Family Well-being in Grandparent-Versus Parent-Headed HouseholdsEli Rapoport, BS,a Nallammai Muthiah, BS,a Sarah A. Keim, PhD, MA, MS,b,c Andrew Adesman, MDa,d

abstractBACKGROUND AND OBJECTIVES: Little is known about the 2% of US children being raised by theirgrandparents. We sought to characterize and compare grandparent- and parent-headedhouseholds with respect to adverse childhood experiences (ACEs), child temperament,attention-deficit/hyperactivity disorder (ADHD), and caregiver aggravation and coping.

METHODS: Using a combined data set of children ages 3 to 17 from the 2016, 2017, and 2018National Survey of Children’s Health, we applied survey regression procedures, adjusted forsociodemographic confounders, to compare grandparent- and parent-headed households oncomposite and single-item outcome measures of ACEs; ADHD; preschool inattention andrestlessness; child temperament; and caregiver aggravation, coping, support, and interactionswith children.

RESULTS: Among 80 646 households (2407 grandparent-headed, 78 239 parent-headed),children in grandparent-headed households experienced more ACEs (b = 1.22, 95%confidence interval [CI]: 1.07 to 1.38). Preschool-aged and school-aged children ingrandparent-headed households were more likely to have ADHD (adjusted odds ratio = 4.29,95% CI: 2.22 to 8.28; adjusted odds ratio = 1.72, 95% CI: 1.34 to 2.20). School-aged children inthese households had poorer temperament (badj = .25, 95% CI: 20.63 to 1.14), and theircaregivers experienced greater aggravation (badj = .29, 95% CI: 0.08 to 0.49). However, thesedifferences were not detected after excluding children with ADHD from the sample. Nodifferences were noted between grandparent- and parent-headed households for caregivercoping, emotional support, or interactions with children.

CONCLUSIONS: Despite caring for children with greater developmental problems and poorertemperaments, grandparent caregivers seem to cope with parenting about as well as parents.

WHAT’S KNOWN ON THIS SUBJECT: Nearly 3 millionchildren today are raised by their grandparents, oftenbecause of social adversity. Research to date hasprimarily demonstrated negative social and healthoutcomes for caregivers and children in grandparent-headed households.

WHAT THIS STUDY ADDS: In a large, nationallyrepresentative US sample, attention-deficit/hyperactivitydisorder and childhood adversity appear to beresponsible for some of the behavioral anddevelopmental disparities observed betweengrandparent- and parent-headed households. Nodifferences in caregiver coping and emotional supportwere found.

To cite: Rapoport E, Muthiah N, Keim SA, et al. Family Well-being in Grandparent- Versus Parent-Headed Households.Pediatrics. 2020;146(3):e20200115

aDivision of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children’s Medical Center ofNew York, Lake Success, New York; bCenter for Biobehavioral Health, The Research Institute at NationwideChildren’s Hospital, Columbus, Ohio; cDepartment of Pediatrics, College of Medicine and Department ofEpidemiology, College of Public Health, The Ohio State University, Columbus, Ohio; and dDepartment of Pediatrics,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York

Mr Rapoport conceptualized and designed the study and conducted the statistical analyses;Ms Muthiah conceptualized and designed the study and drafted the initial manuscript; Dr Keimconducted the statistical analyses; Dr Adesman conceptualized and designed the study; and allauthors reviewed and revised the manuscript and approved the final manuscript as submitted andagree to be accountable for all aspects of the work.

DOI: https://doi.org/10.1542/peds.2020-0115

Accepted for publication Jun 22, 2020

Address correspondence to Andrew Adesman, MD, Division of Developmental and BehavioralPediatrics, Steven and Alexandra Cohen Children’s Medical Center of New York, 1983 Marcus Ave,Suite 130, Lake Success, NY 11042. E-mail: aadesman@northwell.edu

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The number of children being raisedby their grandparents has grownconsiderably in recent years, from 2.5million in 2005 to 2.9 million in2015.1 Although grandparents canprovide support and stability infamilies, the increase in custodialgrandparenting in the United Stateshas primarily been driven by theinability of some parents to care fortheir children,2 and up to 72% ofchildren raised by grandparents havebeen exposed to at least one adverse,traumatic event.3 In light of risingincarceration rates,4,5 the currentopioid crisis,6 and the recenteconomic recession,7 children whoenter nonparental kinship care facea unique living environment andcomplex relationships that can impacttheir long-term development.

