an aging society to provide resources to families to reduce caregiving burdens and benefit health and well-being.

For better and for worse, family relationships play a central role in shaping an individual’s well-being across the life course ( Merz, Consedine, Schulze, & Schuengel, 2009 ). An aging population and concomitant age-related disease underlies an emergent need to better understand factors that contribute to health and well-being among the increasing numbers of older adults in the United States. Family relationships may become even more important to well-being as individuals age, needs for caregiving increase, and social ties in other domains such as the workplace become less central in their lives ( Milkie, Bierman, & Schieman, 2008 ). In this review, we consider key family relationships in adulthood—marital, parent–child, grandparent, and sibling relationships—and their impact on well-being across the adult life course.

We begin with an overview of theoretical explanations that point to the primary pathways and mechanisms through which family relationships influence well-being, and then we describe how each type of family relationship is associated with well-being, and how these patterns unfold over the adult life course. In this article, we use a broad definition of well-being, including multiple dimensions such as general happiness, life satisfaction, and good mental and physical health, to reflect the breadth of this concept’s use in the literature. We explore important directions for future research, emphasizing the need for research that takes into account the complexity of relationships, diverse family structures, and intersections of structural locations.

Pathways Linking Family Relationships to Well-Being

A life course perspective draws attention to the importance of linked lives, or interdependence within relationships, across the life course ( Elder, Johnson, & Crosnoe, 2003 ). Family members are linked in important ways through each stage of life, and these relationships are an important source of social connection and social influence for individuals throughout their lives ( Umberson, Crosnoe, & Reczek, 2010 ). Substantial evidence consistently shows that social relationships can profoundly influence well-being across the life course ( Umberson & Montez, 2010 ). Family connections can provide a greater sense of meaning and purpose as well as social and tangible resources that benefit well-being ( Hartwell & Benson, 2007 ; Kawachi & Berkman, 2001 ).

The quality of family relationships, including social support (e.g., providing love, advice, and care) and strain (e.g., arguments, being critical, making too many demands), can influence well-being through psychosocial, behavioral, and physiological pathways. Stressors and social support are core components of stress process theory ( Pearlin, 1999 ), which argues that stress can undermine mental health while social support may serve as a protective resource. Prior studies clearly show that stress undermines health and well-being ( Thoits, 2010 ), and strains in relationships with family members are an especially salient type of stress. Social support may provide a resource for coping that dulls the detrimental impact of stressors on well-being ( Thoits, 2010 ), and support may also promote well-being through increased self-esteem, which involves more positive views of oneself ( Fukukawa et al., 2000 ). Those receiving support from their family members may feel a greater sense of self-worth, and this enhanced self-esteem may be a psychological resource, encouraging optimism, positive affect, and better mental health ( Symister & Friend, 2003 ). Family members may also regulate each other’s behaviors (i.e., social control) and provide information and encouragement to behave in healthier ways and to more effectively utilize health care services ( Cohen, 2004 ; Reczek, Thomeer, Lodge, Umberson, & Underhill, 2014 ), but stress in relationships may also lead to health-compromising behaviors as coping mechanisms to deal with stress ( Ng & Jeffery, 2003 ). The stress of relationship strain can result in physiological processes that impair immune function, affect the cardiovascular system, and increase risk for depression ( Graham, Christian, & Kiecolt-Glaser, 2006 ; Kiecolt-Glaser & Newton, 2001 ), whereas positive relationships are associated with lower allostatic load (i.e., “wear and tear” on the body accumulating from stress) ( Seeman, Singer, Ryff, Love, & Levy-Storms, 2002 ). Clearly, the quality of family relationships can have considerable consequences for well-being.

Marital Relationships

A life course perspective has posited marital relationships as one of the most important relationships that define life context and in turn affect individuals’ well-being throughout adulthood ( Umberson & Montez, 2010 ). Being married, especially happily married, is associated with better mental and physical health ( Carr & Springer, 2010 ; Umberson, Williams, & Thomeer, 2013 ), and the strength of the marital effect on health is comparable to that of other traditional risk factors such as smoking and obesity ( Sbarra, 2009 ). Although some studies emphasize the possibility of selection effects, suggesting that individuals in better health are more likely to be married ( Lipowicz, 2014 ), most researchers emphasize two theoretical models to explain why marital relationships shape well-being: the marital resource model and the stress model ( Waite & Gallager, 2000 ; Williams & Umberson, 2004 ). The marital resource model suggests that marriage promotes well-being through increased access to economic, social, and health-promoting resources ( Rendall, Weden, Favreault, & Waldron, 2011 ; Umberson et al., 2013 ). The stress model suggests that negative aspects of marital relationships such as marital strain and marital dissolutions create stress and undermine well-being ( Williams & Umberson, 2004 ), whereas positive aspects of marital relationships may prompt social support, enhance self-esteem, and promote healthier behaviors in general and in coping with stress ( Reczek, Thomeer, et al., 2014 ; Symister & Friend, 2003 ; Waite & Gallager, 2000 ). Marital relationships also tend to become more salient with advancing age, as other social relationships such as those with family members, friends, and neighbors are often lost due to geographic relocation and death in the later part of the life course ( Liu & Waite, 2014 ).

Married people, on average, enjoy better mental health, physical health, and longer life expectancy than divorced/separated, widowed, and never-married people ( Hughes & Waite, 2009 ; Simon, 2002 ), although the health gap between the married and never married has decreased in the past few decades ( Liu & Umberson, 2008 ). Moreover, marital links to well-being depend on the quality of the relationship; those in distressed marriages are more likely to report depressive symptoms and poorer health than those in happy marriages ( Donoho, Crimmins, & Seeman, 2013 ; Liu & Waite, 2014 ; Umberson, Williams, Powers, Liu, & Needham, 2006 ), whereas a happy marriage may buffer the effects of stress via greater access to emotional support ( Williams, 2003 ). A number of studies suggest that the negative aspects of close relationships have a stronger impact on well-being than the positive aspects of relationships (e.g., Rook, 2014 ), and past research shows that the impact of marital strain on health increases with advancing age ( Liu & Waite, 2014 ; Umberson et al., 2006 ).

Prior studies suggest that marital transitions, either into or out of marriage, shape life context and affect well-being ( Williams & Umberson, 2004 ). National longitudinal studies provide evidence that past experiences of divorce and widowhood are associated with increased risk of heart disease in later life especially among women, irrespective of current marital status ( Zhang & Hayward, 2006 ), and longer duration of divorce or widowhood is associated with a greater number of chronic conditions and mobility limitations ( Hughes & Waite, 2009 ; Lorenz, Wickrama, Conger, & Elder, 2006 ) but only short-term declines in mental health ( Lee & Demaris, 2007 ). On the other hand, entry into marriages, especially first marriages, improves psychological well-being and decreases depression ( Frech & Williams, 2007 ; Musick & Bumpass, 2012 ), although the benefits of remarriage may not be as large as those that accompany a first marriage ( Hughes & Waite, 2009 ). Taken together, these studies show the importance of understanding the lifelong cumulative impact of marital status and marital transitions.

Gender Differences

Gender is a central focus of research on marital relationships and well-being and an important determinant of life course experiences ( Bernard, 1972 ; Liu & Waite, 2014 ; Zhang & Hayward, 2006 ). A long-observed pattern is that men receive more physical health benefits from marriage than women, and women are more psychologically and physiologically vulnerable to marital stress than men ( Kiecolt-Glaser & Newton, 2001 ; Revenson et al., 2016 ; Simon, 2002 ; Williams, 2004 ). Women tend to receive more financial benefits from their typically higher-earning male spouse than do men, but men generally receive more health promotion benefits such as emotional support and regulation of health behaviors from marriage than do women ( Liu & Umberson, 2008 ; Liu & Waite, 2014 ). This is because within a traditional marriage, women tend to take more responsibility for maintaining social connections to family and friends, and are more likely to provide emotional support to their husband, whereas men are more likely to receive emotional support and enjoy the benefit of expanded social networks—all factors that may promote husbands’ health and well-being ( Revenson et al., 2016 ).

However, there is mixed evidence regarding whether men’s or women’s well-being is more affected by marriage. On the one hand, a number of studies have documented that marital status differences in both mental and physical health are greater for men than women ( Liu & Umberson, 2008 ; Sbarra, 2009 ). For example, Williams and Umberson (2004) found that men’s health improves more than women’s from entering marriage. On the other hand, a number of studies reveal stronger effects of marital strain on women’s health than men’s including more depressive symptoms, increases in cardiovascular health risk, and changes in hormones ( Kiecolt-Glaser & Newton, 2001 ; Liu & Waite, 2014 ; Liu, Waite, & Shen, 2016 ). Yet, other studies found no gender differences in marriage and health links (e.g., Umberson et al., 2006 ). The mixed evidence regarding gender differences in the impact of marital relationships on well-being may be attributed to different study samples (e.g., with different age groups) and variations in measurements and methodologies. More research based on representative longitudinal samples is clearly warranted to contribute to this line of investigation.

Race-Ethnicity and SES Heterogeneity

Family scholars argue that marriage has different meanings and dynamics across socioeconomic status (SES) and racial-ethnic groups due to varying social, economic, historical, and cultural contexts. Therefore, marriage may be associated with well-being in different ways across these groups. For example, women who are black or lower SES may be less likely than their white, higher SES counterparts to increase their financial capital from relationship unions because eligible men in their social networks are more socioeconomically challenged ( Edin & Kefalas, 2005 ). Some studies also find that marital quality is lower among low SES and black couples than white couples with higher SES ( Broman, 2005 ). This may occur because the former groups face more stress in their daily lives throughout the life course and these higher levels of stress undermine marital quality ( Umberson, Williams, Thomas, Liu, & Thomeer, 2014 ). Other studies, however, suggest stronger effects of marriage on the well-being of black adults than white adults. For example, black older adults seem to benefit more from marriage than older whites in terms of chronic conditions and disability ( Pienta, Hayward, & Jenkins, 2000 ).

Directions for Future Research

The rapid aging of the U.S. population along with significant changes in marriage and families indicate that a growing number of older adults enter late life with both complex marital histories and great heterogeneity in their relationships. While most research to date focuses on different-sex marriages, a growing body of research has started to examine whether the marital advantage in health and well-being is extended to same-sex couples, which represents a growing segment of relationship types among older couples ( Denney, Gorman, & Barrera, 2013 ; Goldsen et al., 2017 ; Liu, Reczek, & Brown, 2013 ; Reczek, Liu, & Spiker, 2014 ). Evidence shows that same-sex cohabiting couples report worse health than different-sex married couples ( Denney et al., 2013 ; Liu et al., 2013 ), but same-sex married couples are often not significantly different from or are even better off than different-sex married couples in other outcomes such as alcohol use ( Reczek, Liu, et al., 2014 ) and care from their partner during periods of illness ( Umberson, Thomeer, Reczek, & Donnelly, 2016 ). These results suggest that marriage may promote the well-being of same-sex couples, perhaps even more so than for different-sex couples ( Umberson et al., 2016 ). Including same-sex couples in future work on marriage and well-being will garner unique insights into gender differences in marital dynamics that have long been taken for granted based on studies of different-sex couples ( Umberson, Thomeer, Kroeger, Lodge, & Xu, 2015 ). Moreover, future work on same-sex and different-sex couples should take into account the intersection of other statuses such as race-ethnicity and SES to better understand the impact of marital relationships on well-being.

Another avenue for future research involves investigating complexities of marital strain effects on well-being. Some recent studies among older adults suggest that relationship strain may actually benefit certain dimensions of well-being. These studies suggest that strain with a spouse may be protective for certain health outcomes including cognitive decline ( Xu, Thomas, & Umberson, 2016 ) and diabetes control ( Liu et al., 2016 ), while support may not be, especially for men ( Carr, Cornman, & Freedman, 2016 ). Explanations for these unexpected findings among older adults are not fully understood. Family and health scholars suggest that spouses may prod their significant others to engage in more health-promoting behaviors ( Umberson, Crosnoe, et al., 2010 ). These attempts may be a source of friction, creating strain in the relationship; however, this dynamic may still contribute to better health outcomes for older adults. Future research should explore the processes by which strain may have a positive influence on health and well-being, perhaps differently by gender.

Intergenerational Relationships

Children and parents tend to remain closely connected to each other across the life course, and it is well-established that the quality of intergenerational relationships is central to the well-being of both generations ( Merz, Schuengel, & Schulze, 2009 ; Polenick, DePasquale, Eggebeen, Zarit, & Fingerman, 2016 ). Recent research also points to the importance of relationships with grandchildren for aging adults ( Mahne & Huxhold, 2015 ). We focus here on the well-being of parents, adult children, and grandparents. Parents, grandparents, and children often provide care for each other at different points in the life course, which can contribute to social support, stress, and social control mechanisms that influence the health and well-being of each in important ways over the life course ( Nomaguchi & Milkie, 2003 ; Pinquart & Soerensen, 2007 ; Reczek, Thomeer, et al., 2014 ).

Family scholarship highlights the complexities of parent–child relationships, finding that parenthood generates both rewards and stressors, with important implications for well-being ( Nomaguchi & Milkie, 2003 ; Umberson, Pudrovska, & Reczek, 2010 ). Parenthood increases time constraints, producing stress and diminishing well-being, especially when children are younger ( Nomaguchi, Milkie, & Bianchi, 2005 ), but parenthood can also increase social integration, leading to greater emotional support and a sense of belonging and meaning ( Berkman, Glass, Brissette, & Seeman, 2000 ), with positive consequences for well-being. Studies show that adult children play a pivotal role in the social networks of their parents across the life course ( Umberson, Pudrovska, et al., 2010 ), and the effects of parenthood on health and well-being become increasingly important at older ages as adult children provide one of the major sources of care for aging adults ( Seltzer & Bianchi, 2013 ). Norms of filial obligation of adult children to care for parents may be a form of social capital to be accessed by parents when their needs arise ( Silverstein, Gans, & Yang, 2006 ).

Although the general pattern is that receiving support from adult children is beneficial for parents’ well-being ( Merz, Schulze, & Schuengel, 2010 ), there is also evidence showing that receiving social support from adult children is related to lower well-being among older adults, suggesting that challenges to an identity of independence and usefulness may offset some of the benefits of receiving support ( Merz et al., 2010 ; Thomas, 2010 ). Contrary to popular thought, older parents are also very likely to provide instrumental/financial support to their adult children, typically contributing more than they receive ( Grundy, 2005 ), and providing emotional support to their adult children is related to higher well-being for older adults ( Thomas, 2010 ). In addition, consistent with the tenets of stress process theory, most evidence points to poor quality relationships with adult children as detrimental to parents’ well-being ( Koropeckyj-Cox, 2002 ; Polenick et al., 2016 ); however, a recent study found that strain with adult children is related to better cognitive health among older parents, especially fathers ( Thomas & Umberson, 2017 ).

