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Family Well-being in Grandparent-
Versus Parent-Headed Households
Eli Rapoport, BS,aNallammai Muthiah, BS,aSarah 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 their
grandparents. We sought to characterize and compare grandparent- and parent-headed
households 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 2018
National Survey of Children’s Health, we applied survey regression procedures, adjusted for
sociodemographic confounders, to compare grandparent- and parent-headed households on
composite and single-item outcome measures of ACEs; ADHD; preschool inattention and
restlessness; child temperament; and caregiver aggravation, coping, support, and interactions
with 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 in
grandparent-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 in
these households had poorer temperament (b
adj
= .25, 95% CI: 20.63 to 1.14), and their
caregivers experienced greater aggravation (b
adj
= .29, 95% CI: 0.08 to 0.49). However, these
differences were not detected after excluding children with ADHD from the sample. No
differences were noted between grandparent- and parent-headed households for caregiver
coping, emotional support, or interactions with children.
CONCLUSIONS: Despite caring for children with greater developmental problems and poorer
temperaments, grandparent caregivers seem to cope with parenting about as well as parents.
WHAT’S KNOWN ON THIS SUBJECT: Nearly 3 million
children today are raised by their grandparents, often
because of social adversity. Research to date has
primarily demonstrated negative social and health
outcomes for caregivers and children in grandparent-
headed households.
WHAT THIS STUDY ADDS: In a large, nationally
representative US sample, attention-deficit/hyperactivity
disorder and childhood adversity appear to be
responsible for some of the behavioral and
developmental disparities observed between
grandparent- and parent-headed households. No
differences in caregiver coping and emotional support
were found.
To cite: Rapoport E, Muthiah N, Keim SA, et al. Family Well-
being in Grandparent- Versus Parent-Headed Households.
Pediatri cs. 2020;146(3):e20200115
aDivision of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children’s Medical Center of
New York, Lake Success, New York; bCenter for Biobehavioral Health, The Research Institute at Nationwide
Children’s Hospital, Columbus, Ohio; cDepartment of Pediatrics, College of Medicine and Department of
Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio; and dDepartment of Pediatrics,
Donald and Barbara Zucker School of Medicine at Hofstra/Nor thwell, 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 Keim
conducted the statistical analyses; Dr Adesman conceptualized and designed the study; and all
authors reviewed and revised the manuscript and approved the final manuscript as submitted and
agree 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 Behavioral
Pediatrics, 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
PEDIATRICS Volume 146, number 3, September 2020:e20200115 ARTICLE
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The number of children being raised
by their grandparents has grown
considerably in recent years, from 2.5
million in 2005 to 2.9 million in
2015.
1
Although grandparents can
provide support and stability in
families, the increase in custodial
grandparenting in the United States
has primarily been driven by the
inability of some parents to care for
their children,
2
and up to 72% of
children raised by grandparents have
been exposed to at least one adverse,
traumatic event.
3
In light of rising
incarceration rates,
4,5
the current
opioid crisis,
6
and the recent
economic recession,
7
children who
enter nonparental kinship care face
a unique living environment and
complex relationships that can impact
their long-term development.
The demographic and health
correlates of grandparents assuming
the caregiving role have been well-
characterized by previous research.
Most custodial grandparents are aged
50 to 59 years
8
and, compared with
parents, tend to have poorer
physical
9–12
and mental
13–15
health
before taking on the demanding role
of parenting a child. Custodial
grandparents may also feel isolated
from peers because the demands of
caregiving can be time-consuming.
16
To that end, grandparents raising
their grandchildren often report
receiving inadequate support from
those around them, and evidence
suggests they are less likely to receive
support resources.
17,18
There has historically been less
attention on the positive outcomes
of the grandfamily household
structure. Although it is true that
caregiving is particularly taxing for
older adults,
19
evidence suggests that
even when faced with unique
financial and health burdens,
custodial grandparents and their
grandchildren can thrive.