The demographic and healthcorrelates of grandparents assumingthe caregiving role have been well-characterized by previous research.Most custodial grandparents are aged50 to 59 years8 and, compared withparents, tend to have poorerphysical9–12 and mental13–15 healthbefore taking on the demanding roleof parenting a child. Custodialgrandparents may also feel isolatedfrom peers because the demands ofcaregiving can be time-consuming.16

To that end, grandparents raisingtheir grandchildren often reportreceiving inadequate support fromthose around them, and evidencesuggests they are less likely to receivesupport resources.17,18

There has historically been lessattention on the positive outcomesof the grandfamily householdstructure. Although it is true thatcaregiving is particularly taxing forolder adults,19 evidence suggests thateven when faced with uniquefinancial and health burdens,custodial grandparents and theirgrandchildren can thrive.20 Infact, many grandparents raisinggrandchildren report that theywould perform the same role againif given the chance.21

The literature regarding the healthand developmental outcomes ofchildren raised by grandparentshas yielded mixed findings.Researchers of previous studies havedemonstrated that, in addition tohaving experienced adversity early inlife, these children tend to have fewercoping resources because they cannotturn to their parents for support.22

Some studies indicate that childrenbeing raised by grandparents havea higher prevalence of developmentaldelays,23 behavioral issues,24 andacademic difficulties,25 suggestingthat the combination of highertraumatic event exposure and poorercoping skills in children innonparental care may hinder positivesocial development. However,after adjusting for selection biascaused by child and familybackground factors, other studieshave shown that nonparental care isnot associated with poorer cognitiveskills or behavioral problems.26

Reverse causation is a possibilityas well because poorer child healthmay introduce disruption andinstability to caregivingarrangements.27

Previous researchers have furtherexplored grandparent and grandchildoutcomes among subpopulations ofgrandparent caregivers. Analyseshave individually been focused ongrandmothers15,28,29 andgrandfathers11 raising grandchildren,racial differences amonggrandfamilies,10,29 the diversecultural attitudes and outcomes ofgrandparenting,14,30 and how single-grandparent caregivers compare withsingle-parent caregivers.11,12 Thesestudies individually provide keyinsights into select components of thegrandfamily. However, because ofdifferences in samples and analyticmethods, results are difficult tocompare between studies. No recentstudies have investigated both childand caregiver measures usinga single, large, nationallyrepresentative sample.

The National Survey of Children’sHealth (NSCH), a cross-sectionalannual survey of households in theUnited States with children,18 years old, offers the uniqueopportunity to compare grandparent-and parent-headed households withrespect to both children andcaregivers. In this study, we aimed toassess, using this large nationallyrepresentative data set, differencesbetween grandparent- and parent-headed households in terms ofsociodemographics, caregiver–childinteractions, adverse childhoodexperiences (ACEs), and othercaregiver and child variables,controlling for underlyingsociodemographic differences.

METHODS

Sample

The Maternal and Child HealthBureau of the US Health Resourcesand Services Administrationexamined the physical and emotionalhealth of noninstitutionalizedchildren ages 0 to 17 through thenationally representative NSCH.31 TheNSCH used a 2-phase multimodesurvey approach based on the CensusAddress Master File, and data wereweighted to account for nonresponseand sociodemographics. The 2016,2017, and 2018 NSCH data sets werecombined for cross-sectional analysisper the NSCH Guide to Multi-YearEstimates.32 Children ages 3 to 17were included.

Households in which the respondentwas a grandparent and the otherprimary caregiver in the householdwas a grandparent, or there was noother primary caregiver in thehousehold, were categorized as“grandparent-headed households.”Households in which a primarycaregiver was a biological or adoptiveparent and the other primarycaregiver in the household wasa biological or adoptive parent orstepparent, or there was no otherprimary caregiver in the household,

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were categorized as “parent-headedhouseholds.” Households with otherstructures were excluded.

Single-Item Outcome Measures

Caregivers answered questions aboutwhether the child had everexperienced each of 7 individualACEs (binary) and whether the childhad a current medical diagnosis ofattention-deficit/hyperactivitydisorder (ADHD) (binary).Availability of emotional support wasassessed by using the question,“during the past 12 months, wasthere someone that you could turn tofor day-to-day emotional supportwith parenting or raising children”(binary; “no” or “yes”). Caregivercoping (binary) was measured withthe question, “how well do you thinkyou are handling the day-to-daydemands of raising children?”Responses were dichotomized as“very well” versus “somewhat well,”“not very well,” or “not at all.”

