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Child, teen and family therapy in Houston, TX. Joan's specializations include: ADD/ADHD, Anxiety, LGBT Issues, Abuse Issues, Adjustment Issues, Depression, Eating Disorders, School Trouble, Learning Disabilities, Trauma, Behavioral Problems, and Self-Mutilation. 

Parent Resources

This is a collection of psychiatry and psychology news and studies related to child, teen and family therapy.  These resources may be useful to parents interested in learning more about current topics influencing child, teen and family therapy.

Equivalent Child Outcomes in Same-Sex vs. Different-Sex Parent Households

Joan Lipuscek

In the United States, beliefs about child and family outcomes for same-sex versus different-sex parents have been a source of confusion and debate. To address this topic, the Journal of Developmental & Behavioral Pediatrics published the recent study, "Same-Sex and Different-Sex Parent Households and Child Health Outcomes: Findings from the National Survey of Children’s Health" by Henry M. W. Bos et al. This study found no significant difference between outcomes for children raised in similarly stable same-sex versus different-sex parent households. However, the study did find that same-sex parents report significantly higher levels of parenting stress compared to different-sex parents.

METHODS

In this study, the National Survey of Children's Health (NSCH) data set was used to examine 95 female same-sex parent families and 95 different-sex parent families. the NSCH is a population-based survey on children's health. Families were chosen if they were stable and didn’t experience a major stress event such as divorce or separation.  In order to participate, two parents had to be presently coupled and had to have raised their children since birth. Same-sex male parents were not selected because there were too few households meeting these criteria.  The researchers note that one of the strengths of the investigation was that "the data were drawn from a population-based survey on children's health that was not described to participants as a study of same-sex parent families, thus minimizing potential bias."

Researchers focused on data from households with children ages 6 through 17 and focused on questions about “family relationships, parenting stress and child outcomes.” This data set offered a chance for the researchers to examine whether there “are there differences in family relationships (spouse/partner relationships and parent-child relationships), parenting stress, or child outcomes (general health, emotional difficulties, coping behavior, and learning behavior)" between same-sex and different-sex parent households.

We have created the following visualization (best viewed in landscape on a mobile device) that summarizes the major findings from this study.

THE RESULTS

The study findings illustrate that there is no significant difference between same-sex and different-sex parent households in terms of spouse/partner relationship, parent/child relationship, child general health, child emotional difficulties, child coping behavior and child learning behavior. Thus, the researchers conclude that this study "contributes to the mounting evidence that children reared by same-sex parents fare at least as well as those reared by different-sex parents on a variety of measures used to assess psychological adjustment."  

The one exception to these otherwise equivalent results, however, was that the same sex couples reported experiencing greater parenting stress.  At this point in time little is known as to why same-sex parents experience greater stress as parents, but one theory suggests that the "cultural spotlight on child outcomes in families with same sex-parents” may be a causally contributing to the stress. 

Typically, greater parenting stress is a predictor that is "positively associated with children's emotional difficulties and negatively associated with child coping and learning behavior." Interestingly, however, greater parenting stress in same-sex parents did not manifest in these negative results. In an attempt to explain this, the researchers hypothesize that lesbian mothers are mitigating greater parenting stress by effectively utilizing support systems such as parenting groups and counseling services to allay negative child outcomes.

ADVICE FOR PARENTS

Unfortunately, homophobia in society and concerns about how societal attitudes may impact their families may be contributing to excess parenting stress among same-sex parents. These parents may also feel the pressure of other people judging them more closely and more critically compared to different-sex parents. 

Despite the societal challenges for same-sex parents, challenging days with children are common for all parents alike.  Parenting stress can be alleviated by understanding the triggers that contribute to your anxiety throughout the day. For example, you might feel stressed if your child is having a tantrum in a public place, especially if people begin to stare. Instead of saying, “I am a terrible parent because my child is acting out” try adjusting your self-talk to phrases such as: “my child is having a bad day,” “my child is hungry or tired” or “I am doing the best that I can." It is impossible to avoid all stressful parenting situations, but one key is to understand your limitations and allow yourself more time to accomplish tasks.

Also, attempt to prioritize the duties and responsibilities in your day so that you don’t become overwhelmed while setting healthy boundaries with others. Making time for yourself by eating healthy foods, getting enough sleep and daily exercise may also be beneficial. Finally, forming close emotional connections with family members, friends and cultivating a strong support system can also contribute to a healthier lifestyle. If you find that you are not able to deal effectively with the level of stress in your life or if you find that it is getting in the way of effective parenting, it may be time to contact a professional. 

New Research in the Old Debate Over Spanking

Joan Lipuscek

Parent beliefs on the acceptability of spanking are often influenced by a wide variety of political, religious and cultural variables. Nevertheless, the overall attitude towards spanking in the U.S. has slowly been changing. According to the University of Chicago's General Social Survey, approximately 70% of U.S. parents currently indicate that spanking is an acceptable form of punishment compared to 84% in 1986 . 

