AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE & DENTISTRY

"Being a single parent is becoming more and more common, with the US Census Bureau estimating that there are around 12 million single parent families. As relationships change and dissolve, many children are left with a lone parent." 1

"Rearing a child with disabilities is a challenge, perhaps even more so for single parents who most often are women. Stress and negative psychological effects have been considered likely outcomes for parents of children with disabilities. With the increased family focus in the provision of services for children with disabilities, it becomes even more important to understand the sources of stress and the types of adaptations made in these families…Single mothers of children with disabilities often were younger, had less education, and lower incomes… Findings indicate that gross differences between single- and two-parent mothers tended to become nonsignificant when maternal education and income were taken into account." 2

BY H. BARRY WALDMAN, DDS, MPH, PHD AND STEVEN P. PERLMAN, DDS, MSCD, DHL (HON)

"Children with a disability are often born into low-income families, and families who care for children with a disability often slide into poverty. According to Census 2000, poverty rates among families caring for children with disabilities are 21% higher than families who do not have children with disabilities." 3

KEEP IN MIND

Medicaid and the Child Health Insurance Plan (CHIP) covered about half (48%) of all children with special health care needs in 2016. Less than one in five (19%) children with disabilities receives Medicaid because they also receive federal Supplemental Security Income (SSI) benefits. Other Medicaid coverage pathways for children with disabilities are offered at state option. Reflecting different state policy choices, the share of children with special health care needs covered by Medicaid/CHIP varies by state from 23% to 67%.

• Medicaid's benefit package for children, Early and Periodic Screening Diagnostic and Treatment, covers physical and behavioral health services as well as long-term care services that enable children with chronic needs to live at home with their families. Medicaid supplements special education services and fills in coverage gaps for privately insured children with special health care needs.

• Annual per enrollee spending is over seven times higher for Medicaid children who qualify through a disability pathway ($17,831) compared to those who qualify through another pathway, such as family income ($2,484) as of 2013. This reflects the greater intensity and variety of needs among most children who qualify based on a disability compared to most children who qualify through another pathway. Legislative proposals that would reduce and cap federal Medicaid funding may pose a particular risk to children with special health care needs. 4

IN ADDITION

In terms of parental arrangements – Nationally, (living with two parents currently married) 15.8% of children have special health care needs; ranging from, 11.4% in California and 11.6% in the District of Columbia to 22.0% in Louisiana and 22.4% in West Virginia. Nationally, (living with a single mother) Graph 1. Children with Special Health Care Needs, Aged 0-17 years Nationwide 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 15.8 20.0 27.9 25.2 Children with special health needs (CSHCN) Two parents, currently married Other family type, no parent reported 25.2% of children have special health needs; ranging from 17.3% in Hawaii to 44.8% in Montana. 5 (See Graph 1)

REALITIES

"… divorce, particularly with often-attendant drops in income, parental involvement, and access to community resources, diminishes children's chances for wellbeing. It is revealed that children whose parents live apart are twice as likely to drop out of high school as those in two-parent families, one and a half times as likely to be idle in young adulthood, and twice as likely to become single parents themselves." 6

"Although much has been written suggesting that stress, grief, and other factors associated with parenting a child with disabilities results in high rates of marital discord, marital dissatisfaction, and divorce, this notion is poorly supported by research. Research demonstrates that parents of children with disabilities have marriages that exhibit the full range of function and dysfunction seen in the general population, most parents of children with disabilities have normal marriages, and the same things that predict healthy and unhealthy marriages in the general population also predict healthy and unhealthy marriages among parents of children with disabilities… (But among single divorced mothers raising) children with disabilities, the average income was only 62% of the "minimum subsistence" level." 7

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"… we found that divorce rates were not elevated, on average, in families with a child with developmental disabilities. However, in small families, emphasis added)there was a significantly higher risk of divorce relative to a normative comparison group." 8

Nevertheless, there are over 9 million single mothers in the United States today. On top of demanding work schedules and child care responsibilities, single moms face a higher risk of developing health problems than their married peers. Employed single mothers are 40% more likely to have cardiovascular health problems and 74% more likely to have a stroke compared to married moms who worked. They are also 77% more likely to smoke.