Composite Outcomes

To facilitate analysis of inattention orrestlessness, child temperament,parental aggravation, frequency ofquality family interactions, andneighborhood support, 6 compositescales were derived by aggregatingresponses to individual Likert itemsin the NSCH, as noted in Table 1.Responses to individual componentitems were weighted such that allitems contributed equally to thecomposite scales. Inattention orrestlessness and the frequency ofquality family interactions were onlyassessed for children ages 3 to 5,temperament and parentalaggravation were separately assessedfor children ages 3 to 5 and ages 6 to17, and neighborhood support wasassessed for all children in thesample. Internal consistency, asmeasured by Cronbach a, wascalculated for each scale. Also, theassociation between the inattentionor restlessness scale and ADHDdiagnosis was examined by usinga linear regression to evaluate the

validity of the derived scale. Inaddition to these composite scales,count variables for the number ofACEs experienced were created forchildren with complete responses forall ACEs.

Statistical Analysis

Grandparent-headed householdswere compared against parent-headed households on caregiver andchild sociodemographics and childhealth by using second-orderRao–Scott adjusted x2 tests. Logisticand linear regressions were used tomodel outcomes of interest asfunctions of household structure(grandparent- versus parent-headedhousehold). Regressions wereadjusted for potential confounders,which were selected on the basis ofobserved sociodemographicdifferences between householdstructures and anticipatedassociations with the behavioraloutcomes of interest based on theliterature. Models were adjusted forcaregiver sex, caregiver education,household poverty level, 1- vs 2-caregiver household, and child age,sex, race and ethnicity, and healthstatus, with the exception of modelsfor ADHD diagnosis, which did notcontrol for child health status becauseADHD is a component of child health.Additionally, because ADHD has beenassociated with ACEs,33 an additionallogistic regression was conductedcontrolling for the occurrence of eachindividual ACE.

Statistically significant associationsbetween household structure andchild temperament and parentalaggravation were reexamined ina sample excluding children withADHD. Additionally, the associationbetween household structure andinattention and restlessness wasassessed among 3- to 5-year-oldchildren without a diagnosis of ADHDto determine if subthreshold ADHDphenotypes were associated withhousehold structure. Availability ofemotional support was assessed

separately in 1- and 2-caregiverhouseholds.

For all analyses, P values werederived from 2-sided statisticaltests, and associations with P values,.05 were considered to bestatistically significant. All analyseswere conducted in R, version 4.0.0,by using package survey, version4.0, and all analyses accounted forthe complex survey design of theNSCH combined data set. Thisstudy was exempt from institutionalreview board review because itused publicly available,deidentified data.

RESULTS

The eligible sample included 2407grandparent households (631 single-grandparent households and1776 two-grandparent households)and 78 239 parent households(10 115 single-parent households and68 124 two-parent households).Grandparent caregivers achievedlower levels of education (F = 34.7,P , .001) and had lower householdincomes (F = 51.2, P , .001). Theywere also more likely to be female(F = 8.5, P = .004) and to be in a one-caregiver household (F = 77.8, P ,.001) (Table 2).

Child sex and age were not associatedwith household structure, but thedistribution of child race andethnicity differed with householdstructure, especially in the proportionof grandparents compared withparents who cared for non-HispanicBlack children (30.5% vs 11.4%,respectively). Children ingrandparent-headed households werealso less likely to be in excellent orvery good health (78.2% vs 90.4%;F = 47.4, P , .001).

ACEs

Children in grandparent-headedhouseholds were more likely to haveexperienced each of the ACEs(Table 3); on average, children ingrandparent-headed households

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experienced 1.22 (95% confidenceinterval [CI]: 1.07 to 1.38) more ACEsthan children in parent-headedhouseholds. Even after adjusting for

confounders, children in grandparent-headed households experiencedsignificantly more ACEs overall(Table 4).

ADHD Diagnosis and Symptoms

Caregivers in grandparent-headedhouseholds were more likely to havechildren with ADHD than those inparent-headed households forchildren ages 3 to 5 (7.8% vs 1.5%,adjusted odds ratio [aOR] = 4.29, 95%CI: 2.22 to 8.28) and ages 6 to 17(18.0% vs 9.9%, aOR = 1.72, 95% CI:1.34 to 2.20). After controlling forACEs, ADHD was still more commonin grandparent-headed householdsfor children ages 3 to 5 (aOR = 3.27,95% CI: 1.52 to 7.02) but not childrenages 6 to 17 (aOR = 1.17, 95% CI:0.91 to 1.50).