Adult Children

As children and parents age, the nature of the parent–child relationship often changes such that adult children may take on a caregiving role for their older parents ( Pinquart & Soerensen, 2007 ). Adult children often experience competing pressures of employment, taking care of their own children, and providing care for older parents ( Evans et al., 2016 ). Support and strain from intergenerational ties during this stressful time of balancing family roles and work obligations may be particularly important for the mental health of adults in midlife ( Thomas, 2016 ). Most evidence suggests that caregiving for parents is related to lower well-being for adult children, including more negative affect and greater stress response in terms of overall output of daily cortisol ( Bangerter et al., 2017 ); however, some studies suggest that caregiving may be beneficial or neutral for well-being ( Merz et al., 2010 ). Family scholars suggest that this discrepancy may be due to varying types of caregiving and relationship quality. For example, providing emotional support to parents can increase well-being, but providing instrumental support does not unless the caregiver is emotionally engaged ( Morelli, Lee, Arnn, & Zaki, 2015 ). Moreover, the quality of the adult child-parent relationship may matter more for the well-being of adult children than does the caregiving they provide ( Merz, Schuengel, et al., 2009 ).

Although caregiving is a critical issue, adult children generally experience many years with parents in good health ( Settersten, 2007 ), and relationship quality and support exchanges have important implications for well-being beyond caregiving roles. The preponderance of research suggests that most adults feel emotionally close to their parents, and emotional support such as encouragement, companionship, and serving as a confidant is commonly exchanged in both directions ( Swartz, 2009 ). Intergenerational support exchanges often flow across generations or towards adult children rather than towards parents. For example, adult children are more likely to receive financial support from parents than vice versa until parents are very old ( Grundy, 2005 ). Intergenerational support exchanges are integral to the lives of both parents and adult children, both in times of need and in daily life.

Grandparents

Over 65 million Americans are grandparents ( Ellis & Simmons, 2014 ), 10% of children lived with at least one grandparent in 2012 ( Dunifon, Ziol-Guest, & Kopko, 2014 ), and a growing number of American families rely on grandparents as a source of support ( Settersten, 2007 ), suggesting the importance of studying grandparenting. Grandparents’ relationships with their grandchildren are generally related to higher well-being for both grandparents and grandchildren, with some important exceptions such as when they involve more extensive childcare responsibilities ( Kim, Kang, & Johnson-Motoyama, 2017 ; Lee, Clarkson-Hendrix, & Lee, 2016 ). Most grandparents engage in activities with their grandchildren that they find meaningful, feel close to their grandchildren, consider the grandparent role important ( Swartz, 2009 ), and experience lower well-being if they lose contact with their grandchildren ( Drew & Silverstein, 2007 ). However, a growing proportion of children live in households maintained by grandparents ( Settersten, 2007 ), and grandparents who care for their grandchildren without the support of the children’s parents usually experience greater stress ( Lee et al., 2016 ) and more depressive symptoms ( Blustein, Chan, & Guanais, 2004 ), sometimes juggling grandparenting responsibilities with their own employment ( Harrington Meyer, 2014 ). Using professional help and community services reduced the detrimental effects of grandparent caregiving on well-being ( Gerard, Landry-Meyer, & Roe, 2006 ), suggesting that future policy could help mitigate the stress of grandparent parenting and enhance the rewarding aspects of grandparenting instead.

Substantial evidence suggests that the experience of intergenerational relationships varies for men and women. Women tend to be more involved with and affected by intergenerational relationships, with adult children feeling closer to mothers than fathers ( Swartz, 2009 ). Moreover, relationship quality with children is more strongly associated with mothers’ well-being than with fathers’ well-being ( Milkie et al., 2008 ). Motherhood may be particularly salient to women ( McQuillan, Greil, Shreffler, & Tichenor, 2008 ), and women carry a disproportionate share of the burden of parenting, including greater caregiving for young children and aging parents as well as time deficits from these obligations that lead to lower well-being ( Nomaguchi et al., 2005 ; Pinquart & Sorensen, 2006 ). Mothers often report greater parental pressures than fathers, such as more obligation to be there for their children ( Reczek, Thomeer, et al., 2014 ; Stone, 2007 ), and to actively work on family relationships ( Erickson, 2005 ). Mothers are also more likely to blame themselves for poor parent–child relationship quality ( Elliott, Powell, & Brenton, 2015 ), contributing to greater distress for women. It is important to take into account the different pressures and meanings surrounding intergenerational relationships for men and for women in future research.

Family scholars have noted important variations in family dynamics and constraints by race-ethnicity and socioeconomic status. Lower SES can produce and exacerbate family strains ( Conger, Conger, & Martin, 2010 ). Socioeconomically disadvantaged adult children may need more assistance from parents and grandparents who in turn have fewer resources to provide ( Seltzer & Bianchi, 2013 ). Higher SES and white families tend to provide more financial and emotional support, whereas lower SES, black, and Latino families are more likely to coreside and provide practical help, and these differences in support exchanges contribute to the intergenerational transmission of inequality through families ( Swartz, 2009 ). Moreover, scholars have found that a happiness penalty exists such that parents of young children have lower levels of well-being than nonparents; however, policies such as childcare subsidies and paid time off that help parents negotiate work and family responsibilities explain this disparity ( Glass, Simon, & Andersson, 2016 ). Fewer resources can also place strain on grandparent–grandchild relationships. For example, well-being derived from these relationships may be unequally distributed across grandparents’ education level such that those with less education bear the brunt of more stressful grandparenting experiences and lower well-being ( Mahne & Huxhold, 2015 ). Both the burden of parenting grandchildren and its effects on depressive symptoms disproportionately fall upon single grandmothers of color ( Blustein et al., 2004 ). These studies demonstrate the importance of understanding structural constraints that produce greater stress for less advantaged groups and their impact on family relationships and well-being.

Research on intergenerational relationships suggests the importance of understanding greater complexity in these relationships in future work. For example, future research should pay greater attention to diverse family structures and perspectives of multiple family members. There is an increasing trend of individuals delaying childbearing or choosing not to bear children ( Umberson, Pudrovska, et al., 2010 ). How might this influence marital quality and general well-being over the life course and across different social groups? Greater attention to the quality and context of intergenerational relationships from each family member’s perspective over time may prove fruitful by gaining both parents’ and each child’s perceptions. This work has already yielded important insights, such as the ways in which intergenerational ambivalence (simultaneous positive and negative feelings about intergenerational relationships) from the perspectives of parents and adult children may be detrimental to well-being for both parties ( Fingerman, Pitzer, Lefkowitz, Birditt, & Mroczek, 2008 ; Gilligan, Suitor, Feld, & Pillemer, 2015 ). Future work understanding the perspectives of each family member could also provide leverage in understanding the mixed findings regarding whether living in blended families with stepchildren influences well-being ( Gennetian, 2005 ; Harcourt, Adler-Baeder, Erath, & Pettit, 2013 ) and the long-term implications of these family structures when older adults need care ( Seltzer & Bianchi, 2013 ). Longitudinal data linking generations, paying greater attention to the context of these relationships, and collected from multiple family members can help untangle the ways in which family members influence each other across the life course and how multiple family members’ well-being may be intertwined in important ways.

Future studies should also consider the impact of intersecting structural locations that place unique constraints on family relationships, producing greater stress at some intersections while providing greater resources at other intersections. For example, same-sex couples are less likely to have children ( Carpenter & Gates, 2008 ) and are more likely to provide parental caregiving regardless of gender ( Reczek & Umberson, 2016 ), suggesting important implications for stress and burden in intergenerational caregiving for this group. Much of the work on gender, sexuality, race, and socioeconomic status differences in intergenerational relationships and well-being examine one or two of these statuses, but there may be unique effects at the intersection of these and other statuses such as disability, age, and nativity. Moreover, these effects may vary at different stages of the life course.

Sibling Relationships

Sibling relationships are understudied, and the research on adult siblings is more limited than for other family relationships. Yet, sibling relationships are often the longest lasting family relationship in an individual’s life due to concurrent life spans, and indeed, around 75% of 70-year olds have a living sibling ( Settersten, 2007 ). Some suggest that sibling relationships play a more meaningful role in well-being than is often recognized ( Cicirelli, 2004 ). The available evidence suggests that high quality relationships characterized by closeness with siblings are related to higher levels of well-being ( Bedford & Avioli, 2001 ), whereas sibling relationships characterized by conflict and lack of closeness have been linked to lower well-being in terms of major depression and greater drug use in adulthood ( Waldinger, Vaillant, & Orav, 2007 ). Parental favoritism and disfavoritism of children affects the closeness of siblings ( Gilligan, Suitor, & Nam, 2015 ) and depression ( Jensen, Whiteman, Fingerman, & Birditt, 2013 ). Similar to other family relationships, sibling relationships can be characterized by both positive and negative aspects that may affect elements of the stress process, providing both resources and stressors that influence well-being.

Siblings play important roles in support exchanges and caregiving, especially if their sibling experiences physical impairment and other close ties, such as a spouse or adult children, are not available ( Degeneffe & Burcham, 2008 ; Namkung, Greenberg, & Mailick, 2017 ). Although sibling caregivers report lower well-being than noncaregivers, sibling caregivers experience this lower well-being to a lesser extent than spousal caregivers ( Namkung et al., 2017 ). Most people believe that their siblings would be available to help them in a crisis ( Connidis, 1994 ; Van Volkom, 2006 ), and in general support exchanges, receiving emotional support from a sibling is related to higher levels of well-being among older adults ( Thomas, 2010 ). Relationship quality affects the experience of caregiving, with higher quality sibling relationships linked to greater provision of care ( Eriksen & Gerstel, 2002 ) and a lower likelihood of emotional strain from caregiving ( Mui & Morrow-Howell, 1993 ; Quinn, Clare, & Woods, 2009 ). Taken together, these studies suggest the importance of sibling relationships for well-being across the adult life course.

The gender of the sibling dyad may play a role in the relationship’s effect on well-being, with relationships with sisters perceived as higher quality and linked to higher well-being ( Van Volkom, 2006 ), though some argue that brothers do not show their affection in the same way but nevertheless have similar sentiments towards their siblings ( Bedford & Avioli, 2001 ). General social support exchanges with siblings may be influenced by gender and larger family context; sisters exchanged more support with their siblings when they had higher quality relationships with their parents, but brothers exhibited a more compensatory role, exchanging more emotional support with siblings when they had lower quality relationships with their parents ( Voorpostel & Blieszner, 2008 ). Caregiving for aging parents is also distributed differently by gender, falling disproportionately on female siblings ( Pinquart & Sorensen, 2006 ), and sons provide less care to their parents if they have a sister ( Grigoryeva, 2017 ). However, men in same-sex marriages were more likely than men in different-sex marriages to provide caregiving to parents and parents-in-law ( Reczek & Umberson, 2016 ), which may ease the stress and burden on their female siblings.

Although there is less research in this area, family scholars have noted variations in sibling relationships and their effects by race-ethnicity and socioeconomic status. Lower socioeconomic status has been associated with reports of feeling less attached to siblings and this influences several outcomes such as obesity, depression, and substance use ( Van Gundy et al., 2015 ). Fewer socioeconomic resources can also limit the amount of care siblings provide ( Eriksen & Gerstel, 2002 ). These studies suggest sibling relationship quality as an axis of further disadvantage for already disadvantaged individuals. Sibling relationships may influence caregiving experiences by race as well, with black caregivers more likely to have siblings who also provide care to their parents than white caregivers ( White-Means & Rubin, 2008 ) and sibling caregiving leading to lower well-being among white caregivers than minority caregivers ( Namkung et al., 2017 ).

Research on within-family differences has made great strides in our understanding of family relationships and remains a fruitful area of growth for future research (e.g., Suitor et al., 2017 ). Data gathered on multiple members within the same family can help researchers better investigate how families influence well-being in complex ways, including reciprocal influences between siblings. Siblings may have different perceptions of their relationships with each other, and this may vary by gender and other social statuses. This type of data might be especially useful in understanding family effects in diverse family structures, such as differences in treatment and outcomes of biological versus stepchildren, how characteristics of their relationships such as age differences may play a role, and the implications for caregiving for aging parents and for each other. Moreover, it is important to use longitudinal data to understand the consequences of these within-family differences over time as the life course unfolds. In addition, a greater focus on heterogeneity in sibling relationships and their consequences at the intersection of gender, race-ethnicity, SES, and other social statuses merit further investigation.

Relationships with family members are significant for well-being across the life course ( Merz, Consedine, et al., 2009 ; Umberson, Pudrovska, et al., 2010 ). As individuals age, family relationships often become more complex, with sometimes complicated marital histories, varying relationships with children, competing time pressures, and obligations for care. At the same time, family relationships become more important for well-being as individuals age and social networks diminish even as family caregiving needs increase. Stress process theory suggests that the positive and negative aspects of relationships can have a large impact on the well-being of individuals. Family relationships provide resources that can help an individual cope with stress, engage in healthier behaviors, and enhance self-esteem, leading to higher well-being. However, poor relationship quality, intense caregiving for family members, and marital dissolution are all stressors that can take a toll on an individual’s well-being. Moreover, family relationships also change over the life course, with the potential to share different levels of emotional support and closeness, to take care of us when needed, to add varying levels of stress to our lives, and to need caregiving at different points in the life course. The potential risks and rewards of these relationships have a cumulative impact on health and well-being over the life course. Additionally, structural constraints and disadvantage place greater pressures on some families than others based on structural location such as gender, race, and SES, producing further disadvantage and intergenerational transmission of inequality.

Future research should take into account greater complexity in family relationships, diverse family structures, and intersections of social statuses. The rapid aging of the U.S. population along with significant changes in marriage and families suggest more complex marital and family histories as adults enter late life, which will have a large impact on family dynamics and caregiving. Growing segments of family relationships among older adults include same-sex couples, those without children, and those experiencing marital transitions leading to diverse family structures, which all merit greater attention in future research. Moreover, there is some evidence that strain in relationships can be beneficial for certain health outcomes, and the processes by which this occurs merit further investigation. A greater use of longitudinal data that link generations and obtain information from multiple family members will help researchers better understand the ways in which these complex family relationships unfold across the life course and shape well-being. We also highlighted gender, race-ethnicity, and socioeconomic status differences in each of these family relationships and their impact on well-being; however, many studies only consider one status at a time. Future research should consider the impact of intersecting structural locations that place unique constraints on family relationships, producing greater stress or providing greater resources at the intersections of different statuses.