20
In
fact, many grandparents raising
grandchildren report that they
would perform the same role again
if given the chance.
21
The literature regarding the health
and developmental outcomes of
children raised by grandparents
has yielded mixed findings.
Researchers of previous studies have
demonstrated that, in addition to
having experienced adversity early in
life, these children tend to have fewer
coping resources because they cannot
turn to their parents for support.
22
Some studies indicate that children
being raised by grandparents have
a higher prevalence of developmental
delays,
23
behavioral issues,
24
and
academic difficulties,
25
suggesting
that the combination of higher
traumatic event exposure and poorer
coping skills in children in
nonparental care may hinder positive
social development. However,
after adjusting for selection bias
caused by child and family
background factors, other studies
have shown that nonparental care is
not associated with poorer cognitive
skills or behavioral problems.
26
Reverse causation is a possibility
as well because poorer child health
may introduce disruption and
instability to caregiving
arrangements.
27
Previous researchers have further
explored grandparent and grandchild
outcomes among subpopulations of
grandparent caregivers. Analyses
have individually been focused on
grandmothers
15,28,29
and
grandfathers
11
raising grandchildren,
racial differences among
grandfamilies,
10,29
the diverse
cultural attitudes and outcomes of
grandparenting,
14,30
and how single-
grandparent caregivers compare with
single-parent caregivers.
11,12
These
studies individually provide key
insights into select components of the
grandfamily. However, because of
differences in samples and analytic
methods, results are difficult to
compare between studies. No recent
studies have investigated both child
and caregiver measures using
a single, large, nationally
representative sample.
The National Survey of Children’s
Health (NSCH), a cross-sectional
annual survey of households in the
United States with children
,18 years old, offers the unique
opportunity to compare grandparent-
and parent-headed households with
respect to both children and
caregivers. In this study, we aimed to
assess, using this large nationally
representative data set, differences
between grandparent- and parent-
headed households in terms of
sociodemographics, caregiver–child
interactions, adverse childhood
experiences (ACEs), and other
caregiver and child variables,
controlling for underlying
sociodemographic differences.
METHODS
Sample
The Maternal and Child Health
Bureau of the US Health Resources
and Services Administration
examined the physical and emotional
health of noninstitutionalized
children ages 0 to 17 through the
nationally representative NSCH.
31
The
NSCH used a 2-phase multimode
survey approach based on the Census
Address Master File, and data were
weighted to account for nonresponse
and sociodemographics. The 2016,
2017, and 2018 NSCH data sets were
combined for cross-sectional analysis
per the NSCH Guide to Multi-Year
Estimates.
32
Children ages 3 to 17
were included.
Households in which the respondent
was a grandparent and the other
primary caregiver in the household
was a grandparent, or there was no
other primary caregiver in the
household, were categorized as
“grandparent-headed households.”
Households in which a primary
caregiver was a biological or adoptive
parent and the other primary
caregiver in the household was
a biological or adoptive parent or
stepparent, or there was no other
primary caregiver in the household,
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were categorized as “parent-headed
households.”Households with other
structures were excluded.
Single-Item Outcome Measures
Caregivers answered questions about
whether the child had ever
experienced each of 7 individual
ACEs (binary) and whether the child
had a current medical diagnosis of
attention-deficit/hyperactivity
disorder (ADHD) (binary).
Availability of emotional support was
assessed by using the question,
“during the past 12 months, was
there someone that you could turn to
for day-to-day emotional support
with parenting or raising children”
(binary; “no”or “yes”). Caregiver
coping (binary) was measured with
the question, “how well do you think
you are handling the day-to-day
demands 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 or
restlessness, child temperament,
parental aggravation, frequency of
quality family interactions, and
neighborhood support, 6 composite
scales were derived by aggregating
responses to individual Likert items
in the NSCH, as noted in Table 1.