The inattention and restlessness scalewas associated with ADHD diagnosesin children ages 3 to 5; preschool-agedchildren with ADHD scored an averageof 3.80 (95% CI: 3.43 to 4.16) pointshigher on the scale than those withoutADHD. In the sample of 3- to 5-year-old children without ADHD, householdstructure was not associated withinattention and restlessness (adjustedbeta [badj] = 0.11, 95% CI:20.27 to0.49). Cronbach a for inattention andrestlessness and other compositeoutcome measures is reported inTable 1.

Child Temperament

Children ages 3 to 5 did not differ intemperament between grandparent-headed and parent-headed households(badj = .25, 95% CI: 20.63 to 1.14),whereas children ages 6 to 17 ingrandparent-headed households hadpoorer temperament (badj = .23, 95%CI: 0.07 to 0.40). However, thisassociation was not robust to theremoval of children with ADHD fromthe sample (badj = .19, 95% CI: 20.01to 0.38).

Caregiver Aggravation

Similarly, no association was notedbetween household type andaggravation among caregivers ofchildren ages 3 to 5 (badj = .17, 95% CI:20.23 to 0.57), whereas grandparentcaregivers of children ages 6 to 17were more likely to experience

TABLE 1 Composite Measure Definitions and Component Items From the 2016, 2017, and 2018 NSCH

Scale Component Itemsa (Range)

Inattention and restlessness,ages 3–5

“How often is this child easily distracted?” (0 [none of the time] to 3[all of the time])b

“Compared to other children his or her age, how often is this childable to sit still?” (0 [all of the time] to 3 [none of the time])c

Range: 0–12 “How often does this child keep working at something until he orshe is finished?” (0 [all of the time] to 3 [none of the time])c

Cronbach a: 0.69 “When he or she is paying attention, how often can this child followinstructions to complete a simple task?” (0 [all of the time] to 3[none of the time])c

Temperament, ages 3–5 “How often does this child play well with others?” (0 [all of the time]to 3 [none of the time].)c

“How often does this child become angry or anxious when goingfrom one activity to another?” (0 [none of the time] to 3 [all of thetime])b

“When excited or all wound up, how often can this child calm downquickly?” (0 [all of the time] to 3 [none of the time])c

Range: 0–15 “How often does this child lose control of his or her temper whenthings do not go his or her way?” (0 [none of the time] to 3 [all ofthe time])b

Cronbach a: 0.62 “This child bounces back quickly when things do not go his or herway.” (0 [definitely true] to 3 [not true])d

Temperament, ages 6–17 “This child stays calm and in control when faced with a challenge.”(0 [definitely true] to 3 [not true])d

Range: 0–6 “This child argues too much.” (0 [not true] to 3 [definitely true])e

Cronbach a: 0.56Parental aggravation, ages 3–5and ages 6–17

“During the past month, how often have you felt that this child ismuch harder to care for than most children his or her age?” (0[Never] to 4 [Always])

Range: 0–12 “During the past month, how often have you felt that this child doesthings that really bother you a lot?” (0 [never] to 4 [always])

Cronbach a: 0.76 and 0.79 “During the past month, how often have you felt angry with thischild?” (0 [never] to 4 [always])

Quality family interaction, ages3–5

“During the past week, how many days did you or other familymembers tell stories or sing songs to this child?” (0 [every day]to 3 [0 days])

Range: 0–6 “During the past week, how many days did you or other familymembers read to this child?” (0 [every day] to 3 [0 days])

Cronbach a: 0.76 “During the past week, how many days did you or other familymembers read to this child?” (0 [every day] to 3 [0 days])

Neighborhood support, ages3–17

“People in this neighborhood help each other out.” (0 [definitelydisagree] to 3 [definitely agree])

Range: 0–9 “We watch out for each other’s children in this neighborhood.” (0[definitely disagree] to 3 [definitely agree])

Cronbach a: 0.81 “When we encounter difficulties, we know where to go for help inour community.” (0 [definitely disagree] to 3 [definitely agree])

a Phrasing of several component items changed slightly between NSCH versions. The table reports the phrasing from the2016 NSCH.b Response options differed between NSCH versions. 2016: (0) none of the time, (1) some of the time, (2) most of the time,and (3) all of the time. 2017 and 2018: (0) never, (1) sometimes, (1) approximately half the time, (2) most of the time, and(3) always.c Response options differed between NSCH versions. 2016: (0) all of the time, (1) most of the time, (2) some of the time, (3)none of the time. 2017 and 2018: (0) always, (1) most of the time, (2) approximately half the time, (2) sometimes, and(3) never.d Response options differed between NSCH versions. 2016 and 2017: (0) definitely true, (1.5) somewhat true, and (3) nottrue. 2018: (0) always, (1.5) usually, (1.5) sometimes, and (3) never.e Response options differed between NSCH versions. 2016 and 2017: (0) not true, (1.5) somewhat true, and (3) definitelytrue. 2018: (0) never, (1.5) sometimes, (1.5) usually, and (3) always.