The changing landscape of families combined with population aging present unique challenges and pressures for families and health care systems. With more experiences of age-related disease in a growing population of older adults as well as more complex family histories as these adults enter late life, such as a growing proportion of diverse family structures without children or with stepchildren, caregiving obligations and availability may be less clear. It is important to address ways to ease caregiving or shift the burden away from families through a variety of policies, such as greater resources for in-home aid, creation of older adult residential communities that facilitate social interactions and social support structures, and patient advocates to help older adults navigate health care systems. Adults in midlife may experience competing family pressures from their young children and aging parents, and policies such as childcare subsidies and paid leave to care for family members could reduce burden during this often stressful time ( Glass et al., 2016 ). Professional help and community services can also reduce the burden for grandparents involved in childcare, enabling grandparents to focus on the more positive aspects of grandparent–grandchild relationships. It is important for future research and health promotion policies to take into account the contexts and complexities of family relationships as part of a multipronged approach to benefit health and well-being, especially as a growing proportion of older adults reach late life.

This work was supported in part by grant, 5 R24 HD042849, Population Research Center, awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Conflict of Interest

None reported.

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Family Involvement: What Does Research Say?

  • Posted July 24, 2006
  • By Holly Kreider

illustration of school with school bus and children

Cumulative evidence from several decades of research points to several benefits of family involvement for children's learning, including helping children get ready to enter school, promoting their school success, and preparing youth for college. Read the first in a series of research briefs examining family involvement across the developmental continuum, focused on family involvement in early childhood.

  • Family involvement can help children get ready to enter school. In the early childhood years, family involvement is clearly related to children's literacy outcomes. For example, one study revealed that children whose parents read to them at home recognize letters of the alphabet sooner than those whose parents do not, and children whose parents teach them at home recognize letters of the alphabet sooner than those whose parents do not.  
  • Family involvement can promote elementary school children's success. For school-age children, family involvement is also important. Children in grades K–3 whose parents participate in school activities tend to have high-quality work habits and task orientation compared to children whose parents do not participate. Moreover, parents who provide support with homework have children who tend to perform better in the classroom.  
  • Family involvement can help prepare youth for college. Family involvement matters in middle and high school — and beyond. Adolescents whose parents monitor their academic and social activities have lower rates of delinquency and higher rates of social competence and academic growth. In addition, youth whose parents are familiar with college preparation requirements and are engaged in the application process are most likely to graduate from high school and attend college.  
  • Family involvement can benefit all children, especially those less likely to succeed in school. Family involvement has been shown to benefit children from diverse ethnic and economic backgrounds. For example, low-income African American children whose families maintained high rates of parent participation in elementary school are more likely to complete high school. Latino youth who are academically high achieving have parents who provide encouragement and emphasize the value of education as a way out of poverty.

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Please note you do not have access to teaching notes, the importance of family: a case report.

Advances in Mental Health and Learning Disabilities

ISSN : 1753-0180

Article publication date: 15 March 2010

This case report highlights the importance of the role of the family in supporting a young person with a developmental disability. The young person discussed has a complex neurodevelopmental disorder with co‐morbid physical health problems. Her family have coped with a number of events in CR's life, ensuring that she has always had their support and understanding. At the time of transition there is a risk of failure to understand the complexities of the role of the family in CR's life. The implications will be discussed.

  • Learning disability
  • Intellectual disabilities
  • Behavioural therapy

Bernard, S. , Gratton, S. and Momcilovic, N. (2010), "The importance of family: a case report", Advances in Mental Health and Learning Disabilities , Vol. 4 No. 1, pp. 17-19. https://doi.org/10.5042/amhld.2010.0053

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Copyright © 2010, Emerald Group Publishing Limited

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  • Research article
  • Open access
  • Published: 06 July 2020

What methods are used to promote patient and family involvement in healthcare regulation? A multiple case study across four countries

  • Siri Wiig 1 ,
  • Suzanne Rutz 2 , 3 ,
  • Alan Boyd 4 ,
  • Kate Churruca 5 ,
  • Sophia Kleefstra 3 ,
  • Cecilie Haraldseid-Driftland 1 ,
  • Jeffrey Braithwaite 5 ,
  • Jane O’Hara 6 &
  • Hester van de Bovenkamp 2  

BMC Health Services Research volume  20 , Article number:  616 ( 2020 ) Cite this article

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In the regulation of healthcare, the subject of patient and family involvement figures increasingly prominently on the agenda. However, the literature on involving patients and families in regulation is still in its infancy. A systematic analysis of how patient and family involvement in regulation is accomplished across different health systems is lacking. We provide such an overview by mapping and classifying methods of patient and family involvement in regulatory practice in four countries; Norway, England, the Netherlands, and Australia. We thus provide a knowledge base that enables discussions about possible types of involvement, and advantages and difficulties of involvement encountered in practice.

The research design was a multiple case study of patient and family involvement in regulation in four countries. The authors collected 1) academic literature if available and 2) documents of regulators that describe user involvement. Based on the data collected, the authors from each country completed a pre-agreed template to describe the involvement methods. The following information was extracted and included where available: 1) Method of involvement, 2) Type of regulatory activity, 3) Purpose of involvement, 4) Who is involved and 5) Lessons learnt.

Our mapping of involvement strategies showed a range of methods being used in regulation, which we classified into four categories: individual proactive, individual reactive, collective proactive, and collective reactive methods. Reported advantages included: increased quality of regulation, increased legitimacy, perceived justice for those affected, and empowerment. Difficulties were also reported concerning: how to incorporate the input of users in decisions, the fact that not all users want to be involved, time and costs required, organizational procedures standing in the way of involvement, and dealing with emotions.

Conclusions

Our mapping of user involvement strategies establishes a broad variety of ways to involve patients and families. The four categories can serve as inspiration to regulators in healthcare. The paper shows that stimulating involvement in regulation is a challenging and complex task. The fact that regulators are experimenting with different methods can be viewed positively in this regard.

Peer Review reports

In many countries, patient and family involvement is high on the health policy agenda. Efforts to increase involvement can be seen at multiple levels of decision-making: the individual, the organizational and the policy level. The rationale for involving patients and families is two-fold. First, the expectation is that it will lead to better quality decisions across levels and thereby to better quality, and person-centred care. Second, as patients are the ones affected by decisions, they should have the opportunity to influence decisions [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 ].

In the regulation of healthcare, the subject of patient and family involvement also figures increasingly prominently on the agenda [ 1 , 9 ]. User involvement in regulation can be varied in nature. It can include providing individuals with information about a regulator; mobilizing users and patients as sources of information; and reviewing whether health service providers involve users in service delivery and planning [ 5 , 6 ]. This means that, on the one hand, involvement of patients and families is incorporated in regulatory standards and expectations directed at healthcare service providers [ 1 , 5 , 10 , 11 , 12 ]. On the other hand, involvement figures increasingly in the work of healthcare regulators themselves [ 5 , 6 , 13 , 14 ]. In this paper, our main focus is on involvement initiated by regulators, although we recognize that this is interrelated with regulatory standards addressing involvement in service provision.

There is a growing literature on involving patients and families in their own care, especially in service provision [ 3 , 4 ]. In comparison, the literature on involving patient and families in regulation remains in its infancy [ 5 ]. There are exploratory studies reporting experiments with involvement in different aspects of regulation, such as including patients in inspection teams, theme-based inspections, the investigation of sentinel events, using them as mystery guests and involving patients and families in developing inspection assessment criteria [ 5 , 6 , 9 , 12 , 15 , 16 , 17 ]. However, despite these examples of specific cases in the literature, a more systematic analysis of how patient and family involvement in regulation is accomplished across different health systems is lacking.

In this paper, we provide such an overview by mapping and classifying methods of patient and family involvement in regulatory practice in four countries; Norway, England, the Netherlands, and Australia. We do so by analyzing the literature and other relevant sources such as the grey literature, websites, and documents of regulators that describe user involvement. By mapping methods of involvement and the use of patient and family experiences in the regulation of healthcare organizations, we provide a knowledge base that enables discussions about possible types of involvement, and advantages and difficulties of involvement, encountered in practice. Such an analysis can help regulators, and also shape the agenda for future research.

The following research questions guided our study:

What kind of methods for patient and family involvement in regulatory practice do regulators use in different countries?

What are the reported benefits and challenges of involving patients and family members?

The paper proceeds as follows. First, we describe the methods used in our study. Second, in the results section we categorize and describe the methods of involvement that we found in the selected countries and present available evaluations of these. In the discussion, we reflect on our findings and relate them to the literature in order to identify lessons learnt for involvement in regulation, alongside topics for future research.

Research design and case selection

The research design was a multiple case study of patient and family involvement in regulation in four countries. A case was defined as a country and the methods identified for patient and family involvement in organizational regulation of quality and safety in healthcare [ 18 ]. The scope of our cases was limited to the regulation and regulatory practice related to organizations such as hospitals, nursing homes, youth care and home care. This means that involvement in regulation of individual healthcare professionals, such as involvement in decisions on disciplining or striking off doctors and nurses from their licenses and registries, was omitted. The regulatory bodies included in our country cases are the Norwegian Board of Health Supervision (NBHS) and County Governors in Norway, the Care Quality Commission (CQC) in England, and the Health and Youth Care Inspectorate (HYCI) in the Netherlands. In Australia, the Australian Commission on Safety and Quality in Health Care (ACSQHC), which developed that country’s accreditation standards, was included as the key stakeholder in this particular regulatory system (see Table  1 for details about the country regulatory contexts and references to official web pages).

We aimed to sample a broad range of empirical material from different nations and healthcare systems to illuminate the research questions from several angles [ 18 , 28 , 29 ]. We purposively selected countries with different types of healthcare systems. Notwithstanding this, all are high-income countries where one could expect a developed approach to user involvement at all system levels, including the regulatory level. The rationale for conducting cross-country studies can be for comparative purposes, however the main reason for our case selection was not comparison, but rather to provide a broad-ranging overview. Our case selection enabled access to data on methods of involvement from a variety of contexts. This served as a basis for developing an overview of existing methods and how countries approach user involvement in regulation.

Data collection and analysis

The data collection was conducted between February and April 2019 according to a template designed by the authors centred on the research questions. The authors based in each country collected 1) academic literature if available and 2) documents of regulators that describe user involvement. These documents included: grey literature, project reports, policy documents, and projects conducted by healthcare regulatory bodies described on their web pages. We felt it important to incorporate the grey literature, as involvement projects in regulation are often not designed as research projects, and therefore not published in peer reviewed journals. We conducted a broad search, as the main aim was to map existing methods of involvement in addition to possible existing evaluative data.

In each country the researchers identified relevant articles and reports based on their expertise of the subject. In addition, they searched academic data bases such as Medline, PubMed, Cinahl, and Google Scholar with search words covering user involvement, patient participation, family involvement, regulation, supervision, inspection, healthcare, quality, quality improvement and patient safety in combination with the names of the countries. We used this approach to identify country specific academic literature. In addition, the Norwegian and the Dutch data collection covered relevant journals in native language where native language search words were used. To identify grey literature and information on the web pages of each country’s regulatory body, the researchers used similar search words as in the literature searches. Moreover, some of the regulatory bodies had gathered information about user involvement and published reports on the topic on their web pages. This helped the researchers to identify relevant projects and reports. In addition, due to the limited literature identified in data bases, some of the research team used Twitter to ask if someone knew of published papers or reports covering the topic of patient and family involvement in healthcare regulation or discussed this question with experts in the field.

The authors from each country completed a pre-agreed template to describe the involvement methods found. The following information was extracted and included if available: 1) Method of involvement, 2) Type of regulatory activity, 3) Purpose of involvement, 4) Who is involved, and 5) Lessons learnt. In addition, researchers from each country provided a short description of their regulatory system, the actors, and their roles and responsibilities in order to provide contextual understanding of the different healthcare systems from which the data was collected.

During the data collection, questions from the researchers were handled by authors SW and HvB, in order to clarify and align the methodological approach across the research team. The discussions were important to ensure a similar approach and trustworthiness of the results. The completed templates were submitted to authors SW and HvB who led the cross-country analysis. During the cross-country analyses, results were synthesized [ 30 , 31 ], which enabled us to identify existing methods of involvement, commonalities and differences, and clusters of similar types of involvement activities.

In order to find a meaningful way to categorize the involvement methods and to learn from the diversity and similarities, the cross-country synthesis sought to categorize involvement methods inspired by Tritter’s [ 1 ] framework from two dimensions: individual vs collective, and proactive vs reactive involvement. This synthesis resulted in four categories of involvement methods, described as 1) individual and proactive 2) individual and reactive, 3) collective and proactive, and 4) collective and reactive (see Tables  2 , 3 , 4 and 5 ). The results were categorized as individual if they related to individual patients/user/family experiences with their own care in specific situations. Results were categorized as collective if they related to general aspects where involvement was not related to a specific patient’s own case or treatment, but those involved were expected to represent a group of interests or inform regulatory inspectors on specific topics based on their experiences. We categorized involvement as proactive if the involvement was about collecting information or involving patients/users/families as part of planning future inspections, setting the regulatory agenda or standards, or conducting routine, planned inspections. We characterized results as reactive if the involvement was related to follow up or handling of issues, for example, adverse events, deviances from standards or regulations, or complaints. The results of this synthesis are presented in Tables  2 , 3 , 4 and 5 . Footnote 1 We also analyzed the results in light of the reported benefits and challenges present in the material.

All authors are experienced researchers in the field of health services research, regulation, health policy and user involvement. Among the authors, there are also members with a background as regulatory inspectors (SW) or in a current main position as members of an inspectorate (authors SK, SR) in addition to being researchers. This experience in the author team was beneficial in helping to identify important cases, challenges, possible literature, projects, and to suggest possible recommendations of relevance for both the research community and for other regulatory bodies. In England, a senior manager within the CQC was also consulted, to ensure thoroughness in our search, and clarification of the breadth of available involvement methods.

First, we present a short introduction to the regulatory context of the four countries, before presenting the overall findings relating to involvement methods across countries. We then describe the reported benefits and challenges of involvement based on the evaluations, if available, of experiments included in the study.

Regulatory context

In Table 1 we provide a brief overview of the regulatory context of Norway, England, the Netherlands, and Australia as a backdrop for this paper. Some countries use the term regulation, while others use supervision or inspection about their role and activity. This is reflected in the context description in Table 1 .

Methods of involvement in regulation across countries

The data synthesis identified a wide variety of methods for user involvement in regulatory practice. In the following, we present the four categories of activities within these. A summary of these results per country can be found in Tables 2 , 3 , 4 and 5 . (To ease readability of Tables 2 , 3 , 4 and 5 and the four involvement methods categories, we present this text without references. All references are included when we present the reported benefits and difficulties of involvement identified in research studies or in the published grey literature).