Responses to individual component
items were weighted such that all
items contributed equally to the
composite scales. Inattention or
restlessness and the frequency of
quality family interactions were only
assessed for children ages 3 to 5,
temperament and parental
aggravation were separately assessed
for children ages 3 to 5 and ages 6 to
17, and neighborhood support was
assessed for all children in the
sample. Internal consistency, as
measured by Cronbach a, was
calculated for each scale. Also, the
association between the inattention
or restlessness scale and ADHD
diagnosis was examined by using
a linear regression to evaluate the
validity of the derived scale. In
addition to these composite scales,
count variables for the number of
ACEs experienced were created for
children with complete responses for
all ACEs.
Statistical Analysis
Grandparent-headed households
were compared against parent-
headed households on caregiver and
child sociodemographics and child
health by using second-order
Rao–Scott adjusted x
2
tests. Logistic
and linear regressions were used to
model outcomes of interest as
functions of household structure
(grandparent- versus parent-headed
household). Regressions were
adjusted for potential confounders,
which were selected on the basis of
observed sociodemographic
differences between household
structures and anticipated
associations with the behavioral
outcomes of interest based on the
literature. Models were adjusted for
caregiver sex, caregiver education,
household poverty level, 1- vs 2-
caregiver household, and child age,
sex, race and ethnicity, and health
status, with the exception of models
for ADHD diagnosis, which did not
control for child health status because
ADHD is a component of child health.
Additionally, because ADHD has been
associated with ACEs,
33
an additional
logistic regression was conducted
controlling for the occurrence of each
individual ACE.
Statistically significant associations
between household structure and
child temperament and parental
aggravation were reexamined in
a sample excluding children with
ADHD. Additionally, the association
between household structure and
inattention and restlessness was
assessed among 3- to 5-year-old
children without a diagnosis of ADHD
to determine if subthreshold ADHD
phenotypes were associated with
household structure. Availability of
emotional support was assessed
separately in 1- and 2-caregiver
households.
For all analyses, Pvalues were
derived from 2-sided statistical
tests, and associations with Pvalues
,.05 were considered to be
statistically significant. All analyses
were conducted in R, version 4.0.0,
by using package survey, version
4.0, and all analyses accounted for
the complex survey design of the
NSCH combined data set. This
study was exempt from institutional
review board review because it
used publicly available,
deidentified data.
RESULTS
The eligible sample included 2407
grandparent households (631 single-
grandparent households and
1776 two-grandparent households)
and 78 239 parent households
(10 115 single-parent households and
68 124 two-parent households).
Grandparent caregivers achieved
lower levels of education (F= 34.7,
P,.001) and had lower household
incomes (F= 51.2, P,.001). They
were 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 associated
with household structure, but the
distribution of child race and
ethnicity differed with household
structure, especially in the proportion
of grandparents compared with
parents who cared for non-Hispanic
Black children (30.5% vs 11.4%,
respectively). Children in
grandparent-headed households were
also less likely to be in excellent or
very good health (78.2% vs 90.4%;
F= 47.4, P,.001).
ACEs
Children in grandparent-headed
households were more likely to have
experienced each of the ACEs
(Table 3); on average, children in
grandparent-headed households
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experienced 1.22 (95% confidence
interval [CI]: 1.07 to 1.38) more ACEs
than children in parent-headed
households. Even after adjusting for
confounders, children in grandparent-
headed households experienced
significantly more ACEs overall
(Table 4).
ADHD Diagnosis and Symptoms
Caregivers in grandparent-headed
households were more likely to have
children with ADHD than those in
parent-headed households for
children 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 for
ACEs, ADHD was still more common
in grandparent-headed households
for children ages 3 to 5 (aOR = 3.27,
95% CI: 1.52 to 7.02) but not children
ages 6 to 17 (aOR = 1.17, 95% CI:
0.91 to 1.50).