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elevated aggravation (badj = .29, 95%CI: 0.08 to 0.49). This association was

not robust to the removal of children

with ADHD from the sample (badj = .16,

95% CI: 20.06 to 0.38).

Additional Caregiver Measures

Caregivers in grandparent-headedhouseholds had more frequentquality family interactions with theirchild (b = .54, 95% CI: 0.19 to 0.90),

but this difference was not robust toadjustment for confounders (badj =.10, 95% CI: 20.26 to 0.46).Caregivers in grandparent-headedhouseholds had slightly moresupportive neighborhoods (badj = .32,95% CI: 0.04 to 0.59). No differenceswere noted in caregiver coping (aOR= 0.96, 95% CI: 0.77 to 1.19).Additionally, in 2-caregiverhouseholds, no statistically significantdifferences were noted in caregiverlikelihood of having someone to turnto for day-to-day emotional supportwith parenting and raising children(70.2% grandparents versus 76.1%parents, aOR = 1.00, 95% CI: 0.75 to1.35). Among 1-caregiver households,fewer grandparents reported havingsomeone for day-to-day emotionalsupport, but no differences werenoted in the adjusted model (59.4%grandparents versus 69.0% parents,aOR = 0.77, 95% CI: 0.53 to 1.10).

DISCUSSION

In this cross-sectional analysis ofa large nationally representativesample of children ages 3 to 17,children being raised by grandparentswere more likely to have had adverseexperiences and a diagnosis of ADHD.Additionally, school-aged children ingrandparent-headed households hadpoorer temperaments, and theircaregivers experienced greateraggravation from parenting.Importantly, after excluding childrenwith ADHD from our analyses,differences in child temperament andcaregiver aggravation were no longerstatistically significant. Additionally,although ADHD was more prevalentamong children in grandparent-headed households, we did not finddifferences in inattention andrestlessness among young childrenwithout an ADHD diagnosis.

The results from our analyses, inmany ways, are similar to what iscurrently known about grandparentsraising grandchildren. Compared withparent caregivers, custodialgrandparents had lower educational

TABLE 2 Sample Characteristics and Demographics of Grandparent Households and ParentHouseholds of Children Ages 3–17, 2016–2018 NSCH (N = 80 646)

Characteristics GrandparentHouseholds(n = 2407)

ParentHouseholdsa

(n = 78 239)

Rao–ScottAdjustedF-statistic

P

n %b n %b

Primary caregiver sex 8.5 .004Male 674 24.9 25 347 31.1Female 1697 75.1 52 550 68.9

Primary caregivereducation

34.7 ,.001

Less than or equal toeighth grade

48 7.3 694 4.2

Ninth to 12th grade,no diploma

202 20.9 1535 7.5

High schoolgraduate or GED

687 28.6 8047 14.5

Vocational or tradeprogram

209 6.8 3614 6.1

Some college 481 14.3 11 395 13.9Associate degree 269 10.1 8173 8.5Bachelor’s degree 281 6.1 24 898 25.4Master’s degree 153 4.3 14 362 14.9Doctorate or

professionaldegree

37 1.6 5040 5.0

Household income, % offederal poverty level

51.2 ,.001

0–99 563 33.2 7169 17.9100–199 585 31.8 11 577 21.0200–399 770 21.8 24 168 27.7$400 489 13.1 35 325 33.4

No. caregivers 77.8 ,.0011 caregiver 631 30.6 10 115 15.02 caregivers 1776 69.4 68 124 85.0

Child age, y 2.7 .073–8 406 21.7 13 544 19.19–12 958 43.5 27 022 40.213–17 1043 34.9 37 673 40.7

Child sex 0.0 .98Male 1240 51.0 40 300 51.0Female 1167 49.0 37 939 49.0

Child race and ethnicity 46.0 ,.001Hispanic 303 20.2 8471 24.7White, non-Hispanic 1406 40.7 55 970 53.6Black, non-Hispanic 376 30.5 4003 11.4Multiracial or other,

non-Hispanic322 8.6 9795 10.4

Child health status 47.4 ,.001Excellent or very

good health1985 78.2 72 078 90.4

Good, fair, or poorhealth

415 21.8 5958 9.6

GED, general equivalency diploma.a Parent households included 2 biological or adoptive parents, 1 biological or adoptive parent plus 1 stepparent, or 1biological or adoptive parent.b Prevalence figures weighted to be nationally representative.