Individual proactive methods of involvement

Individual proactive methods refer to involvement of individuals with the purpose of collaboration and use of information for setting the future regulatory agenda and planning regulatory activities. The results in this category showed that the regulators in Norway, England, and Australia used some kind of patient and user surveys to collect information as part of setting the regulatory agenda and informing inspection activities. National surveys are a way of collecting information about experiences and outcomes of the health services from broad groups of patients and users. We also identified more targeted surveys. In such cases, surveys were designed for specific groups, such as next of kin, and used to inform future system audits and make these more context-specific and relevant for the target group of regulation (e.g., children). Questionnaires were also utilized as part of a regulatory activity to collect information from a broader audience of users in planned inspections.

The regulators also made use of qualitative methods such as individual interviews and meetings with service users. Regulators spoke with children, adolescents, parents, families, next of kin, social and mental healthcare users, disabled users, and frail older service users. We found these methods were part of planned inspections (not initiated due to an adverse event) in Norway, England, and the Netherlands. Regulators collected information based on users’ experiences with the services and used this information to assess if services were provided according to standards and regulation.

The synthesis identified specific efforts among the regulators to involve and get in contact with vulnerable groups with increased risk of not being heard through routine approaches. For example, in some Australian states, surveys are specifically directed at ‘hard to reach’ groups (with low response rates, however). In other countries, hard to reach groups such as young asylum seekers, young people with autism, people with a migrant background, elderly and people with learning disabilities are targeted through qualitative methods. Such methods included the development of digital tools for communication with children under 13, and experimenting with including interpreters in system audits of under aged refugees in child protective service institutions.

Individual reactive methods of involvement

Individual reactive methods of involvement refer to how regulators involve individuals (patient, user, or next of kin), when they have experienced either an adverse event or filed a complaint about the service provision to the regulator. The Netherlands, Australia and Norway have regulation enabling users, or next of kin, to file complaints to the regulator or an ombudsman, or both. This legal right is one way of involvement in itself, but we also sought to identify if, and how, people were involved in the regulatory process after filing a formal complaint. In the included countries, a complaint can relate to both lack of service provision and being denied a service. In addition, complaints can include reporting experiences of adverse events, near misses, or patient harm. We found examples from Norway where the regulator established meeting arenas between regulatory inspectors, service providers, and users or next of kin. The purpose was to gather the involved parties and through a dialogue-based approach, try to solve each complaint case so it did not proceed to a formal and often long-lasting written information exchange process between the parties before reaching a conclusion.

In this category, we also found methods of involvement in the regulatory investigation of adverse events. A regulatory investigation may be initiated based on patient complaints, or by mandatory reporting of adverse events from the service providers to the regulator. In Norway, results showed several examples of individual involvement methods in the investigation process. In the most severe cases (e.g., deaths), investigated by the NBHS at the national level, the regulator always consults with the family, informs them about the progress and collects their views on the event. Moreover, there were examples at the county level in Norway of regulators organizing formal face-to-face meetings between regulatory inspectors and next of kin to collect information about the adverse event leading to patient death from the next of kin’s perspective. In the Netherlands and Australia, we identified regulatory requirements for service providers to conduct investigations of adverse events, but the regulator does not usually investigate these. However, since both countries require service providers to involve patients and the families in the investigations, this implies that one way of prompting user involvement is by regulating and requiring the service providers themselves to involve patients and family in investigations (as described in the introduction of this paper). In addition, Norway has recently made it mandatory for health service providers to invite patients and users to a meeting after a severe adverse event. In addition, in long-term care, the Dutch inspectorate experiments with checking directly with next of kin whether the service provider has involved them in the investigation process.

Collective proactive methods of involvement

In collective proactive methods of involvement, the involvement is not so much focused on a patient’s specific case or treatment, but more generally. Users involved are expected to represent a group of interests. The purpose is to inform the future regulatory agenda or specific inspections. The collective and proactive methods of involvement demonstrated a wide repertoire in all the included countries. England and the Netherlands were at the forefront in utilizing a range of approaches. Methods identified in this category related to involvement of user panels and user organizations, campaigns, expert-by-experience and mystery guests, data sharing, and commissioning of research.

Across countries, the most common method of this type is using experts-by-experience, peer-inspectors (in inspection processes) or co-surveyors (in accreditation processes). These methods consider users, patients and family members to be experts on care, which warrants them being a part of planned inspection activities (or accreditation surveys in Australia). The degree of involvement varied from being involved in an inspection planning meeting, to being part of the inspection team as co-investigator on site and in the analysis of results. Experts-by-experience were reported to be involved in thematic reviews and system audits. We identified variations on the expert-by-experience approach in different fields. Examples included adolescents involved in the inspection team to interview adolescents in thematic inspections, co-designing regulatory frameworks, or involvement of people with learning disabilities and next of kin in an investigation process. Moreover, the synthesis uncovered examples of older people being trained and included in the inspection process in elderly care homes. Similarly, the “mystery guest” method was applied in the Netherlands. Mystery guests are a subset of the experts-by-experience approach, where potential service users visited service providers “undercover” and evaluated aspects of the services given. For example, people with learning disabilities assessed the accessibility of services as mystery guests. Another example of the ways in which mystery guests were used, was considering whether the information they received from the service provider would be easy to understand for the group they represented. Based on these experiences the people with learning disabilities, service providers and inspectors discussed the accessibility of the services, what information they wanted to keep and what could be improved. In this particular example, managers were also later involved. The regulator used this information in the assessment of the service provider.

Our synthesis found that user panels and user advisory groups were common in the regulatory bodies across countries. In England, the CQC has user panels to provide input and advice regarding the regulation of children and mental healthcare services. In Norway, the NBHS recently established a user panel at the national level to inform all regulatory activity. Several Norwegian regional regulatory offices have established user panels. The Dutch inspectorate organizes user panels on specific regulatory topics and is investigating the possibility of a structural user advisory board. Furthermore, the Dutch inspectorate involved users in developing their multi annual policy plan ‘20–23’, and the Youth Care department of this inspectorate has been advised by a Children’s Council in 2019. Similar methods that focus on involvement in committees and panels are human research ethic committees and clinical governance committees which are established in Australia. In England, the CQC commissioned research with users.

The regulators also collaborated and organized seminars with user groups, councils, charities, and organizations to collect information and experiences as part of the planning of inspection activities. Some of these activities were co-produced by the user organizations and the regulatory bodies. We also found examples of organizing co-investigator workshops to collect experiences and lessons learnt from the experts-by-experience who had been involved in some kind of regulatory activity.

In this category, we also identified virtual involvement initiatives and campaigns using social media, digital marketing, and other online platforms to encourage patients and families to share their knowledge and experiences with the service providers. Other initiatives online related to disseminating general information to user groups about the regulators’ role and responsibility. In the Netherlands, the ratings and reviews of an independent patient rating website are used by inspectors to identify risks and themes for theme based regulation and to prioritize their visits. The Dutch inspectorate also searches social media for signals from users about the quality of care in the health services they visit. Furthermore, we identified an English initiative where CQC had established a public online community for involvement in health policy and service design. This included both a representative panel and self-selected groups. The CQC additionally took advantage of a data sharing partnership with other websites collecting intelligence from users that is then used by the regulator.

The results show collective user involvement for proactive purposes in Australia in accreditation requiring healthcare organizations to partner with consumers in planning, designing, measuring, delivering and evaluating care. A final example in this category is the national recommendations for user involvement in regulations in Norway. Results from Norway suggest a large emphasis on user involvement in regulation over the previous four-year period (2014–2018), where the NBHS made a strategic effort to improve user involvement in regulation by different means, such as funding innovation projects to test new ways of approaching user involvement in regulation. As a result of the four-year involvement program, the NBHS developed national recommendations for user involvement in regulation. Lessons learnt and strategic actions were summarized and the recommendations related to methods, experiences, and how regulators can and should involve users in their own regulatory activities and their training of inspectors. The recommendations underline patient and user involvement as a core value for health service provision and for regulatory bodies.

Collective reactive methods of involvement

This category relates to collective involvement after healthcare has failed, in terms of adverse events or complaints, but implies that it is not related to an individual’s own specific case. The collective reactive methods repertoire was limited in all countries. Nevertheless, we note some direct examples whereby the Dutch inspectorate aggregated the information from complaints collected at the National Healthcare Report Centre by sector and by theme. Also, the Dutch inspectorate performed an explorative pilot on text mining the content of the complaints for relevant topics. Similarly, in England, the CQC analyses complaints and concerns from various sources. This information is used as a signal in risk-based regulation for agenda setting and prioritization in both countries.

Reported benefits of involvement

The above synthesis shows the varied nature of user participation in regulation in terms of the type of regulation and the type of involvement. Not all the initiatives mentioned above have been evaluated. Evaluation practices differ between countries. Comparatively, most practices have been evaluated in the Netherlands where the inspectorate works with researchers in an academic collaborative. The practices that have been evaluated do offer important insights into the main reported benefits and challenges of involvement practice.

First, the primary espoused reason for involvement is improving regulatory work, and by consequence improving the quality and safety of care [ 5 , 16 , 17 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. In this view, patients and families are seen as an additional information source. In case of incident investigations for example, patients and families are able to put incidents into a broader perspective and offer a more holistic understanding of what happened [ 13 , 14 , 16 , 32 , 33 , 48 ]. The espoused reasons are similar for the input they provide during thematic inspections [ 17 ]. Similarly, experts-by-experience can provide important knowledge as they are more able to tap into experiences of patients, especially in the case of sensitive subjects such as alcohol misuse amongst adolescents [ 12 , 15 , 49 , 50 ]. Experts-by-experience and related methods also offer another view on quality of care by focusing more on relations and ‘softer’ aspects of service provision (such as quality of the food, time spent outside, decorative aspects of living facilities) rather than concentrating on safety [ 15 , 51 , 52 , 53 , 54 ]. Also, by analyzing reviews written on an independent patient rating website and social media posts, the regulator may identify risks from the patient’s perspective [ 35 , 36 , 37 , 55 , 56 , 57 , 58 ].

Second, involvement is said to legitimize decision-making of the regulator by using information gathered from patients and the family in the regulatory assessment, but also by co-producing inspection criteria [ 5 , 6 , 54 ]. This relates to the goal of democratic decision-making. For example, when patients and the families support the findings of the regulator this is added to regulatory reports [ 6 , 12 , 54 ]. Patient and family involvement is also related to being transparent about the work of the regulator, and connecting with patients or the public more generally improves the image of, or trust in, the regulator [ 5 , 13 , 14 , 48 ]. This argument is not only used to support the active involvement of patients and families, but also to send information through, for example social media, about the work of the regulator to the public [ 55 , 56 ].

Third, involvement is a way of achieving justice for those affected. This especially applies to the involvement of patients and families during incident investigations as shown in Norway, the Netherlands and Australia. Here their involvement is a way of regaining trust and restoring the therapeutic relationship, including the opportunity to apologize [ 13 , 14 , 32 , 48 ]. Moreover, involvement allows for the provision of information to the patient and family, as well as space to share emotions and provide aftercare [ 13 , 14 , 16 , 32 , 33 , 40 , 48 , 59 , 60 ]. Also, some reports mentioned that through involvement escalation of issues to legal claims could be avoided [ 16 , 40 ]. The need for justice for those affected by poor care can also be found in relation to other methods. For example, in a case of conducting interviews with the elderly, it was shown that participants appreciated the genuine interest in their perspective and felt it was positive to be heard [ 61 ]. This was also found in relation to involvement of next of kin in the regulatory investigation of adverse event when patients had died. Next of kin expected to be involved and evaluation showed that involvement could have a therapeutic effect [ 13 ]. The regulatory inspectors in this case found involvement to be in accordance with overall political expectation [ 14 ].

Fourth, involvement can be a way for users to empower themselves and learn new skills [ 12 , 17 , 41 , 49 , 50 , 54 ]. For example, experts-by-experience learn a lot about a specific subject (e.g., elderly care, alcohol misuse) and the work of the inspectorate [ 17 , 49 , 52 ].

Reported difficulties concerning participation

Along with the possible benefits reported above, the results also show a number of difficulties experienced by regulators when putting involvement into practice. First, it can prove difficult to incorporate the input of patients and families into the decisions or reports of the regulator [ 6 , 15 , 16 , 32 , 40 , 48 ]. This has partly to do with the perceived lack of legitimacy of patient or family input. It was regularly argued that patients lack the necessary knowledge to contribute, and less weight is given to their input than, for instance, the input of professionals (e.g., in case of incident investigations, theme based inspections or experts-by-experience) [ 6 , 12 , 13 , 14 , 16 , 32 , 35 , 48 , 51 ]. As described earlier, the main argument for involvement is that patients and families provide additional information. However, in cases of conflicting input (e.g., different views on what an incident is, what should be the focus of the investigation or what should be considered good quality care) the contribution of patients and family appears to be difficult to incorporate [ 6 , 16 , 48 ]. As a result, there is a danger that involvement becomes tokenistic [ 44 , 45 ]. A recent example from Dutch research tackles this conflict by making the client perspective the starting point for regulation. Inspectors followed the client’s perspective and judgements throughout the whole inspection process [ 54 ]. However, possible conflicts are likely to persist, and the question remains “how will inspectors make informed judgements in such cases in order to do justice to the complexities of regulatory practice”?

Second, not all patients or family members want to be involved or are easy to involve. For example, in case of incident investigations it has been reported that participation is too burdensome as the incident can have a large impact on patients and families [ 16 , 32 , 33 , 48 ]. In other cases, it is difficult to do justice to the diversity of patients, as some groups are more inclined to participate than others. This leads to questions concerning the representativeness of those involved and for whom they can speak [ 5 , 48 ]. This is also an important difficulty attached to professionalization attempts of participants. For example, experts-by-experience are often trained for their task. This may ultimately diminish the value of the authentic perspective that they can provide [ 12 ].

This leads us to the third difficulty we identified, that participation involves time and costs [ 5 , 13 , 14 , 33 , 34 , 40 , 48 , 54 ]. This is especially true for practices directed at so-called ‘hard to reach’ groups because the regulator must expend significant time and effort to come into contact with them, and attune participation to their needs. User participation in general is also expensive. For example, the CQC’s Experts By Experience program has cost an average of £4 million annually in recent years (CQC news). Inspectors in a pilot project in Norway sometimes found it time consuming to involve next of kin due to difficulties in scheduling meetings and the need for additional follow up contacts to collect new information from, for example, actors newly implicated in contributing to the cause of an adverse event. Inspectors did not recommend continuing this involvement method unless it was compensated properly in the work schedule and incorporated in the organization [ 48 ].