The inattention and restlessness scale
was associated with ADHD diagnoses
in children ages 3 to 5; preschool-aged
children with ADHD scored an average
of 3.80 (95% CI: 3.43 to 4.16) points
higher on the scale than those without
ADHD. In the sample of 3- to 5-year-
old children without ADHD, household
structure was not associated with
inattention and restlessness (adjusted
beta [b
adj
] = 0.11, 95% CI:20.27 to
0.49). Cronbach afor inattention and
restlessness and other composite
outcome measures is reported in
Table 1.
Child Temperament
Children ages 3 to 5 did not differ in
temperament between grandparent-
headed and parent-headed households
(b
adj
= .25, 95% CI: 20.63 to 1.14),
whereas children ages 6 to 17 in
grandparent-headed households had
poorer temperament (b
adj
=.23,95%
CI: 0.07 to 0.40). However, this
association was not robust to the
removal of children with ADHD from
the sample (b
adj
= .19, 95% CI: 20.01
to 0.38).
Caregiver Aggravation
Similarly, no association was noted
between household type and
aggravation among caregivers of
children ages 3 to 5 (b
adj
=.17,95%CI:
20.23 to 0.57), whereas grandparent
caregivers of children ages 6 to 17
were more likely to experience
TABLE 1 Composite Measure Definitions and Component Items From the 2016, 2017, and 2018 NSCH
Scale Component Items
a
(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 child
able 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 or
she 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 follow
instructions 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 going
from one activity to another?”(0 [none of the time] to 3 [all of the
time])
b
“When excited or all wound up, how often can this child calm down
quickly?”(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 when
things do not go his or her way?”(0 [none of the time] to 3 [all of
the time])
b
Cronbach a: 0.62 “This child bounces back quickly when things do not go his or her
way.”(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: 0.56
Parental aggravation, ages 3–5
and ages 6–17
“During the past month, how often have you felt that this child is
much 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 does
things 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 this
child?”(0 [never] to 4 [always])
Quality family interaction, ages
3–5
“During the past week, how many days did you or other family
members 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 family
members 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 family
members read to this child?”(0 [every day] to 3 [0 days])
Neighborhood support, ages
3–17
“People in this neighborhood help each other out.”(0 [definitely
disagree] 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 in
our community.”(0 [definitely disagree] to 3 [definitely agree])
a
Phrasing of several component items changed slightly between NSCH versions. The table repor ts the phrasing from the
2016 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) not
true. 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) definitely
true. 2018: (0) never, (1.5) sometimes, (1.5) usually, and (3) always.
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elevated aggravation (b
adj
= .29, 95%
CI: 0.08 to 0.49). This association was
not robust to the removal of children
with ADHD from the sample (b
adj
= .16,
95% CI: 20.06 to 0.38).
Additional Caregiver Measures
Caregivers in grandparent-headed
households had more frequent
quality family interactions with their
child (b= .54, 95% CI: 0.19 to 0.90),
but this difference was not robust to
adjustment for confounders (b
adj
=
.10, 95% CI: 20.26 to 0.46).
Caregivers in grandparent-headed
households had slightly more
supportive neighborhoods (b
adj
= .32,
95% CI: 0.04 to 0.59). No differences
were noted in caregiver coping (aOR
= 0.96, 95% CI: 0.77 to 1.19).
Additionally, in 2-caregiver
households, no statistically significant
differences were noted in caregiver
likelihood of having someone to turn
to for day-to-day emotional support
with parenting and raising children
(70.2% grandparents versus 76.1%
parents, aOR = 1.00, 95% CI: 0.75 to
1.35). Among 1-caregiver households,
fewer grandparents reported having
someone for day-to-day emotional
support, but no differences were
noted 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 of
a large nationally representative
sample of children ages 3 to 17,
children being raised by grandparents
were more likely to have had adverse
experiences and a diagnosis of ADHD.