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attainment and household income.Children raised by grandparents werealso more likely to have experienceda variety of ACEs than children raisedby parents, reinforcing past findingsabout children in nonparental care.34

Adverse experiences have been shownto have cumulative associations withbehavioral problems, developmentaldelays, and difficulties in school andadult outcomes like substance abuseand depression.35 In light of risingincarceration rates4,5 and the current

opioid crisis,6 our findings are similarto previous research about theprecipitating factors of the grandfamilyhousehold structure, as well as itsfinancial and health correlates.3,22

Given the established associationbetween ACE exposure and ADHD,33

it is unsurprising that we identifiedelevated rates of ADHD among bothpreschool and school-aged childrenraised in grandparent-headedhouseholds. However, after

accounting for ACE exposure,although our effect estimate wasattenuated, grandparent-headedhouseholds remained more likely tohave children with ADHD. A possibleexplanation may be the heritability ofADHD.36 Mothers with ADHD aremore likely to experience unplannedpregnancies,37 which are a commonprecipitating factor for grandparentsraising their grandchildren; becausethe children of mothers with ADHDare more likely to also have ADHD,this pathway may explain elevatedrates of ADHD among children ingrandparent-headed households.Furthermore, there is a higherprevalence of substance abuse amongadults with ADHD38; substance abuse,as well as the elevated incarcerationrates associated with it, furthercontributes to grandparent caregivingbecause of parents’ inability toeffectively care for their children.Importantly, we did not find evidenceof differences in inattention andrestlessness among preschool-agedchildren without an ADHD diagnosisbetween grandparent-headed andparent-headed households.

In our sample, grandparent-headedhouseholds were much more likely tohave children with ADHD. Becausechildren with ADHD tend to exhibitmore externalizing behaviors and areoften perceived as harder to care forby their caregivers, it is not surprisingthat we found poorer childtemperament and elevated parentalaggravation in grandparent-headedhouseholds. These findings are alsoconsistent with the currentunderstanding of behavioral andsocial characteristics of childrenraised by grandparents.3,8,25,39

The fact that significant differences inchild temperament and parentalaggravation disappeared when weexcluded children with ADHD fromanalyses suggests that ADHD itselfmay be responsible for manybetween-group differences in childbehaviors and social characteristics.Children in nonparental care are at

TABLE 3 ACEs Among Grandparent and Parent Households, 2016–2018 NSCH (N = 80 646)

ACEs GrandparentHouseholds(n = 2407)

ParentHouseholdsa

(n = 78 239)

ORb (95% CI) aORb,c (95% CI)

n %b n %b

Child experienced parentor guardian divorcingor separatingNo 852 43.6 61 268 77.5 Reference ReferenceYes 1478 56.4 16 251 22.5 4.47 (3.64 to 5.49) 4.34 (3.28 to 5.73)

Child experienced parentor guardian dyingNo 1953 87.0 75 496 97.3 Reference ReferenceYes 359 13.0 1867 2.7 5.40 (4.09 to 7.14) 3.84 (2.63 to 5.59)

Child experienced parentor guardian servingtime in jailNo 1331 64.4 73 728 94.2 Reference ReferenceYes 986 35.6 3534 5.8 8.92 (7.34 to 10.84) 6.24 (4.92 to 7.93)

Child saw or heardparents or adultsslapping, hitting,kicking, or punchingone another in thehomeNo 1687 79.1 74 131 95.3 Reference ReferenceYes 604 20.9 3086 4.7 5.38 (4.35 to 6.66) 4.32 (3.35 to 5.57)

Child was a victim ofviolence or witnessedviolence in theneighborhoodNo 1986 88.8 74 774 96.4 Reference ReferenceYes 318 11.2 2440 3.6 3.34 (2.59 to 4.31) 2.27 (1.67 to 3.09)

Child lived with anyonewho was mentally ill,suicidal, or severelydepressedNo 1828 85.9 70 759 92.6 Reference ReferenceYes 476 14.1 6341 7.4 2.08 (1.68 to 2.56) 2.00 (1.57 to 2.54)

Child lived with anyonewho had a problemwith alcohol or drugsNo 1375 70.3 70 850 92.6 Reference ReferenceYes 932 29.7 6362 7.4 5.26 (4.35 to 6.35) 5.20 (4.17 to 6.47)

OR, odds ratio.a Parent households included 2 biological or adoptive parents, 1 biological or adoptive parent plus 1 stepparent, or 1biological or adoptive parent.b Weighted to be nationally representative.c Adjusted for caregiver sex, caregiver education, household poverty level, number of caregivers, child age, child sex, childrace and ethnicity, and child health status.