Fourth, organizational procedures can stand in the way of involvement. This includes the language used by inspectors, and is also due to certain protocols [ 6 , 16 , 32 ]. For example, incident investigations need to happen in a specific timeframe, the deadline of which can be too soon for the patients or family to be able to participate [ 16 , 32 , 33 ]. Also, the regulatory context can prohibit taking the input of patients on board. The case of youth involvement in a thematic inspection on care for children growing up poor by the Dutch inspectorate is a case in point. The interviewed youths stated that they felt their privacy was very important and therefore professionals should not share information about them with each other. In this case part of this conflict was influenced by the regulatory context as policy makers and regulators put much emphasis on sharing information in response to fatal incidents, which were analyzed as resulting from a lack of sharing information [ 6 ].

A final difficulty was identified as dealing with the emotions of those involved. This not only applies to the emotions of patients and family members, but of the professionals and regulators themselves, who can also be affected by participation. Emotions can be felt especially keenly during incident investigations [ 13 , 14 , 16 , 48 ]. For the next of kin who have lost a close relative, it can be a considerable mental strain to be part of the entire investigation process when they are grieving and sometimes traumatized. The investigation process can repeatedly remind them of the event leading to the death. However, the interpersonal skills of the inspectors may help to reduce this emotional burden. From the inspectors’ point of view, it can be emotionally challenging to involve next of kin in investigation meetings, because the inspectors can worry about attending beforehand and might continue to dwell on things after the meeting, especially in severe cases. Some inspectors have a legal professional background where they were not trained for face-to-face meetings with people in grief, as inspectors with a healthcare background may have been. At the same time, inspectors report that it is a positive experience to offer support to the next of kin and clarify any misunderstandings or questions [ 13 , 14 , 48 ]. In other cases emotions can play a role as, for example, a project involving mystery guests, where civil servants providing services to people with learning disabilities reported feeling left out as their perspective was not sufficiently taken into account [ 54 ].

Unpacking the landscape of user involvement in regulation

As studies into patient and family involvement in regulation are scarce (e.g., [ 5 , 9 ]) one could question whether regulatory bodies have been part of the general trend in healthcare to involve patients and family members in decision-making. Our study reveals that regulators are very much part of this development. They are in fact experimenting with a wide variety of user, patient, and family involvement methods. Although the context, way of organizing and regulatory environment varied by country, and some regulators are experimenting more intensively with involvement than others, we saw a variety of methods in each of our cases. Regulators used methods in all four categories identified in the paper.

The study shows that the benefits of involvement are multi-faceted. Reported advantages from the published empirical research include for example increased quality of regulatory practice – because it is informed by the unique experiences and insight of people who use care services. Moreover, patient and family involvement increased legitimacy, empowerment, and contributed to justice done to those affected by adverse events (see also [ 13 , 14 , 54 ]). We thus found that involvement can serve multiple purposes – such as in strengthening the quality of regulatory practice, and being beneficial for the users, patients and families involved [ 13 , 14 ]. In addition, involvement can be used as an instrument to prevent further escalation of problems, through formal regulatory investigation processes or legal claims [ 11 , 16 ].

Despite this reported added value, our study also identified challenges of user involvement in regulation. It is not easy to develop a regulatory culture where involvement is meant to be integrated into work practice. Also, it is not clear how to use information from experts-by-experience. This is especially important if involvement is conducted to comply with political expectations and not as a way of improving the quality of regulatory activities [ 40 , 62 ]. In many cases, information provided by users introduces an additional, and different, perspective, but this also means that it can clash with the perspective of, for instance, professionals or regulators [ 6 , 16 , 48 , 63 ].

Our findings suggest that the input from users has sometimes been put aside by questioning its legitimacy. If this happens, it equates to epistemic injustice [ 64 , 65 ] – especially if the knowledge base of users, patients, and family members is considered of less value than those of other actors. This can clearly occur if these extra perspectives do not fit with longstanding regulatory procedures, or with views held strongly by professionals, managers and regulators [ 66 , 67 , 68 ].

Other challenges include that not all patients and family members want to be involved, involvement costs time and money, and it can pose an emotional burden on those involved (see also [ 13 , 14 , 69 ]). The emotional burden is especially pertinent to the individual reactive involvement category discussed above [ 5 , 13 , 14 ]. If user involvement in regulation is a question of morality or logic [ 8 ] then how regulators deal with the challenge of emotionality, or epistemic injustice [ 64 ], should be further investigated to understand the rationale and experiences of regulatory bodies.

There are a number of lessons for regulatory practice. A clear lesson is to target involvement activities and to take advantage of existing opportunities [ 5 , 6 , 54 ]. Since participation is time-consuming for all involved, it is important to consider for which situations it is most important, and to identify the best ways to go about it. The case of using mystery guests with learning disabilities in the Netherlands is a good example in this regard [ 17 , 54 ]. The mystery guests were asked to assess the access to municipal services for people with learning disabilities, an assessment which can only be adequately made through experience.

There are also ways to include users, patient, and family perspectives based on existing information which can be exploited [ 5 ]. Examples of such involvement are 1) to use social media as a way to trace problems in healthcare, 2) to aggregate information from patient complaints, or 3) to perform text mining from patient complaints to search for new types of risks and topics for future inspections [ 35 , 36 , 37 , 38 , 57 , 58 , 70 , 71 , 72 ]. While uniquely representing quality of care from a patient’s point of view, however, this requires further reflection on methodological issues such as the reliability and validity of these (public) resources.

Another lesson is that involvement needs an embedding strategy. Regulators should think about how to support involvement in their activities, including valuing the financial and time investments [ 69 ]. There is also a need to train inspectors such that they can reflect on how to judge different perspectives on quality and how to deal with the emotional burden that can accompany involved users [ 13 , 14 ]. Good judgement on how and when to incorporate the input of patients is also needed, if that input is to be productive. This might warrant changes in procedures and regulatory frameworks as patients and regulators can have different values and perspectives (e.g., what counts as an incident, how quality of care should be judged) [ 6 , 16 , 54 , 63 ]. In this regard, it should be emphasized that participation on its own does not necessarily lead to increased patient-centeredness or learning [ 2 , 32 ]. An important question to reflect on is how to conduct training of users, patients, family members, and inspectors to succeed with involvement in regulation [ 12 ]. The danger is that such training may lead to the professionalization of patient input, which can distance the participants from their experiences as patients [ 62 ]. This is problematic because tapping into these experiences is often considered the most important reason for involvement [ 2 , 73 ].

Finally, it is important to make participation user-friendly and to ensure inclusiveness. In England, much effort is used in making forms and websites accessible, and in building relationships and trust with people from vulnerable groups. Our findings indicate that involving ‘hard to reach’ groups might be challenging, but it can be done [ 74 ]. All-in-all, further investigation is needed to evaluate targeted involvement methods of hard to reach groups.

Strengths and limitations

Several researchers participated in the data collection, which made it possible to include information from various countries and sources. This, however, may also have created variation in data sources. This limitation was moderated by using the template and having numerous discussions between authors.

The regulatory regime is complex [ 74 ] and the available data in each country varied, especially in terms of the number of published empirical studies. Most research on involvement in regulation has been conducted in the Dutch setting. We cannot be sure that this is a complete mapping, since involvement methods can be used in regulatory practice without being published or even identified as ‘regulatory practice’. We used data from different sources, such as internet websites, evaluation reports, and peer reviewed papers. This broad approach was important in providing an overview of methods available, in addition to documenting possible advantages and disadvantages and lessons learnt that are relevant to other regulators.

We categorized methods according to the proactive-reactive and individual-collective dimensions inspired by Tritter’s [ 1 ] published framework. We used the dimensions as a heuristic tool to gain insight into the variety of methods. Tritter’s [ 1 ] original work on reactive and proactive involvement distinguished between whether participation is responding to a pre-existing agenda, in our case set by a regulator (reactive), or if the participants are helping to shape it (proactive). We have added to this conceptualization by including: 1) if participants have experienced an adverse event and responded according to the regulators’ procedures for follow up (reactive), or 2) if the participants have not experienced an adverse event, but provide information to the regulator based on their experiences, to influence future regulatory activities (proactive). On the one hand, this illustrates the strengths, showing that with a few changes, Tritter’s [ 1 ] framework may be broadly applicable, including in the regulatory context. On the other hand, the slight deviance from the original version could be considered a limitation.

We do not know whether the diversity we found in methods relates to country characteristics, regulatory regimes or other factors. Further studies might continue investigations along these lines. Examining a number of different countries with diverse regulation systems was a strength as it enabled us to identify a variety of ways of involving users. However, it also made it difficult to determine to what extent differences in user involvement were the result of the different countries’ regulatory systems.

Our mapping of user involvement methods brought into focus a broad variety of methods. These can serve as inspiration to regulators in healthcare. Based on our mapping exercise we suggest that future regulatory practice continues to develop and pilot new types of user involvement methods including individual and collective, and proactive and reactive activities. The paper shows that making involvement in regulation successful is a challenging and complex task. Our findings suggest that it is not easy to reach the goals of increased involvement and democratic decision-making. The fact that regulators are experimenting with different methods can be valued positively in this regard. As a result, regulators have room to innovate and evaluate work involving new kinds of groups (e.g., older people, youths, people with learning disabilities); new topics and areas of inspections (e.g., social care, elderly care, care transition); different degrees of involvement (e.g., involved in a meeting vs part of inspection team during inspection processes); and new ways of engaging with users and service provision (e.g., mystery guests). Experimenting with these methods means that lessons can be drawn to improve involvement practices, such as how the perspective of users can be incorporated in the judgements that regulators make or in accessing hard to reach groups. For this, further research into these programs is recommended.

Most research is seen in the Dutch context. However, these studies suggest that the promotion of collaboration between regulatory bodies and research groups to build a network for research-based-regulation and regulation-based-research, may help stimulate better research, regulation, and educational programs for future regulators. More international collaborations between researchers and inspectorates could provide further impetus, for instance via the European Partnership for Supervisory Organisations in Health Services and Social Care (EPSO) or the Supervision and regulation Innovation Network for Care (SINC) that inspectorates from various countries established recently. Further development of similar collaboration arenas should be stimulated. As the issue of user involvement is high on the agenda of many regulators, it underscores the importance of this collaborative research agenda.

Availability of data and materials

All data are publicly available online and cited in the manuscript and in the reference list.

The Tables  2 , 3 , 4 and 5 may be empty or sparse because of how regulation and governance of healthcare is organized. For example, in England, one reactive category in the country table is empty because CQC does not routinely have a role in investigating adverse incidents, and most complaints are handled by other organizations. We would also note that analyses of complaints and incident reports occur at various levels, but not necessarily as a direct response or mechanism of regulatory agencies, or with patients and families involved.

Abbreviations

Australian Commission on Safety and Quality in Health Care

Care Quality Commission

European Partnership for Supervisory Organisations in Health Services and Social Care

Dutch Health and Youth Care Inspectorate

Norwegian Board of Health Supervision

Root Cause Analysis

Supervision and regulation Innovation Network for Care

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Acknowledgements

The authors would like to thank Jill Morrell, Head of Public Engagement at the Care Quality Commission (CQC), for helping the research to identify and understand the range of involvement methods used by CQC. The views expressed in this paper are those of the authors, and are not necessarily those of Jill, or of the Care Quality Commission. Any errors are solely the responsibility of the authors.

Authors would like to thank the two reviewers for valuable input to improve the paper.

Finally, we would like to thank Kate Gibbons, PhD, Centre for Healthcare Resilience and implementation Science, Australian Institute of Health Innovation, Macquarie University, Australia for her help with proof reading and language editing.

The study did not receive funding. The two research projects SAFE-LEAD primary care (grant agreement no 256681) and Resilience in Healthcare (grant agreement no 275367), funded by the Research Council of Norway, contributed to fund two research visits for author SW to Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands (January–May 2019), and the Australian Institute of Health Innovation, Macquarie University, Sydney Australia (July–October 2019). The paper was drafted during these visits.

JO is supported by funding from the National Institute for Health Research Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). JB reports funding from the National Health and Medical Research Council for grants: NHMRC Partnership Grant for Health Systems Sustainability (ID: 9100002); NHMRC Centre of Research Excellence grant (1135048); NHMRC Project grant (ID: 1143223) and NHMRC Investigator grant (ID: 1176620). AB reports funding from the Care Quality Commission to investigate CQC’s impact on the quality of care (ID: CQC PSO 140).

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SW and HvB had the idea, designed the study and the data collection framework, contributed to data collection, led the analysis and drafted the first version of the manuscript. Authors SR, SK, CHD, JO, AB, KC, and JB all contributed to data collection, analysis, and had significant contributions and commented on the manuscript in several iterations. All authors have approved the final version.

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Wiig, S., Rutz, S., Boyd, A. et al. What methods are used to promote patient and family involvement in healthcare regulation? A multiple case study across four countries. BMC Health Serv Res 20 , 616 (2020). https://doi.org/10.1186/s12913-020-05471-4

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Family Dynamics and Child Outcomes: An Overview of Research and Open Questions

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Previous research has documented that children who do not live with both biological parents fare somewhat worse on a variety of outcomes than those who do. In this article, which is the introduction to the Special Issue on “Family dynamics and children’s well-being and life chances in Europe,” we refine this picture by identifying variation in this conclusion depending on the family transitions and subpopulations studied. We start by discussing the general evidence accumulated for parental separation and ask whether the same picture emerges from research on other family transitions and structures. Subsequently, we review studies that have aimed to deal with endogeneity and discuss whether issues of causality challenge the general picture of family transitions lowering child well-being. Finally, we discuss whether previous evidence finds effects of family transitions on child outcomes to differ between children from different socioeconomic and ethnic backgrounds, and across countries and time-periods studied. Each of the subsequent articles in this Special Issue contributes to these issues. Two articles provide evidence on how several less often studied family forms relate to child outcomes in the European context. Two other articles in this Special Issue contribute by resolving several key questions in research on variation in the consequences of parental separation by socioeconomic and immigrant background, two areas of research that have produced conflicting results so far.

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1 Introduction

The recent decades of family change—including the increases in divorce and separation rates, single parenthood, cohabitation, and step family formation—led to an explosion in popular and academic interest in the consequences of family dynamics for children’s well-being and life chances (cf. Amato 2000 , 2010 ; Amato and James 2010 ; Ribar 2004 ; Sweeney 2010 ; McLanahan et al. 2013 ). Most notably, previous studies have found that children who do not live with both biological parents fare somewhat worse than those who do in terms of psychological well-being, health, schooling, and later labor market attainment, and differ with respect to their own family lives in adulthood. Scholars have interpreted these findings through a relatively small group of factors that include parental and children’s stress associated with family transitions, family conflict, changes in economic resources, and parenting styles. Beyond these established findings, however, several questions remain imperfectly answered.