To add to the debate, last month a new meta-analysis entitled "Spanking and Child Outcomes: Old Controversies and New Meta-Analyses" by Gershoff and Grogan-Kaylor was published in the Journal of Family Psychology. The study "found no evidence that spanking is associated with improved child behavior and rather found spanking to be associated with increased risk of 13 detrimental outcomes."  The study went on to recommend that "Parents who use spanking, practitioners who recommend it, and policymakers who allow it might reconsider doing so given that there is no evidence that spanking does any good for children and all evidence points to the risk of it doing harm."

This new analysis evaluated a total of 1,574 studies related to the use of spanking children as a disciplinary measure used by parents.  Then, the list of studies was narrowed using the following criteria:

1) Studies had to be published in a peer-reviewed journal.
2) Studies had to include "a measure of parents' use of customary, noninjurious spanking (or slapping or hitting)" to insure that studies of physical abuse were not included.
3) Studies had to report an association between spanking and child outcomes.
4) Studies had to include "appropriate statistics for calculating effect sizes" (Cohen's d).

As a result of this criteria, the list of studies was narrowed to 75. These studies produced a total of 111 effect sizes that the researchers used for their analysis.  The 111 effect sizes included data from 160,927 unique children. The oldest studies included in the analysis are from 1961, while the newest are from 2014.  Thus, research from over five decades has been included.

We have created the following visualizations that summarize a portion of the findings from this study.

Note: The calculations in the graphic are based on Cohen's d reported by outcome and study. Each Cohen's d is converted into a Number Needed to Treat using the Excel formula: 

Number Needed to Treat = 1/(NORMSDIST(Cohen's d +NORMSINV(Control Event Rate))-Control Event Rate)

Because we do not know the exact rate of negative child and adult outcomes for children that were not spanked (Control Event Rate), we allow readers to change this variable from 10% to 40%. Then, we determine the % Increase of Negative Outcomes for Spanked Children Compared to Not Spanked Children using 1/Number Needed to Treat.

THE RESULTS

The first tab "Spanking Outcomes" lists 17 different negative psychological outcomes. The study found that spanked children experienced each negative outcome more than children who were not spanked.  However, only 13 of the 17 negative outcomes showed a statistically significant increase among spanked children. Of these, 10 were child outcomes.  Spanked children were at an increased risk of being a victim of physical abuse, having mental health problems, having a negative parent-child relationship, externalizing behavior problems, anti-social behavior, low moral internalization, aggression, internalizing behavior problems, impaired cognitive ability and low self-esteem. In addition, the study showed that spanked children are at an increased risk of negative adult outcomes including support for physical punishment of children, antisocial behavior and mental health problems.

The second tab "Spanking Studies" shows all the different studies that the researchers used to obtain these results. Positive results indicate that spanked children are at elevated risk for negative psychological outcomes. Negative results indicate that spanked children are at reduced risk for negative psychological outcomes.

Of all the studies that were included, 102 of the 111 effect sizes showed elevated risk of negative psychological outcomes for children that were spanked. Only nine studies showed reduced risk of negative psychological outcomes for children that were spanked and only one (Tennant, Detals, & Clark, 1975) was statistically significant. 

COUNTER EVIDENCE

Professor Gershoff has long been associated with research on spanking and corporal punishment. Her 2002 study, "Corporal Punishment by Parents and Associated Child Behaviors and Experiences: A Meta-Analytic and Theoretical Review" is widely cited and critiqued using two primary arguments.

Argument #1: Professor Gershoff's 2002 study grouped spanking with other forms of more severe physical punishment.  As a result, her 2002 study overstated the negative outcomes due to spanking. This line of argument was explored in "Ordinary Physical Punishment: Is It Harmful? Comment on Gershoff (2002)" by Baumrind et al.  When this critique reanalyzed the sample used in Professor Gershoff's 2002 study, it found that negative child outcomes were more highly associated with severe forms of corporal punishment compared to less severe forms such as spanking.

Thus, this study concluded that "Because her [Professor Gershoff's] measure included many instances of extreme and excessive physical punishment, her analyses are not relevant to the current political debate about whether normative spanking...is harmful for children. At present we conclude that the evidence presented in Gershoff’s meta-analyses does not justify a blanket injunction against mild to moderate disciplinary spanking." 

In their new paper, Professors Gershoff and Grogan-Kaylor respond to this critique by noting that these researchers "concluded that only severe methods of physical punishment are harmful." However, the professors note that this critique included statistics comparing more severe and less severe forms of corporal punishment that indicate "that both are associated with more undesirable child outcomes." 

This critique led Professors Gershoff and Grogan-Kaylor to modify the criteria for a study's inclusion in their updated analysis. In their latest analysis, only studies that had "a measure of parents' use of customary, noninjurious spanking (or slapping or hitting)" were included to insure that studies of physical abuse were excluded (Criteria #2 for inclusion of a study described above).