Additionally, school-aged children in
grandparent-headed households had
poorer temperaments, and their
caregivers experienced greater
aggravation from parenting.
Importantly, after excluding children
with ADHD from our analyses,
differences in child temperament and
caregiver aggravation were no longer
statistically significant. Additionally,
although ADHD was more prevalent
among children in grandparent-
headed households, we did not find
differences in inattention and
restlessness among young children
without an ADHD diagnosis.
The results from our analyses, in
many ways, are similar to what is
currently known about grandparents
raising grandchildren. Compared with
parent caregivers, custodial
grandparents had lower educational
TABLE 2 Sample Characteristics and Demographics of Grandparent Households and Parent
Households of Children Ages 3–17, 2016–2018 NSCH (N= 80 646)
Characteristics Grandparent
Households
(n= 2407)
Parent
Households
a
(n= 78 239)
Rao–Scott
Adjusted
F-statistic
P
n%
b
n%
b
Primary caregiver sex 8.5 .004
Male 674 24.9 25 347 31.1
Female 1697 75.1 52 550 68.9
Primary caregiver
education
34.7 ,.001
Less than or equal to
eighth grade
48 7.3 694 4.2
Ninth to 12th grade,
no diploma
202 20.9 1535 7.5
High school
graduate or GED
687 28.6 8047 14.5
Vocational or trade
program
209 6.8 3614 6.1
Some college 481 14.3 11 395 13.9
Associate degree 269 10.1 8173 8.5
Bachelor’s degree 281 6.1 24 898 25.4
Master’s degree 153 4.3 14 362 14.9
Doctorate or
professional
degree
37 1.6 5040 5.0
Household income, % of
federal poverty level
51.2 ,.001
0–99 563 33.2 7169 17.9
100–199 585 31.8 11 577 21.0
200–399 770 21.8 24 168 27.7
$400 489 13.1 35 325 33.4
No. caregivers 77.8 ,.001
1 caregiver 631 30.6 10 115 15.0
2 caregivers 1776 69.4 68 124 85.0
Child age, y 2.7 .07
3–8 406 21.7 13 544 19.1
9–12 958 43.5 27 022 40.2
13–17 1043 34.9 37 673 40.7
Child sex 0.0 .98
Male 1240 51.0 40 300 51.0
Female 1167 49.0 37 939 49.0
Child race and ethnicity 46.0 ,.001
Hispanic 303 20.2 8471 24.7
White, non-Hispanic 1406 40.7 55 970 53.6
Black, non-Hispanic 376 30.5 4003 11.4
Multiracial or other,
non-Hispanic
322 8.6 9795 10.4
Child health status 47.4 ,.001
Excellent or very
good health
1985 78.2 72 078 90.4
Good, fair, or poor
health
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 1
biological or adoptive parent.
b
Prevalence figures weighted to be nationally representative.
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attainment and household income.
Children raised by grandparents were
also more likely to have experienced
a variety of ACEs than children raised
by parents, reinforcing past findings
about children in nonparental care.
34
Adverse experiences have been shown
to have cumulative associations with
behavioral problems, developmental
delays, and difficulties in school and
adult outcomes like substance abuse
and depression.
35
In light of rising
incarceration rates
4,5
and the current
opioid crisis,
6
our findings are similar
to previous research about the
precipitating factors of the grandfamily
household structure, as well as its
financial and health correlates.
3,22
Given the established association
between ACE exposure and ADHD,
33
it is unsurprising that we identified
elevated rates of ADHD among both
preschool and school-aged children
raised in grandparent-headed
households. However, after
accounting for ACE exposure,
although our effect estimate was
attenuated, grandparent-headed
households remained more likely to
have children with ADHD. A possible
explanation may be the heritability of
ADHD.
36
Mothers with ADHD are
more likely to experience unplanned
pregnancies,
37
which are a common
precipitating factor for grandparents
raising their grandchildren; because
the children of mothers with ADHD
are more likely to also have ADHD,
this pathway may explain elevated
rates of ADHD among children in
grandparent-headed households.