This Special Issue on “Family Dynamics and Children’s Well-Being and Life Chances in Europe” consists of this introductory article and four empirical studies that address some of these open questions. In general, they give more nuance to the overall association between growing up with both biological parents and child outcomes. More precisely, do these associations differ according to the type of family structure studied? Are these differences in child outcomes due to causal effects of family structures and transitions, or do they reflect preexisting disadvantages between families? And finally, are all children equally affected by family structures and transitions?

In this introduction, we first introduce the theme of family dynamics and children’s outcomes by giving an overview of the findings of parental separation and child outcomes (Sect.  2 ). Parental separation has been the family transition that has attracted most attention among social scientists, and many of our examples later in the article consider this research too. In addition to summarizing the evidence on the relationship between parental separation and psychological well-being, education, social relationships, and own family lives, we discuss how parental separations have been conceptualized, an issue we return to in the subsequent sections.

Parental separation is, however, just one of the family transitions children can experience during their childhoods. The first open question that in our view requires more attention regards the effects of these other family transitions and forms, namely the number of transitions, stepfamilies, and joint residential custody after parental separation (Sect.  3 ). Two of the articles in this Special Issue contribute to this stream of research. Mariani et al. ( 2017 ) present the first European analysis of the effects of family trajectories on children born to lone mothers. Radl et al. ( 2017 ) investigate, in addition to parental separation effects, whether co-residing with siblings or grandparents is related to child outcomes and whether the latter condition the former effects.

The second open question concerns the causal status of the estimated effects (Sect.  4 ): Do family structures and their changes really affect child outcomes, or do the associations reflect some unmeasured underlying factors? This question has attracted deserved attention (e.g., Amato 2000 ; Ribar 2004 ; McLanahan et al. 2013 ), and we review some commonly used methods, using the effects of parental separation as our example. We pay attention to what effects the methods can estimate, in addition to assessing which unobserved variables the different methods adjust for. This discussion highlights the importance of thinking about methodological choices and interpretations of the results in light of the underlying theoretical model of parental separation. The article in this Special Issue by Bernardi and Boertien ( 2017 ) provides also an empirical contribution to this field.

Finally, the last question refers to the heterogeneity in the effects of family dynamics: Are the consequences of parental separation and other family transitions similar for all children? Existing evidence suggests that the answer is no (Amato 2000 ; Demo and Fine 2010 ), but the conclusions about who suffers and who does not remain imperfect, as discussed in Sect.  5 . Three of the articles of this Special Issue analyze these questions, one from a cross-national perspective (Radl et al. 2017 ), one by comparing parental separation effects by socioeconomic background (Bernardi and Boertien 2017 ), and one by immigrant background (Erman and Härkönen 2017 ).

In the final section of this introduction (Sect.  6 ), we discuss some ways forward for future research on family dynamics and children’s outcomes. Two articles in this Special Issue fulfill part of this research agenda by providing evidence on how several less often studied family forms relate to child outcomes in the European context (Mariani et al. 2017 ; Radl et al. 2017 ). The two other articles in this Special Issue (Bernardi and Boertien 2017 ; Erman and Härkönen 2017 ) contribute to the research on heterogeneous consequences of parental separation by clarifying some open questions regarding variation in these consequences by socioeconomic and immigrant background.

2 Parental Separation and Children’s Outcomes

In the 2000s, the share of children who experienced their parents’ separation before age 15 ranged from 10 to 12% in countries such as Bulgaria, Georgia, Italy, and Spain to 35–42% in France, Estonia, Lithuania, and Russia (Andersson et al., forthcoming). In the late 1980s/early 1990s, the corresponding figures ranged from 7 to 30% (Italy and Sweden, respectively, Andersson and Philipov 2002 ).

Parental separation changes children’s lives in many ways. Many scholars conceptualize separations as processes, which often begin way before and last well beyond the actual separation (e.g., Amato 2000 ; Demo and Fine 2010 ; Härkönen 2014 ), even if these starting and ending points can be hard to define. The pre-separation process often involves increasing estrangement and conflict between the parents. These can themselves have negative effects on children’s well-being, and parental separation might therefore already start leaving its traces even before the parents have formally broken up. Not all separations follow such a trajectory. Some families may have had long-lasting conflicts, and other separations might have ended relatively well-functioning partnerships with at least moderate levels of satisfaction (Amato and Hohmann-Marriott 2007 ). The parental separation can in such cases come as an unexpected event for children.

As a result of the separation, children cease to live full-time with both parents, which requires adjustment to the new situation and can start, intensify, or end exposure to parental conflict (Amato 2010 ; Cherlin 1999 ; Pryor and Rodgers 2001 ). Even if joint residential custody of the child post-separation (i.e., children’s alternate living with each parent) is becoming increasingly common, up to one-third and above in Sweden (Bergström et al. 2015 ), the child often receives less involved parenting from the nonresident parent (usually the father), whereas the resident parent’s (usually the mother’s) parenting styles can be affected by increasing time demands (Amato 2000 , 2010 ; McLanahan and Sandefur 1994 ; Seltzer 2000 ). Besides changes in family relationships, a breakup of a household can lead to a drop in economic resources (e.g., Uunk 2004 ). Depending on the country, separated parents may need to adjust their labor supply to meet their new time and economic demands (Kalmijn et al. 2007 ; Uunk 2004 ). Many children also need to move after their parents’ separation, which requires adjustment to a new home environment and possibly a new neighborhood and school. A separation can be followed by further changes in the family structure, such as parental re-partnering, entry of step-siblings, and sometimes, another family dissolution.

Several studies have documented that on average, the lives of children whose parents separated differ from children who lived with both of their parents throughout childhood (Amato 2000 , 2010 ; McLanahan and Sandefur 1994 ; McLanahan et al. 2013 ; Härkönen 2014 ). In the next paragraphs, we provide an overview of the associations of parental separation with some of the most commonly studied child outcomes: psychological well-being and behavioral problems, education, social relationships, and own family lives. In the subsequent sections, we will refine this basic picture by concentrating on other family forms, causality, and heterogeneity in effects.

2.1 Psychological Well-Being and Behavioral Problems

Children of divorce have lower psychological well-being and more behavioral problems than children who grew up in intact families (Amato 2001 ; Amato and James 2010 ; Gähler and Palmtag 2015 ; Kiernan and Mensah 2009 ; Mandemakers and Kalmijn 2014 ). In general, parental separation is more strongly related to externalizing than internalizing problems (Amato 2001 ), and these associations can persist, and even become stronger, into adulthood (Chase-Lansdale et al. 1995 ; Cherlin et al. 1991 ; Lansford 2009 ).

Growing up in a conflict-ridden but stable family can have more negative effects on children’s psychological well-being than parental separation (e.g., Amato et al. 1995 ; Dronkers 1999 ; Hanson 1999 ; Demo and Fine 2010 ). Kiernan and Mensah ( 2009 ) found a role for both maternal depression and economic resources when explaining the lower emotional well-being of children from separated families, whereas Turunen ( 2013 ) found that parental involvement explained part of the lower emotional well-being of children with separated parents, but economic resources did not.

2.2 Education

Children of divorce have lower school grades and test scores (Dronkers 1992 ; Mandemakers and Kalmijn 2014 ; Grätz 2015 ), have lower school engagement (Havermans et al. 2014 ), differ in the kind of track entered in high school (Dronkers 1992 ; Jonsson and Gähler 1997 ; Grätz 2015 ), and have lower final educational attainment (Bernardi and Radl 2014 ; Bernardi and Boertien 2016a ; Gähler and Palmtag 2015 ).

Lower school grades and cognitive performance explain part, but not all of the effect of parental separation on completed education (Dronkers 1992 ). A recent study found that British children of divorce were less likely to continue to full-time upper secondary education even though the parental separation did not affect their school grades (Bernardi and Boertien 2016a ). Parental separation can therefore affect the children’s educational decisions irrespective of their school performance.

Changes in parental resources are an important explanation for the lower educational performance of the children of divorce (Bernardi and Boertien 2016a ; Jonsson and Gähler 1997 ; McLanahan and Sandefur 1994 ; Thomson et al. 1994 ). Studies that have looked into the role of parenting have found differing results, some reporting that parenting partly mediates the effect of separation on educational attainment, while others found parenting to not influence the relationship between parental divorce and school outcomes (Dronkers 1992 ).

2.3 Social Relationships

Despite the increase in shared residential custody (Bjarnason and Arnarsson 2011 ), parental separation generally reduces the child’s contact frequency and relationship quality with the nonresident parent (usually the father), with grandparents and, sometimes, the mother (e.g., Kalmijn 2012 ; Kalmijn and Dronkers 2015 ; Lansford 2009 ). These effects can last into adulthood (Albertini and Garriga 2011 ; Kalmijn 2012 ). Joint residential custody, good inter-parental relations, and good early child-father relations can improve post-separation contact with the father (Kalmijn 2015 ; Kalmijn and Dronkers 2015 ). On the other hand, parental separation can improve the relationships between siblings due to mutual support (Geser 2001 ), but does not seem to trigger more support from friends and other kin (Kalmijn and Dronkers 2015 ).

Good parent–child relationships are desirable by themselves and can also improve other child outcomes (Bastaits et al. 2012 ; Swiss and Le Bourdais 2009 ). For example, having a close relationship with the nonresident parent who engages in authoritative parenting has been found to foster children’s well-being and academic success (Amato and Gilbreth 1999 ). At the same time, contact frequency alone is less important and in some cases, the nonresident parent’s involvement may have negative effects if it increases instability and stress for the child (Laumann-Billings and Emery 2000 ), for example due to continued parental conflict (Kalil et al. 2011 ).

2.4 Own Family Lives

Children of divorce tend to start dating and have their sexual initiation earlier (Wolfinger 2005 ) and many move out of the parental home at a younger age (e.g., Ní Bhrolcháin et al. 2000 ; Ongaro and Mazzuco 2009 ), often because of conflict with parents and their potential new partners (Wolfinger 2005 ). Some studies have also found that children of divorce start cohabiting earlier, are more likely to cohabit than to marry, and have partners of lower socioeconomic status (Erola et al. 2012 ; Reneflot 2009 ; but see also Ní Bhrolcháin et al. 2000 ).

The most consistent family demographic finding is that children whose parents divorced are more likely to divorce themselves as adults (e.g., Diekmann and Engelhardt 1999 ; Dronkers and Härkönen 2008 ; Kiernan and Cherlin 1999 ; Lyngstad and Engelhardt 2009 ; Wolfinger 2005 ). Differences in the life course trajectories before forming the union explain part of this association (Diekmann and Engelhardt 1999 ; Kiernan and Cherlin 1999 ). Other studies have pointed out that parental separation can lead to poorer interpersonal skills and set an example of a feasible solution to relationship problems (Wolfinger 2005 ).

3 What About Other Family Forms?

We have so far focused on parental separation and its relation to child outcomes. Parental separation is not the only family transition children can experience. Between <5% (much of Europe) and up to 15% (Czech Republic, Russia, UK, and USA) of children are born to lone mothers (Andersson et al., forthcoming; Mariani et al. 2017 , this Special Issue). Furthermore, between 14% (Italy and Georgia) and 60% (Belgium) of European children whose parents separate end up living with a stepparent within 6 years (Andersson et al., forthcoming) and often, with step-siblings (Halpern-Meekin and Tach 2008 ). Children’s residence arrangements likewise vary, with some residing primarily with one parent (usually the mother), whereas others alternate between parents (joint residential custody). Extending the focus of research beyond parental separation is necessary to form a more comprehensive view of the effects of the changing family landscape on children’s lives (King 2009 ; Sweeney 2010 ). Footnote 1

One argument puts forward that family stability rather than family structure matters for children’s well-being (cf. Fomby and Cherlin 2007 ; Waldfogel et al. 2010 ). From this perspective, children born to lone mothers who do not experience any family transitions during their childhood (such as the entrance of a stepparent) should do better than children who were born in a two-parent family but experienced a family transition (such as parental separation). Others claim that specific family forms and movements between them do matter beyond general family instability (Magnuson and Berger 2009 ; Lee and McLanahan 2015 ). The findings of Mariani et al. ( 2017 , this Special Issue) are among those that speak against the general instability thesis and show that the types of family transitions experienced by children born to lone mothers matter for their well-being.

Stepfamilies have gained the attention of many scholars. Children in stepfamilies tend to have poorer outcomes compared to those from intact families and display patterns of well-being closer to single-parent families (Amato 1994 , 2001 ; Gennetian 2005 ; Jonsson and Gähler 1997 ; Thomson et al. 1994 ). Indeed, children in stepfamilies can even have lower psychological well-being and educational achievement than children living with a single mother (Amato 1994 ; Biblarz and Raftery 1999 ; Thomson et al. 1994 ).

Reasons for the poorer performance of children with stepparents include the added complexity in family relationships that is often introduced by the presence of a stepparent. This can lead to ambiguity in roles and to conflict in the family (Thomson et al. 1994 ; Sweeney 2010 ), which is among the reasons why having a stepparent often leads to an earlier move from the parental home, especially among girls (Ní Bhrolcháin et al. 2000 ; Reneflot 2009 ). Another explanation points to the presence of step-siblings as stepparents may put less time and effort into their stepchildren than their biological ones (Biblarz and Raftery 1999 ; Evenhouse and Reilly 2004 ). However, having a stepparent can also have positive effects as (s)he can provide financial resources or help in monitoring the children (Thomson et al. 1994 ; King 2006 ; Sweeney 2010 ). Erola and Jalovaara ( 2016 ) showed how a stepparent’s SES was more predictive on adulthood SES than the nonresident father’s SES, and as predictive as the biological father’s SES in intact families. All in all, the effects of step-parenthood are complex and can differ between children who experienced a parental separation and those who never lived with their biological father (Sweeney 2010 ).

The increase in joint residential custody after parental separation has raised interest in its consequences for children. Many studies have reported that children in joint residential custody fare better than children who reside with only one of the parents (usually the mother) on outcomes such as health and psychological well-being, and contact and relationships with their parents and grandparents (Bjarnason and Arnarsson 2011 ; Turunen 2016 ; Westphal et al. 2015 ). However, questions of causality remain unresolved and parents who opt for joint custody might have been particularly selected from those with higher socioeconomic status and lower levels of post-separation conflict. Indeed, many studies find that joint custody may have negative consequences for children in case of high parental conflict (e.g., Vanassche et al. 2014 ; also, Kalil et al. 2011 ). This suggests that policy changes toward joint custody as a default solution may produce unwanted consequences.