The more time women spend parenting alone, the more likely their health will worsen as they age, affecting their ability to do even the most menial tasks. 9

THOUGHTS FOR SINGLE PARENTS OF CHILDREN WITH SPECIAL NEEDS

"Parenting as a single parent is difficult enough in "normal" circumstances, but when your child has special needs, there's an even greater level of difficulty. The challenges seem to double, and if there is no support from the other parent, you're on your own to manage the care of your child with special needs, and sometimes your other children as well." 10

• Create a schedule and try to be consistent. A schedule can help reduce many stressors. If your child knows what to expect, he/she will probably have fewer meltdowns, leaving you more time to handle other things, and decreasing your stress.

• If your child's other parent can be involved, work on co-parenting for the best interest of your child. Each of you will have ideas about how your child should be raised, but do your best to keep routines consistent in both households.

• Network with other single parents who have kids with special needs. Many parents feel the need to meet other parents who are going through similar challenges. Lots of parents are now using social media to gather and support each other online. Again, there will be groups that are for all disabilities, and some will be diagnosis specific. No matter how you choose to find support, other parents can be your best resource.

• Create opportunities for family time. Even with a busy schedule, it is important to spend time together as a family.

• Counseling can provide great relief.

• If you have other children who are old enough to help, let them help, but not too much.

• If you need assistance with housing, food, healthcare, or childcare find assistance from your local social service agencies.

• Take some time for yourself. As a single parent, this is the most important thing, but also may seem like the most impossible. A good way to get in a few minutes for yourself here and there is by setting strict bedtimes for your children. Of course there will be interruptions to your routine, but generally that time can be yours. 10 Are the children worth it? You're darn right! •

ABOUT THE AUTHORS: H. Barry Waldman, DDS, MPH, PhD is a SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. E-mail: h.waldman@stonybrook.edu Steven P. Perlman, DDS, MScD, DHL (Hon) is the Global Clinical Director and founder, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine.

References 1. Marriage.com. Impact of single parenting on children's development. February 2017. Available from: marriage.com/advice/parenting/impact-of-single-par- enting-on-childrens-development Accessed November 15, 2018. 2. Boyce GC, Miller BC, White Kr, et al. Single Parenting in Families of Children with Disabilities. Marriage and Family Review, 20(3-4):389-409, 1994. 3. Millennial Voice: Raising Children with Special Needs—Are Mothers disabled too? Available from: workflexibility.org/millennial-voice-raising-children-with- special-needs-mothers-disabled Accessed November 15, 2018 4. Kaiser Family Foundation. Medicaid for children with disabilities Available from: Accessed November 16, 2018. 5. Child and Adolescent Health Measurement Initiative. 20162017. National Survey of Children's Health. Available from: childhealthdata.org/browse/survey/results?q=5355&g=65 8&r=1 and childhealthdata.org/browse/survey/results?q=5355&g=65 8Accessed November 16, 2018. 6. McLanahan S, Sandefur G. Growing up with a single parent. What hurts, what helps. Harvard University Press, Cambridge, MA, 1994. 7. Sobsey D.. Marital stability and marital satisfaction in families of children with disabilities: Chicken or egg? Developmental Disabilities Bulletin, 2004;32(1):62-83. 8. Peterson C. Are divorce rates really higher for parents of kids with disabilities? Available from: themighty.com/2018/03/divorce-rates-parents-of-kids-with-dis- abilities Accessed November 16, 2018. 9. Mehta S. The health toll of single motherhood: single mothers at higher risk for health issues. Available from: healthi- fy.us/healthify-insights/the-health-toll-of-single-motherhood Accessed November 16, 2018. 10. Medical Home Portal. Tips for single parents of children with special needs. Available from: medicalhomeportal.org living-with-child/taking-care-of-yourself-and-your-family/tips-for-single-parents-of-children-with-special-needs Accessed November 16, 2018.