Furthermore, there is a higher
prevalence of substance abuse among
adults with ADHD
38
; substance abuse,
as well as the elevated incarceration
rates associated with it, further
contributes to grandparent caregiving
because of parents’inability to
effectively care for their children.
Importantly, we did not find evidence
of differences in inattention and
restlessness among preschool-aged
children without an ADHD diagnosis
between grandparent-headed and
parent-headed households.
In our sample, grandparent-headed
households were much more likely to
have children with ADHD. Because
children with ADHD tend to exhibit
more externalizing behaviors and are
often perceived as harder to care for
by their caregivers, it is not surprising
that we found poorer child
temperament and elevated parental
aggravation in grandparent-headed
households. These findings are also
consistent with the current
understanding of behavioral and
social characteristics of children
raised by grandparents.
3,8,25,39
The fact that significant differences in
child temperament and parental
aggravation disappeared when we
excluded children with ADHD from
analyses suggests that ADHD itself
may be responsible for many
between-group differences in child
behaviors and social characteristics.
Children in nonparental care are at
TABLE 3 ACEs Among Grandparent and Parent Households, 2016–2018 NSCH (N= 80 646)
ACEs Grandparent
Households
(n= 2407)
Parent
Households
a
(n= 78 239)
OR
b
(95% CI) aOR
b,c
(95% CI)
n%
b
n%
b
Child experienced parent
or guardian divorcing
or separating
No 852 43.6 61 268 77.5 Reference Reference
Yes 1478 56.4 16 251 22.5 4.47 (3.64 to 5.49) 4.34 (3.28 to 5.73)
Child experienced parent
or guardian dying
No 1953 87.0 75 496 97.3 Reference Reference
Yes 359 13.0 1867 2.7 5.40 (4.09 to 7.14) 3.84 (2.63 to 5.59)
Child experienced parent
or guardian serving
time in jail
No 1331 64.4 73 728 94.2 Reference Reference
Yes 986 35.6 3534 5.8 8.92 (7.34 to 10.84) 6.24 (4.92 to 7.93)
Child saw or heard
parents or adults
slapping, hitting,
kicking, or punching
one another in the
home
No 1687 79.1 74 131 95.3 Reference Reference
Yes 604 20.9 3086 4.7 5.38 (4.35 to 6.66) 4.32 (3.35 to 5.57)
Child was a victim of
violence or witnessed
violence in the
neighborhood
No 1986 88.8 74 774 96.4 Reference Reference
Yes 318 11.2 2440 3.6 3.34 (2.59 to 4.31) 2.27 (1.67 to 3.09)
Child lived with anyone
who was mentally ill,
suicidal, or severely
depressed
No 1828 85.9 70 759 92.6 Reference Reference
Yes 476 14.1 6341 7.4 2.08 (1.68 to 2.56) 2.00 (1.57 to 2.54)
Child lived with anyone
who had a problem
with alcohol or drugs
No 1375 70.3 70 850 92.6 Reference Reference
Yes 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 1
biological 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, child
race and ethnicity, and child health status.
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higher risk for living under unstable
caregiving arrangements,
35
which
puts these children at greater risk for
externalizing behavior problems.
40
However, many other factors may also
be involved. Although our analyses
controlled for many key
sociodemographic variables, residual
confounding related to other risk
factors (eg, prenatal alcohol exposure,
lead exposure, or family history of
ADHD) may have impacted our
analyses. Large-scale longitudinal
studies examining children in
nonparental care would be necessary
to determine the extent to which
externalizing behavior contributes to
child placement in nonparental care.
Although the differences between
grandparent- and parent-headed
households have important implications
for children and caregivers, so too do
the similarities between these 2 groups.