4 But What About Causality?

There is a long-standing debate that concerns whether associations between family types and child outcomes reflect causal effects, or whether they are confounded by unmeasured variables. For example, parents who separate can have different (unmeasured) personality traits from those who do not. Other examples include parental unemployment, mental health, or a developing substance abuse problem, which may not only lead to separation, but also affect the parent’s children.

Researchers have used increasingly sophisticated methods to control for different unmeasured sources of bias (for reviews, Amato 2000 , 2010 ; Ribar 2004 ; McLanahan et al. 2013 ). In this section, we discuss some of these methods. We focus on studies that have estimated the effects of parental separation, which serves to illustrate some of the questions involved.

Like most similar reviews, we discuss which (un)measured confounders can be controlled for by the different methods and provide examples of studies that have used them. We also discuss some of the limitations to causal inference in these methods, particularly in light of the underlying theoretical model of parental separation that is assumed. Above, we discussed how parental separations are often theorized as processes that can follow quite different trajectories for different families (Amato 2000 ; Demo and Fine 2010 ; Härkönen 2014 ). Some separations are characterized by a downward spiral of increasing conflict, which can leave its mark on children already before the parents physically separate. Other separations end relatively well-functioning families and can come as a surprise to the children, whereas in some cases the families had high conflict levels for a long time. In this section, we discuss causal inference in light of these underlying models. In the next section, we discuss how these different types of parental separations can have different effects on children.

In addition, we engage in a related but much smaller discussion of what causal questions the different methods can be used to answer (cf., Manski et al. 1992 ; Ní Bhrolcháin 2001 ; Sigle-Rushton et al. 2014 ). A major issue in this regard concerns the counterfactual scenario assumed by different methods. In most studies, the estimated effects are interpreted as telling about how the parents’ physical separation (the separation event) affected the children compared to the counterfactual case in which the parents did not separate. This is, however, not the only possible effect that can be estimated, nor is this interpretation necessarily the correct one in each case.

First, knowing about the effects of the parental separation event is obviously important, but scholars, parents, counselors, and policy makers could likewise benefit from knowing about the “total” effects of parental separation that include the effects of the preceding separation process as well. Second, instead of asking what the effect of the parental separation (compared to them staying together) is, one can ask what the effect is of the parents separating at a specific point in time (the effect of postponing separation) (cf. Furstenberg and Kiernan 2001 ). Our discussion below points to these issues and suggests how some methods can be more appropriate for answering certain questions than others. Rather than providing a comprehensive discussion on this relatively uncovered topic, we wish to stimulate closer consideration of these issues in future research.

4.1 Regression Models

Before discussing methods that adjust for unmeasured confounding factors, we briefly discuss estimation of parental separation effects with linear and logistic (or similar) regression models, which are by far the most common methods used. With these methods, one compares the outcomes of children who experienced parental separation to the outcomes of children from intact families, adjusting for observed confounding variables. Because the possibilities for controlling for all factors that may bias the results are limited, the estimates from regression models cannot usually be interpreted as causal effects (e.g., McLanahan et al. 2013 ; Ribar 2004 ).

Pre-separation parental conflict is often pointed out as an omitted variable that can threaten causal claims. Controlling for pre-separation conflict generally leads to a substantial reduction in the effect of parental separation (e.g., Hanson 1999 ; Gähler and Garriga 2013 ), suggesting that exposure to the parental conflict rather than the parental separation event is largely responsible for the poorer performance of the children of divorce. This example can be used to think about the correspondence between the specified regression model and the underlying theoretical model of parental separation. Controlling for the level of pre-separation parental conflict (or related measures of the family environment) is most appropriate if it is reasonable to assume that families’ conflict levels remain stable; comparing children from separated and intact families at similar levels of earlier conflict can then inform about how the children of divorce would have fared had the parents remained together. However, this is not obvious if the separation followed an increase in parental conflict, because the family environment may have continued to worsen had the parents not separated.

If the above and other conditions for making causal claims are met, which effects do they inform us about? A regression model that controls for pre-separation parental conflict or other related measures is best seen as telling about the effects of the parental separation event. However, an increase in parental conflict is often an inherent part of the parental separation process, and controlling for levels of parental conflict close to the parental separation would not be warranted if one is interested in understanding how exposure to the parental separation process, in addition to the separation event, affects children’s outcomes (cf. Amato 2000 ). The choice of control variables should thus be done with a consideration to the underlying model of parental separation and the effect one wants to estimate.

4.2 Sibling Fixed Effects

Sibling fixed effects (SFE) models compare siblings from the same family who differ in their experience of parental separation before a certain age or life stage, or in the amount of time spent in a specific family type (cf. McLanahan et al. 2013 ; Sigle-Rushton et al. 2014 ). SFE controls for factors and experiences that are shared by the siblings, such as parental SES and many neighborhood and school characteristics. This has made SFE a popular method, not least in Europe. Some SFE studies found no effects of parental separation or other family forms on educational outcomes (Björklund and Sundström 2006 ). Others have found a weak to moderate negative effect on various outcomes even in an SFE design (e.g., Ermisch et al. 2004 ; Sandefur and Wells 1999 ; Sigle-Rushton et al. 2014 ; Grätz 2015 ).

Comparison of siblings from the same family is a core aspect of the SFE design. This affects the data requirements and the interpretation of the results. To fix ideas, we can use an example of the effects of parental separation on children’s school grades at age 15. For an SFE analysis, one needs data on multiple siblings, some of whom experienced the parental separation before age 15 whereas others did not. This requirement reduces the effective sample size. The sibling who did not experience the parental separation is always the older one, and her grades are used to infer about the counterfactual grades of her younger sibling, had she not experienced the parental separation. SFE controls for everything shared by the siblings, but additional controls are needed to adjust for differences between them. Some of these—such as birth order and birth cohort and/or parental age (Sigle-Rushton et al. 2014 )—are available in many datasets, but remaining unobserved differences (as well as measurement error) can cause important bias to the estimates (Ermisch et al. 2004 ; Frisell et al. 2012 ).

SFE models are most informative of the effects of parental separation if it is reasonable to assume that the family environment (including levels of parental conflict) would remain stable in the absence of the parental separation (Sigle-Rushton et al. 2014 ). In such a case, it is most likely that the younger sibling would have experienced a similar family environment as the older sibling, had the parents not separated. The interpretation of SFE results becomes more problematic if the parental separation is the culmination of a deterioration of the family environment (such as increased parental conflict). It is likely that the family environment would have continued to deteriorate had the parents not separated, and the younger sibling would have been taking her grades in a more conflictual family (than her older sibling experienced). Without additional measures, SFE models thus generally rely on the assumption of the stability of the family environment (cf. Sigle-Rushton et al. 2014 ).

SFE models estimate the effect of the event of the parental separation rather than the separation process. Because SFE models are estimated from a subsample of families that dissolved, the estimates are difficult to generalize without making additional assumptions. Also, because the estimates tell about differences between siblings who experienced parental separation but at different ages, or experienced a different amount of time in a separated family, the estimates are best interpreted as effects of the timing of the separation, as argued in detail by Sigle-Rushton and colleagues (2014).

4.3 Longitudinal Designs

Research with longitudinal data has been more applied  in the USA than in Europe (McLanahan et al. 2013 ), possibly because of data access issues. Such data can be analyzed using many methods, but unlike with SFE, these methods can only be used to analyze outcomes that are measured more than once. Similar to SFE models, longitudinal studies generally report weaker effects on child outcomes of parental separation and other family transitions than found in cross-sectional analyses.

4.3.1 Lagged Dependent Variables

In lagged dependent variable (LDV) analyses, one controls for the dependent variable at an earlier measurement point (before parental separation) (Johnson 2005 ; McLanahan et al. 2013 ). The idea is to adjust for initial differences in outcomes between children from separated and intact families. LDV is mostly used in cohort and other studies with just two or few measurement points. Early examples include studies in Britain, which found that although children of divorce had lower psychological well-being already pre-divorce, parental divorce had negative long-term effects (Cherlin et al. 1991 ; Chase-Lansdale et al. 1995 ). Limitations of LDV models include that the estimates are sensitive to omitted variables that affect both the separation and the pre-separation outcome, as well as measurement error in the latter (Johnson 2005 ).

The pre-separation measurement point can correspond poorly to the stages of the parental separation process, especially in cohort studies in which measurements are often done several years apart. LDV models are therefore most appropriate if the differences in the outcome between children who experienced parental separation and those who did not can be assumed to be stable. If one assumes that the child’s well-being deteriorated prior to the separation, the lagged dependent variable can capture part of the effect of the separation process. However, if the measurements are taken several years apart, it is even more difficult than usual to tell whether the outcome was measured before or during the pre-separation deterioration in well-being and consequently, how the estimated coefficient should be interpreted.

4.3.2 Individual Fixed Effects

Individual fixed effects (IFE) models are based on comparing individuals before and after the parental separation and in effect, use individuals as their own control groups to control for time-constant unobserved factors. In an early British IFE study, Cherlin et al. ( 1998 ) concluded that experience of parental separation had weak to moderate negative effects on adulthood psychological well-being, and Amato and Anthony ( 2014 ) reported similar effects on educational, psychological, and health outcomes in the USA. Other American studies have used IFE designs to analyze the effects of the number of transitions (e.g., Fomby and Cherlin 2007 ), of different family transitions (e.g., Lee and McLanahan 2015 ), or combined SFE and IFE approaches (Gennetian 2005 ).

IFE methods estimate the effect of parental separation if it is reasonable to assume that the child whose parents separated would have experienced similar (age-specific) outcomes in the absence of separation as observed before the separation (Aughinbaugh et al. 2005 ). Again, this is most feasible if the child’s level of well-being can be assumed to have remained stable. This is less likely if the child’s well-being began to deteriorate already before the separation, because this deterioration could have continued had the parents not separated. Two US studies attempted to address this issue by tracing behavioral problems and academic achievement before and after the parental separation (Aughinbaugh et al. 2005 ) and by using a triple-difference approach, which compares trends (and not just levels) in the outcome between children from separated and intact families (Sanz-de-Galdeano and Vuri 2007 ). Neither study found the event of parental separation to have appreciable effects.

Furthermore, as in SFE models, IFE effects are estimated only from those children who actually experienced the separation. This generally means a reduction in sample size. For the same reason, IFE results generalize primarily to that group.

4.3.3 Placebo Tests and Growth-Curve Models

Longitudinal data can also be used to conduct “placebo tests,” that is, to analyze whether future separation (e.g., t  + 1) predicts earlier outcomes ( t , or earlier). Bernardi and Boertien (in this Special Issue) found with British data that although children who experienced parental separation before age 16 had a lower probability of transitioning to post-compulsory secondary education, this was not the case for children whose parents separated between ages 17 and 19 (i.e., after the educational transition age). This supports the view that the separation, and not the family environment that preceded it, had an effect on educational decisions.

Finally, longitudinal data have been analyzed with growth-curve models (GCM) to track trajectories in children’s outcomes. Cherlin et al. ( 1998 ) reported that the effects of parental separation on psychological problems increased through adolescence and young adulthood. Even though growth-curve models enable analysis of how effects develop, they are not immune to confounding from unmeasured variables that can affect both the initial level of well-being and its development over time (McLanahan et al. 2013 ). To address this, Kim ( 2011 ) combined matching methods with GCM and found that cognitive skills and non-cognitive traits developed negatively already through the separation period and the effects were amplified by the separation event.

4.4 Interpreting Causal Effects

Controlling for measured and unmeasured confounders practically always leads to reduced effect sizes, which means that children who experienced parental separation would have fared differently to children from intact families regardless. Some studies have found no effects, but the prevailing conclusion is that parental separation can have weak to moderate negative effects (Amato 2000 , 2010 ; McLanahan et al. 2013 ; Ribar 2004 ).

Increasing adoption of advanced methods to control for unmeasured variables improves our understanding of the consequences of family change. None of the methods are, however, completely immune to confounding by unobserved variables. Relatedly, they also correspond differently to underlying theoretical models of parental separation, which affects their interpretation.

We repeatedly mentioned how the methods are most robust if it is reasonable to assume that the family environment, and the children’s well-being, remained stable before the separation and would have remained stable in its absence. Such a scenario characterizes some separations but provides a poorer description of many others where separation was a culmination of a deteriorating family environment (Amato 2000 ; Demo and Fine 2010 ; Härkönen 2014 ). In some cases, additional (time-varying) control variables (e.g., Ermisch et al. 2004 ; Lee and McLanahan 2015 ) or more complex research designs (e.g., Sanz-de-Galdeano and Vuri 2007 ) can be used to alleviate these problems. When choosing the appropriate variables or designs, one should decide whether one is interested in the effects of the separation event or the exposure to the whole separation process. Both are relevant, and their analysis each carries specific challenges. We also discussed how some estimates might be better interpreted as indicators of the influence of the timing of parental separation (cf. Furstenberg and Kiernan 2001 ), another relevant yet different question. All in all, scholars should pay attention to which effects their methods estimate and think of this in light of the underlying theoretical model of parental separation or other family dynamics they are interested in (cf. Manski et al. 1992 ; Ní Bhrolcháin 2001 ).

5 For Whom, When, and Where are Family Transitions Most Consequential?

Most studies reviewed above analyzed what happens on average . Whereas the finding that children growing up in non-traditional families have different outcomes is very consistent, this result hides a large variation in effects at the individual level. A minority of children suffer from a parental separation, but a somewhat smaller minority shows improvements in well-being and performance, and even if parental separation can be a taxing experience associated with sadness and feelings of loss, a large minority or even a majority of children do “just fine” without robust effects in either direction (Amato 2000 , 2010 ; Amato and Anthony 2014 ; Amato and James 2010 ; Demo and Fine 2010 ). Next, we discuss how this heterogeneity in effects is related to pre-separation parental conflict and children’s and parents’ socio-demographic attributes. After that, we review what is known about variation in the effects over time and cross-nationally.

5.1 For Whom Does It Matter?

Which children are more likely to suffer from parental separation than others? Studies both from the USA (Amato et al. 1995 ; Hanson 1999 ; Booth and Amato 2001 ) and Europe (Dronkers 1999 ) have found that pre-separation parental conflict moderates the effects of the separation. Parental separation can be beneficial for children from high-conflict families, but is more likely to have negative effects when parental conflict was low and the separation came as a relative surprise.

Other studies have analyzed variation in the effects of parental separation by demographic characteristics. Although some studies have found gender-specific effects, most have not, leading Amato and James ( 2010 ) to conclude that the gender differences in effects are modest at most. Similar variation in findings characterizes research on effects of stepfamilies (Sweeney 2010 ).

