It was hard to hear him over the rhythmic humming of the ventilation, so I leaned in as his other classmates filtered out of the room.

“How do you be a dad?”

As a pediatrician, most of the questions I am asked are technical ones.  What is this rash?  How do you change the diaper without getting peed on?  Is this normal?  Should I be worried?  What am I doing wrong?  How do I do this right? I was reminded of my own experiences in a prenatal classroom with other newly expectant fathers, coaching them to articulate their fears about accidentally hurting the baby or dealing with other insecurities they didn’t quite know how to ask for help with.  But the question he asked sounded more philosophical, more similar to the questions I have asked myself in moments of exasperation and self-doubt: What does it mean to a father?  How do I parent in a way that isn’t a simple replication of the way in which I was parented?  How has society changed the roles and norms of the father, and what do I do with all that?

He clarified.

“I haven’t seen my older kids in years.  They come and visit… but I don’t really have a relationship any more with them.  That’s all going to change in a couple of weeks, especially with the youngest, and I want to be a good dad… it’s just… how do you be a dad?”

Most of my clinical practice in pediatrics has been with newborns in the hospital.  I have spent countless hours refining and delivering advice to nervous and new caretakers of all situations.  Some are teenagers that are sixteen or even fourteen years old.  Others are grandparents, brought literally out of retirement to parent on behalf of a mother unable to.  Some refuse immunizations and the medications; some are struggling to stay in treatment and on meds.  Most are mothers, though I particularly enjoy conversations with fathers as they seemed to be the most uncomfortable and out of sorts in hospital & healthcare settings.

But this wasn’t the hospital, and as I absently looked at the correctional officer waiting patiently outside the classroom door for my response and the conclusion of our conversation, I realized that nothing in my professional or personal experiences had explicitly prepared me to answer his question.

A 2018 commentary in Pediatrics on a new study summarized the issue plainly (emphasis mine):

Overall, >2.7 million US children (1 in 28; roughly 1 per school classroom or dozens per general pediatrician’s average panel) have a parent who is currently incarcerated.² For African American children, the proportion is 1 in 9.² On any given day, approximately one-half of federal and state prisoners are parents of children <18 years of age.³ Moreover, parental incarceration is disproportionately high among poor children, and for immigrant children, concomitant parent status concerns may dramatically heighten risks.²

Given the limitations of the data set, there is a lack of clarity on the precise mechanisms linking parents’ incarceration with their children’s worsening long-term health and higher rates of forgone care. The authors speculate that mechanisms may relate to disruptions in a child’s family unit. These disruptions may result in both direct psychological damage and indirect damage through the overburdening of other caregivers, financial stress, and the learned mistrust of systems (including health systems) that foster a lifelong pattern of higher-risk behaviors and weaker engagement in care. These pathways, although plausible, need to be examined. What also needs to be examined is how parental incarceration may both overlap with and be distinct from other types of family separation, including parent death, parent divorce, child protective services involvement, parent deportation, or inhumane border policies.

Findings that reveal differential effects of maternal versus paternal incarceration are novel and intriguing… Although the mechanisms for these differences are unclear, they suggest that parental incarceration may impact youth differently depending on parent sex.

Given the observed associations, what should be done next?

The commentary goes on to recommend screening, referrals to social work & psychology, and even Sesame Street’s clinician toolkit.  A series of Google searches revealed a few more pragmatic resources:

• Practical: This short article best summarized things I’d be able to fit into an outpatient clinical visit, such as different stages of adjustment that children may go through after reunification (honeymoon, suspicion, resistance, expression or withholding) and highlights of the various emotions they may express.  I also appreciated the resource guide for parents incarcerated in Colorado with specific guidance for walking through legal issues such as paternity cases & claims (though this is state dependent).
• Comprehensive: The National Responsible Fatherhood Clearinghouse has a toolkit and subsection dedicated to working with incarcerated and re-entry fathers.  Perhaps most helpful is the Resources section which includes links (with curricula) for practitioners.  The Child Welfare Information Gateway also has a resource list that is fairly recent.
• Academic: Mixed-method studies from DHHS are illuminating and disturbing to read.  Of particular note is this 2018 study by Western & Smith that clarifies some of the traditionally held views that negative effects on children of formerly incarcerated parents is primarily related to economic insecurity, demonstrating more specifically and more strongly the negative impact of unstable housing for parents after release (as compared to low income).

But I didn’t know any of this at the time.  I can hardly remember what I said except for the generic parenting advice about respecting the limits & routines already established and giving frequent reassurances, verbal and otherwise, to the children that they were safe and loved.  Even as we parted, I could hear the residual tone of a deep, unresolved anxiety in his “thank you”.

As the correctional officer walked our team out through the corridors and beyond the series of gates, as I drove through the old neighborhood in which nearly all my neighbors who were fathers had walked the same path and breathed the same stale air as that young man, I felt an undefinable restlessness.  I returned to a home in which my children ran to hug me, oblivious (or accustomed) to my quietness after these rare “evening meetings” so close to their bedtime.  When they went to sleep I lay down next to my eldest, listening to the white noise of the air purifier and absorbing its low, resonant, dissonant hum.

One in nine.