For example, although we found that
grandparent-headed households have
a higher frequency of quality
interactions between caregivers and
children, our analyses indicate that
sociodemographic differences, rather
than differences inherent to
grandparent and parent caregivers, may
explain this small disparity. Additionally,
although caregivers in grandparent-
headed households were more likely to
experience aggravation from parenting,
we did not identify differences in
caregivers’reported ability to cope
with the daily demands of caregiving.
We found that grandparent and parent
caregivers in both 1- and 2-caregiver
households did not differ in their odds
of having someone to turn to for day-
to-day emotional support with
parenting or raising children, after
controlling for confounders.
Of concern, 24% of parent caregivers
and 30% of grandparent caregivers in
2-caregiver households did not have
someone to turn to for day-to-day
emotional support. Moreover, 31% of
single-parent caregivers and 41% of
single-grandparent caregivers lacked
this type of support. Given the
demographic characteristics of our
sample, it is possible that custodial
grandparents may not have as many
friends and family to rely on for
parenting support. Notably, after
controlling for sociodemographic
confounders, we found that
grandparents report greater support
from their neighborhoods. However,
this difference in neighborhood
support between grandparents and
parents was fairly small and unlikely
to have substantial implications.
Given grandparent caregivers’limited
access to emotional support, it has
been suggested that grandparent
households may be particularly in
need of social support services to
cope with the difficulties associated
with raising grandchildren.
21
In
conjunction with previous evidence
that grandparents who serve as the
primary caregiver for a child were
twice as likely to develop symptoms
of depression than noncaregiving
grandparents,
41
it is vital that
grandparents raising grandchildren
take advantage of support groups in
their community and on-line. Policies
to create local grandparent-raising-
grandchildren support programs can
provide ways to cope, informational
support, social support, and resource
connections to caregivers.
20,42,43
In
a recent randomized controlled trial,
Pandey et al
43
(2018) compared the
effectiveness of traditional child
welfare services with 3 community-
based forms of support for custodial
grandmothers. They concluded that
traditional child welfare is better
suited for the needs of parents and
foster parents and that peer-based
community programs provide greater
informational and emotional support
to grandmothers raising their
grandchildren. Given the difficulties
many grandparent caregivers face
with respect to emotional support
with parenting, pediatricians should
refer these caregivers to community-
based organizations oriented toward
supporting grandparents raising
grandchildren; in particular,
pediatricians should be mindful of the
additional support needed by
grandparents in one-caregiver
households. Organizations such as
Grandfamilies.org provide a directory
TABLE 4 ACE Composite Measures Among Grandparent and Parent Households, 2016–2018 NSCH
(N= 77 281)
ACE Composite
Measures
Grandparent
Households
(n= 2148)
Parent
Households
a
(n= 75 133)
OR
b
(95% CI) aOR
b,c
(95% CI)
n%
b
n%
b
Child experienced
$1 ACE
No 447 28.4 52 567 68.8 Reference Reference
Yes 1701 71.6 22 566 31.2 5.56 (4.27 to 7.24) 5.20 (3.71 to 7.29)
Child experienced
$2 ACEs
No 956 56.6 66 326 87.8 Reference Reference
Yes 1192 43.4 8807 12.2 5.49 (4.50 to 6.71) 4.88 (3.79 to 6.30)
Child experienced
$3 ACEs
No 1310 70.0 71 014 94.2 Reference Reference
Yes 838 30.0 4119 5.8 6.99 (5.70 to 8.57) 6.19 (4.78 to 8.01)
Child experienced
$4 ACEs
No 1605 82.5 73 238 97.2 Reference Reference
Yes 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 1
biological 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, child
race and ethnicity, and child health status.
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of national and state-specific
resources and support groups, which
pediatricians can use to guide and
counsel custodial grandparents.