Child’s age at parental separation has been another moderator of interest. Breakups occurring while children are adults have no or the smallest effects (Cherlin et al. 1998 ; Kiernan and Cherlin 1999 ; Furstenberg and Kiernan 2001 ; Lyngstad and Engelhardt 2009 ). Studies on educational outcomes often find the effects to be most pronounced when parents divorced close to important educational decision points (Jonsson and Gähler 1997 ; Lyngstad and Engelhardt 2009 ; Sigle-Rushton et al. 2014 ). Otherwise, findings differ in their conclusions about the childhood stages most sensitive to family disruption, and the specific pattern of heterogeneity is likely to depend on the outcome studied.

Recently, scholars have become increasingly interested in whether effects of parental separation differ by parental socioeconomic status (Augustine 2014 ; Grätz 2015 ; Mandemakers and Kalmijn 2014 ). Although having resources can help families to deal with family transitions, children from resourceful families could also lose more from parental separation (Bernardi and Radl 2014 ; Bernardi and Boertien 2016a ). In line with these contrasting predictions, empirical results are mixed, with some findings pointing to stronger negative effects in families with high (Augustine 2014 ; Grätz 2015 ; Mandemakers and Kalmijn 2014 ) or low socioeconomic status (Bernardi and Boertien 2016a ; Bernardi and Radl 2014 ; Biblarz and Raftery 1999 ; Martin 2012 ; McLanahan and Sandefur 1994 ). Bernardi and Boertien ( 2017 , this Special Issue) address this inconsistency. They show that methodological choices underlie part of this variation in results, but their substantive conclusion is that the negative effect of parental separation on educational choices is stronger for children whose high-socioeconomic status father moves out. The greater financial losses are an important part of the explanation, which also suggests that the results might be different for outcomes that are less responsive to financial resources.

Other studies have compared the effects of parental separation and single parenthood between ethnic, racial, and migrant groups. Many US studies have found that Black children are less affected by growing up in a non-intact family than White children (Fomby and Cherlin 2007 ; McLanahan and Bumpass 1988 ; McLanahan and Sandefur 1994 ; Sun and Li 2007 ). Some European studies have found variation in family structure effects by ethnic and immigrant background (Kalmijn 2010 , forthcoming; Erman and Härkönen, this ‘Special Issue’). In general, the family structure effects are weaker in groups in which parental separation and single motherhood are more common, which has been explained by less stigma, better ways of handling father absence, a broadly disadvantaged position with less to lose, or differential selection by unobserved factors, as argued by Erman and Härkönen in this Special Issue.

Instead of analyzing different predictors of separation separately, Amato and Anthony ( 2014 ) used several of these predictors together to, first, predict the children’s propensity to experience parental separation, and second, analyze whether parental divorce effects vary by this propensity. They found that the effects were the strongest for children with the highest risk of experiencing parental divorce, a result seemingly at odds with the above-mentioned findings of weaker effects in groups with higher separation rates.

5.2 Stability Over Time

It is straightforward to expect that the effects of family transitions on child outcomes should have waned over time. As non-traditional family forms have become more common, the social stigma attached to them should decrease (Lansford 2009 ). Children of divorce are also increasingly likely to retain close contact with both of their parents (e.g., Amato and Gilbreth 1999 ; Gähler and Palmtag 2015 ) and families and societies may have in general become better in handling the consequences of family change. Yet, several studies have reported remarkable stability in the negative associations between parental separation and educational attainment, psychological well-being, and own family dissolution risk (Albertini and Garriga 2011 ; Biblarz and Raftery 1999 ; Dronkers and Härkönen 2008 ; Sigle-Rushton et al. 2005 ; Li and Wu 2008 ; Gähler and Palmtag 2015 ). Some studies have found changing effects, but in opposite directions: a waning intergenerational transmission of divorce (Wolfinger 2005 ; Engelhardt et al. 2002 ), but a strengthening effect of parental separation on educational attainment (Kreidl et al. 2017 ).

Why this general stability? One possibility is that although some factors associated with parental separation, such as stigma, have become less common, other proximate consequences—including shock, grief, and anger over the separation of the parents (Pryor and Rodgers 2001 )—have remained stable. Another potential explanation refers to changing selection into separation. Parental separation has become increasingly associated with low levels of maternal education (Härkönen and Dronkers 2006 ). The motives for divorce have also changed over time. Fewer parental separations are today preceded by severe conflict and violence, whereas more are characterized by psychological motives and disagreements upon the division of labor (De Graaf and Kalmijn 2006 ; Gähler and Palmtag 2015 ). In general, changing selectivity of parental separation can have offset any weakening trend in its effects. The data requirements to disentangle these explanations are high, but those studies which have appropriate variables support the conclusion of a generally stable effect (Sigle-Rushton et al. 2005 ; Gähler and Palmtag 2015 ).

5.3 Cross-National Variation

Associations between family structure and child outcomes are robust in the sense that they are generally found in each country (cf. Amato and James 2010 ) and are often more similar than one might expect (Härkönen 2015 ). However, many studies have reported cross-national variation in the strength of associations (e.g., Brolin Låftman 2010 ; Radl et al. 2017 , this Special Issue). A series of studies found that countries with policies aimed at equalizing the living conditions between different types of families had smaller family structure gaps in educational achievement (Pong et al. 2003 ; Hampden-Thompson 2013 ; however, see Brolin Låftman 2010 ). Larger family structure differences have also been reported in economically more developed societies, where the nuclear family plays a more important role (Amato and Boyd 2014 ).

Dronkers and Härkönen ( 2008 ) found that the intergenerational transmission of divorce was weaker in countries where parental divorce was more common. This fits the intuition of weaker penalties when certain family behaviors are more common. However, other studies have found the opposite (Pong et al. 2003 ; Kreidl et al. 2017 ). An explanation is that in societies in which separation is uncommon, it is more often a solution to ending very troubled relationships and therefore more likely to be beneficial for the children.

6 Discussion and Recommendations for Future Research

We set the stage for future research in four directions. First, understanding the effects of heterogeneous family forms and transitions will be a research priority in the future as well (Amato 2010 ). Most of the research reviewed in this introduction has focused on the effects of parental separation, but scholars have been increasingly aware of and interested in the complexity of family forms in today’s societies. Some of this research was addressed in this article, and the analyses by Mariani, Özcan, and Goisis, and Radl, Salazar, and Cebolla-Boado in this Special Issue are further contributions to this topic: the former being the first to look at the outcomes of children born in lone mother families within one European country (the UK), and the latter providing a cross-national overview of the effects of various types of family structures. Future research, particularly in Europe, should continue addressing questions such as the effects of experiencing multiple family transitions and of complex family life course trajectories during childhood. Family complexity can also mean that the boundaries between family forms become blurred. An example is the increasing popularity of joint residential custody, which questions earlier divisions into single-parent and two-parent families. Understanding the effects of family forms under family complexity thus also means an update in conceptual thinking.

Second, children react to (changes in) family circumstances in remarkably different ways (e.g., Amato and Anthony 2014 ), which is hidden under the average effects reported in most studies. Three of the papers in this Special Issue address these questions and identify subgroups for which effects appear to be more limited compared to other groups such as low SES families and children from ethnic minorities. Better understanding the sources of vulnerability and resilience in the face of family change will continue to be a priority for research, and in this task, future research will benefit from combining theoretical and methodological approaches from sociology, demography, psychology, and genetics (cf. Amato 2010 ; Demo and Fine 2010 ).

Another related task for future research will be to systematize the research on variation in family structure effects across individuals and families, groups, and societal contexts. As reviewed in this article, the findings often point to confusingly different directions. Many studies, including the ones by Erman and Härkönen and Bernardi and Boertien in this Special Issue, have found that parental separation effects on educational outcomes are weaker in socioeconomic and ethnic groups where it is more frequent, but Amato and Anthony ( 2014 ) reported that the effects are more negative for children who had the highest risk of experiencing parental separation. Yet another group of studies have reported that the effects of parental separation are more negative when the parents had lower levels of conflict—and presumably, low likelihood of separating—before the separation (Amato et al. 1995 ; Dronkers 1999 ; Hanson 1999 ; Demo and Fine 2010 ). Many cross-national studies have concluded that these effects are stronger in societies in which parental separation is more common (Pong et al. 2003 ; Kreidl et al. 2017 ). At the same time, most studies continue to find that parental separation effects have remained stable even though more children have been experiencing it. Understanding these seemingly contradictory results will need theoretical development and appropriate data and designs to test them. Bernardi’s and Boertien’s study in this Special Issue provides a good example of such research.

Third, future research will undoubtedly continue employing sophisticated methods to analyze whether family structures and transitions have causal effects on children’s lives. Yet as discussed above, conceptual thought of what effects can be estimated with different methods and what effects are of most theoretical interest has not necessarily kept up with the methodological advances (for exceptions: Manski et al. 1992 ; Ní Bhrolcháin 2001 ; Sigle-Rushton et al. 2014 ). Using parental separation as our example, we distinguished between the effects of separations as events and separations as processes, as well as between the experience of separation and its timing. Researchers should pay more attention to these differences in the conceptualization of effects, which essentially boils down to the consideration of the underlying theoretical model of parental separation. Better recognition of these differences can contribute to theory-building and methodological advancement and help in formulating advice to parents, family counselors, and policy makers.

Last, these issues have implications for understanding social inequality in a time of family change. The “diverging destinies” thesis (McLanahan and Percheski 2008 ) holds that socioeconomically uneven family change, in which the retreat from stable two-parent families is happening particularly among those with low levels of education, can reduce social mobility. Yet whether this is the case depends not only on differences in family structures by socioeconomic background, but also on the strength of the effects of these family structures on the outcomes in question; if the effects are nil or weak, it does not matter who lives in which kind of family. The inequality-amplifying effects of socioeconomic differences in family structures can furthermore be shaped by heterogeneity in family structure effects (Bernardi and Boertien 2016b ). Bernardi’s and Boertien’s (2017, this Special Issue) findings, that the negative effects of parental separation are weaker for children whose parents have low levels of education, imply that the socioeconomic differences in family instability are less important in affecting intergenerational inequality than often thought. Erman’s and Härkönen’s ( 2017 , this Special Issue) results show that parental separation effects are weaker among ancestry groups where parental separation is more common suggest the same for ethnic inequalities. Together, these findings refine arguments stating that divergence in family structures will lead to an increase in inequality. Instead, the results imply that whether this happens or not is contingent on the strength of these effects and on whether they are similar across groups.

This quest will likely continue in the future; Ultee ( 2016 ) anticipated that in 2096, the book awarded for preservation of European sociological research will be called “Growing Up With Four Parents”.

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Acknowledgements

This Special Issue features research done within work package 5 (Family Transitions and Children’s Life Chances) of FamiliesAndSocieties ( www.familiesandsocieties.eu ). We thank the members of the consortium and our work package for productive collaborations and fruitful discussions during the project. We also thank the editorial team of European Journal of Population for the opportunity to publish this Special Issue and their feedback on earlier drafts. In addition, we are grateful to the reviewers for constructive comments to earlier versions to each of the articles in this Special Issue. The research leading to these results has received funding from the European Union’s Seventh Framework Programme (FP7/2007–2013) under Grant Agreement No. 320116 for the research project FamiliesAndSocieties and from the Strategic Research Council of the Academy of Finland (Decision Number: 293103) for the research consortium Tackling Inequality in Time of Austerity (TITA).

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Juho Härkönen

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Diederik Boertien

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Härkönen, J., Bernardi, F. & Boertien, D. Family Dynamics and Child Outcomes: An Overview of Research and Open Questions. Eur J Population 33 , 163–184 (2017). https://doi.org/10.1007/s10680-017-9424-6

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Accepted : 12 March 2017

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Issue Date : May 2017

DOI : https://doi.org/10.1007/s10680-017-9424-6

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5 Benefits of Learning Through the Case Study Method

Harvard Business School MBA students learning through the case study method

  • 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

Your Guide to Online Learning Success | Download Your Free E-Book

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

  • Business essentials
  • Leadership and management
  • Entrepreneurship and innovation
  • Finance and accounting
  • Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

discuss the importance of family case study

About the Author

COMMENTS

  1. PDF Teaching Multiple Perspectives: Family Theory and Case Assignments

    case study approach. Creswell (2013) states that case study research can begin with a specific project that is "in progress" or with continuing situations such as an educational course that evolves over time to better address needs of the students. A good qualitative case study presents an "in-depth understanding of the case" (p. 98).

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  11. PDF A Family Case Study: How Money Might Matter for Academic Learning

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  12. The importance of family: a case report

    This case report highlights the importance of the role of the family in supporting a young person with a developmental disability. The young person discussed has a complex neurodevelopmental disorder with co‐morbid physical health problems. Her family have coped with a number of events in CR's life, ensuring that she has always had their ...

  13. Full article: 'Ordinary' and 'diverse' families. A case study of family

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    A study by O'Connor et al. (2018) found educators were hesitant to engage with parents even though they acknowledged the importance of the parent-child relationship. Given evidence about the importance of educator-parent relationships, and as part of a large exploratory project, we explored current partnership practice across the ECEC ...

  15. PDF Real Cases Project: Family-Oriented Social Work Treatment

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  16. The Importance of Family and the Role of Systemic Family Therapy

    Systemic family therapy (SFT) is the mental health profession and practice that focuses on family relationships. In this overview chapter, we describe the defining characteristics of the field that include (a) focus on family relational processes as the primary mechanism of treatment, (b) a broad definition of family, and (c) flexibility as to which family members are seen directly in treatment.

  17. What Is a Case Study?

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  18. What methods are used to promote patient and family involvement in

    The research design was a multiple case study of patient and family involvement in regulation in four countries. A case was defined as a country and the methods identified for patient and family involvement in organizational regulation of quality and safety in healthcare . The scope of our cases was limited to the regulation and regulatory ...

  19. Family Dynamics and Child Outcomes: An Overview of Research ...

    The recent decades of family change—including the increases in divorce and separation rates, single parenthood, cohabitation, and step family formation—led to an explosion in popular and academic interest in the consequences of family dynamics for children's well-being and life chances (cf. Amato 2000, 2010; Amato and James 2010; Ribar 2004; Sweeney 2010; McLanahan et al. 2013).

  20. Family‐centred care in early intervention: A systematic review of the

    1 INTRODUCTION. Family-centred care (FCC) is widely established as the standard model of professional practice in early intervention (EI) and paediatric hospital settings (Espe-Sherwint, 2008).Positioned as part of the family systems paradigm, FCC has theoretical origins in both empowerment and help-giving philosophies (Dempsey & Keen, 2008), with contemporary theories taking a social systems ...

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  22. 5 Benefits of the Case Study Method

    Through the case method, you can "try on" roles you may not have considered and feel more prepared to change or advance your career. 5. Build Your Self-Confidence. Finally, learning through the case study method can build your confidence. Each time you assume a business leader's perspective, aim to solve a new challenge, and express and ...

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