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higher risk for living under unstablecaregiving arrangements,35 whichputs these children at greater risk forexternalizing behavior problems.40

However, many other factors may alsobe involved. Although our analysescontrolled for many keysociodemographic variables, residualconfounding related to other riskfactors (eg, prenatal alcohol exposure,lead exposure, or family history ofADHD) may have impacted ouranalyses. Large-scale longitudinalstudies examining children innonparental care would be necessaryto determine the extent to whichexternalizing behavior contributes tochild placement in nonparental care.

Although the differences betweengrandparent- and parent-headedhouseholds have important implicationsfor children and caregivers, so too dothe similarities between these 2 groups.For example, although we found thatgrandparent-headed households havea higher frequency of qualityinteractions between caregivers andchildren, our analyses indicate thatsociodemographic differences, rather

than differences inherent tograndparent and parent caregivers, mayexplain this small disparity. Additionally,although caregivers in grandparent-headed households were more likely toexperience aggravation from parenting,we did not identify differences incaregivers’ reported ability to copewith the daily demands of caregiving.We found that grandparent and parentcaregivers in both 1- and 2-caregiverhouseholds did not differ in their oddsof having someone to turn to for day-to-day emotional support withparenting or raising children, aftercontrolling for confounders.

Of concern, 24% of parent caregiversand 30% of grandparent caregivers in2-caregiver households did not havesomeone to turn to for day-to-dayemotional support. Moreover, 31% ofsingle-parent caregivers and 41% ofsingle-grandparent caregivers lackedthis type of support. Given thedemographic characteristics of oursample, it is possible that custodialgrandparents may not have as manyfriends and family to rely on forparenting support. Notably, after

controlling for sociodemographicconfounders, we found thatgrandparents report greater supportfrom their neighborhoods. However,this difference in neighborhoodsupport between grandparents andparents was fairly small and unlikelyto have substantial implications.

Given grandparent caregivers’ limitedaccess to emotional support, it hasbeen suggested that grandparenthouseholds may be particularly inneed of social support services tocope with the difficulties associatedwith raising grandchildren.21 Inconjunction with previous evidencethat grandparents who serve as theprimary caregiver for a child weretwice as likely to develop symptomsof depression than noncaregivinggrandparents,41 it is vital thatgrandparents raising grandchildrentake advantage of support groups intheir community and on-line. Policiesto create local grandparent-raising-grandchildren support programs canprovide ways to cope, informationalsupport, social support, and resourceconnections to caregivers.20,42,43 Ina recent randomized controlled trial,Pandey et al43 (2018) compared theeffectiveness of traditional childwelfare services with 3 community-based forms of support for custodialgrandmothers. They concluded thattraditional child welfare is bettersuited for the needs of parents andfoster parents and that peer-basedcommunity programs provide greaterinformational and emotional supportto grandmothers raising theirgrandchildren. Given the difficultiesmany grandparent caregivers facewith respect to emotional supportwith parenting, pediatricians shouldrefer these caregivers to community-based organizations oriented towardsupporting grandparents raisinggrandchildren; in particular,pediatricians should be mindful of theadditional support needed bygrandparents in one-caregiverhouseholds. Organizations such asGrandfamilies.org provide a directory

TABLE 4 ACE Composite Measures Among Grandparent and Parent Households, 2016–2018 NSCH(N = 77 281)

ACE CompositeMeasures

GrandparentHouseholds(n = 2148)

ParentHouseholdsa

(n = 75 133)

ORb (95% CI) aORb,c (95% CI)

n %b n %b

Child experienced$1 ACENo 447 28.4 52 567 68.8 Reference ReferenceYes 1701 71.6 22 566 31.2 5.56 (4.27 to 7.24) 5.20 (3.71 to 7.29)

Child experienced$2 ACEsNo 956 56.6 66 326 87.8 Reference ReferenceYes 1192 43.4 8807 12.2 5.49 (4.50 to 6.71) 4.88 (3.79 to 6.30)

Child experienced$3 ACEsNo 1310 70.0 71 014 94.2 Reference ReferenceYes 838 30.0 4119 5.8 6.99 (5.70 to 8.57) 6.19 (4.78 to 8.01)

Child experienced$4 ACEsNo 1605 82.5 73 238 97.2 Reference ReferenceYes 543 17.5 1895 2.8 7.50 (6.04 to 9.33) 6.41 (4.86 to 8.45)

OR, odds ratio.a Parent households included 2 biological or adoptive parents, 1 biological or adoptive parent plus 1 stepparent, or 1biological or adoptive parent.b Weighted to be nationally representative.c Adjusted for caregiver sex, caregiver education, household poverty level, number of caregivers, child age, child sex, childrace and ethnicity, and child health status.