44
Although past studies have revealed
that children raised in grandparent-
headed households may have poorer
outcomes throughout adolescence and
adulthood, our findings suggest that
efforts to identify children who would
benefit from medical or mental health
interventions would be best served
through screening that identifies ACEs
and ADHD. The American Academy of
Pediatrics has suggested that
pediatricians screen their patients for
early childhood adversity to identify
children at high risk for toxic stress.
45
Given that pediatricians tend to under-
identify risk factors such as ACEs and
unmet social needs,
46
and given the
elevated prevalence of ACEs among
children in grandparent-headed
households, pediatricians should be
particularly mindful of the importance
of early childhood screening in this
population. Continued research into the
complex interplay between childhood
adversity, ADHD, and physical and
emotional health is essential for the
development and refinement of
effective screening and interventions in
this high-risk population.
One strength of our study is its large,
nationally representative sample of
80 646 caregivers of children,
including 2407 grandparents raising
their grandchildren, making this the
largest study to date examining
childhood adversity, caregiver–child
relationships, and other related
measures in grandparent-headed
households using a nationally
representative sample. The sample
size allowed analytical models to
control for many key confounders.
Whereas most previous studies of
grandparent households have focused
on psychological, behavioral, and
health measures among either the
caregivers or the children, in this
study, we directly compare
grandparent households and parent
households with respect to both
caregiver variables and child
variables using the same large,
nationally representative sample.
This methodology allows for
consistent interpretations of findings
pertaining to both children and
caregivers. Additionally, whereas
researchers of many studies analyzed
individual Likert items when
examining child and caregiver
outcomes, in our study, we used
composite measures, reducing the
impact of random variation and
measurement error on our findings.
However, the use of these composite
measures also introduced notable
limitations to this study. In particular,
with the exception of the inattention
and restlessness scale, we could not
evaluate the construct validity of our
composite scales. Another potential
limitation of these measures was
caused by minor variation between
individual components in different
iterations of the NSCH, which may
have introduced some inconsistency
to our composite measures. However,
the majority of our composite
measures had strong internal
consistency, indicating that the
individual component items were
closely related to each other.
In addition to the limitations
introduced by our composite
measures, our study was also limited
by the reliance on caregiver report. It
is possible that grandparents are
more critical about or have higher
expectations for the behavior of their
grandchildren. However, this type of
bias is less likely to apply to reports
about ACEs or medical diagnosis of
ADHD. Additionally, the NSCH
questionnaire’s focus on lifetime
exposure to adversity did not allow
us to determine if the ACEs occurred
before or after the child’s placement
with their caregiver. Finally, although
we had the ability to control for
demographic differences between
groups, as with any retrospective
cross-sectional analysis, residual
confounding remains a possibility. For
example, beyond the number of
caregivers, the NSCH did not include
questions evaluating important
characteristics of caregivers and the
caregiver–child relationship, such as
caregiver race or the duration of time
that the child has been in the care of
their parent or grandparent. Our
inability to account for these
underlying household characteristics
may have impacted our findings.
CONCLUSIONS
In this study, we highlight many
profound differences between
grandparent- and parent-headed
households. Even after adjusting for
potential confounders, children in
grandparent-headed households were
much more likely to have experienced
psychosocial adversity. Additionally,
school-aged children in grandparent-
headed households had poorer
temperaments and their caregivers
reported greater aggravation.
However, no differences were noted
with respect to how well caregivers
were handling the day-to-day
demands of parenting. With nearly 3
million children now being raised by
one or both grandparents,
pediatricians must be mindful of the
demographic, psychosocial, and
parenting challenges that characterize
many grandparent-headed
households. In addition to screening
children in these families for
adversity and heightened stress,
pediatricians should refer these
families to appropriate support
groups and other resources
committed to meeting the needs of
parenting grandparents.
ABBREVIATIONS
ACE: adverse childhood experience
ADHD: attention-deficit/
hyperactivity disorder
aOR: adjusted odds ratio
CI: confidence interval
NSCH: National Survey of
Children’s Health
b
adj
: 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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