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of national and state-specificresources and support groups, whichpediatricians can use to guide andcounsel custodial grandparents.44

Although past studies have revealedthat children raised in grandparent-headed households may have pooreroutcomes throughout adolescence andadulthood, our findings suggest thatefforts to identify children who wouldbenefit from medical or mental healthinterventions would be best servedthrough screening that identifies ACEsand ADHD. The American Academy ofPediatrics has suggested thatpediatricians screen their patients forearly childhood adversity to identifychildren at high risk for toxic stress.45

Given that pediatricians tend to under-identify risk factors such as ACEs andunmet social needs,46 and given theelevated prevalence of ACEs amongchildren in grandparent-headedhouseholds, pediatricians should beparticularly mindful of the importanceof early childhood screening in thispopulation. Continued research into thecomplex interplay between childhoodadversity, ADHD, and physical andemotional health is essential for thedevelopment and refinement ofeffective screening and interventions inthis high-risk population.

One strength of our study is its large,nationally representative sample of80 646 caregivers of children,including 2407 grandparents raisingtheir grandchildren, making this thelargest study to date examiningchildhood adversity, caregiver–childrelationships, and other relatedmeasures in grandparent-headedhouseholds using a nationallyrepresentative sample. The samplesize allowed analytical models tocontrol for many key confounders.Whereas most previous studies ofgrandparent households have focusedon psychological, behavioral, andhealth measures among either thecaregivers or the children, in thisstudy, we directly comparegrandparent households and parenthouseholds with respect to both

caregiver variables and childvariables using the same large,nationally representative sample.This methodology allows forconsistent interpretations of findingspertaining to both children andcaregivers. Additionally, whereasresearchers of many studies analyzedindividual Likert items whenexamining child and caregiveroutcomes, in our study, we usedcomposite measures, reducing theimpact of random variation andmeasurement error on our findings.

However, the use of these compositemeasures also introduced notablelimitations to this study. In particular,with the exception of the inattentionand restlessness scale, we could notevaluate the construct validity of ourcomposite scales. Another potentiallimitation of these measures wascaused by minor variation betweenindividual components in differentiterations of the NSCH, which mayhave introduced some inconsistencyto our composite measures. However,the majority of our compositemeasures had strong internalconsistency, indicating that theindividual component items wereclosely related to each other.

In addition to the limitationsintroduced by our compositemeasures, our study was also limitedby the reliance on caregiver report. Itis possible that grandparents aremore critical about or have higherexpectations for the behavior of theirgrandchildren. However, this type ofbias is less likely to apply to reportsabout ACEs or medical diagnosis ofADHD. Additionally, the NSCHquestionnaire’s focus on lifetimeexposure to adversity did not allowus to determine if the ACEs occurredbefore or after the child’s placementwith their caregiver. Finally, althoughwe had the ability to control fordemographic differences betweengroups, as with any retrospectivecross-sectional analysis, residualconfounding remains a possibility. Forexample, beyond the number of

caregivers, the NSCH did not includequestions evaluating importantcharacteristics of caregivers and thecaregiver–child relationship, such ascaregiver race or the duration of timethat the child has been in the care oftheir parent or grandparent. Ourinability to account for theseunderlying household characteristicsmay have impacted our findings.

CONCLUSIONS

In this study, we highlight manyprofound differences betweengrandparent- and parent-headedhouseholds. Even after adjusting forpotential confounders, children ingrandparent-headed households weremuch more likely to have experiencedpsychosocial adversity. Additionally,school-aged children in grandparent-headed households had poorertemperaments and their caregiversreported greater aggravation.However, no differences were notedwith respect to how well caregiverswere handling the day-to-daydemands of parenting. With nearly 3million children now being raised byone or both grandparents,pediatricians must be mindful of thedemographic, psychosocial, andparenting challenges that characterizemany grandparent-headedhouseholds. In addition to screeningchildren in these families foradversity and heightened stress,pediatricians should refer thesefamilies to appropriate supportgroups and other resourcescommitted to meeting the needs ofparenting grandparents.

ABBREVIATIONS

ACE: adverse childhood experienceADHD: attention-deficit/

hyperactivity disorderaOR: adjusted odds ratioCI: confidence intervalNSCH: National Survey of

Children’s Healthbadj: adjusted beta

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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