Argument #2: Professor Gershoff's meta-analysis is relying on a sample of methodologically weak studies that have have not conducted randomized controlled experiments. However, as Professors Gershoff  and Grogan-Kaylor note in their latest analysis, "parents' use of spanking is not easily or ethically studied through an experimental design, as children cannot be randomly assigned to parents with varying predispositions to spank, nor can parents typically be randomly assigned to spank or not spank."

Due to this problem, studies have not been able to "causally link spanking with child outcomes" because they suffer from "selection bias in who gets spanked - children with more behavior problems elicit more discipline generally and spanking in particular." This critique is covered in "The Intervention Selection Bias: An Underrecognized Confound in Intervention Research" by Larzelere et al.

In response, Professors Gershoff and Grogan-Kaylor note that analyses that have used advanced statistical methods to mitigate these concerns and focused only on the most methodologically sound studies have failed to find evidence that spanking produces positive child outcomes. Instead, studies such as "Spanking, corporal punishment and negative long-term outcomes: a meta-analytic review of longitudinal studies" by Ferguson have found "small but non-trivial long-term relationships between spanking/corporal punishment use and negative outcomes." 

Advice for parents

As mentioned in the introduction, the decision to spank or not spank a child is deeply personal and the aim of this post is not to judge individual parenting decisions. However, it may be valuable for interested parents to understand the latest research and counter-arguments in this area of study.

In our review of the research, it appears reasonable to conclude the following:

1) There is little evidence to suggest that spanking leads to positive child outcomes.
2) At best, mild spanking adds little to no risk of negative child outcomes.
3) At worst, even mild spanking significantly increases risk of negative child and adult psychological outcomes.

With the evidence stacking up in favor of not spanking children, parents may want to question why they are continuing this practice. Would alternative forms of non-physical discipline prove as effective without the increased risk of negative psychological outcomes? Would brief "time-outs" or a short-term loss of privileges accomplish the same goals as spanking?

If trends on attitudes towards the acceptability of spanking continue, the practice of spanking is in no danger of a quick extinction. However, with new research and critiques working to improve methods and provide more sound conclusions, there appears to be mounting evidence that spanking is a practice that is ineffective at best and detrimental at worst.

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Youngest Children in Class at Greater Risk for ADHD Diagnosis & Medication

Joan Lipuscek

In March 2016, a new Taiwanese study was published in The Journal of Pediatrics that showed that the youngest children in a class are at greater risk of being diagnosed and medicated for ADHD compared to older classmates. The implication is that the youngest children in a class are overdiagnosed with ADHD due simply to immaturity. 

The results of this study appear consistent with a number of other studies from around the world. The U.S., Canada, Iceland and now Taiwan have all produced studies that find that relative age in a classroom is a very important factor when diagnosing and medicating for ADHD.

Although countries and states have different cutoff dates for school children to enter a class, we adjusted the data for each study so that readers can easily see the trend of higher rates of ADHD diagnosis and medication for the youngest children in the class.

THE STUDIES

  1. Taiwan, 2016 Chen, et al. "Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in Taiwanese Children" This is the latest study on the importance of relative age in diagnosing ADHD.  The sample was 378,881 Taiwanese school children ages 4-17 in school from 1997 to 2011. Kids born just one month prior to the grade cutoff date were 61% more likely to be diagnosed with ADHD compared to their oldest classmates. These youngest children were also 75% more likely to be medicated compared to their oldest classmates. Results were consistent for both boys and girls.

  2. Canada, 2012Morrow, et al. "Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children" Consistent with the findings in Taiwan, this Canadian study also found a higher risk for the youngest boys and girls of a class being both diagnosed and medicated for ADHD. The sample was 937,943 children in British Columbia ranging between 6 and 12 years of age using data from the 11 years between 1997 through 2008. The study found that male children born one month prior to the grade cutoff date were 30% more likely to be diagnosed with ADHD and 41% more likely to be medicated compared to the oldest male children in the same grade. Female children born one month prior to the grade cutoff date were 69% more likely to be diagnosed with ADHD and 73% more likely to be medicated compared to the oldest female children in the same grade. According to the study, "The potential harms of overdiagnosis and overprescribing and the lack of an objective test for ADHD strongly suggest caution be taken in assessing children for this disorder and providing treatment."

  3. Iceland, 2012 (Medication Only)Zoëga et al. "Age, Academic Performance, and Stimulant Prescribing for ADHD: A Nationwide Cohort Study" Although this study did not include statistics on ADHD diagnoses or monthly statistics, it's findings for ADHD medication in children are consistent with other studies. The study reviewed data from 11,785 Icelandic children at ages 9 and 12. Male children born 1-4 months prior to the grade cutoff date were 52% more likely to be medicated for ADHD compared to the oldest male children in the same grade. Female children born 1-4 months prior to the grade cutoff date were 73% more likely to be medicated for ADHD compared to the oldest female children in the same grade. The study concluded that, “Relative age among classmates affects children’s…risk of being prescribed stimulants for ADHD.” (Note: Data from this study was approximated from graphics included in the published version.)

  4. USA, 2010 (Elder)Elder, "The Importance of Relative Standards in ADHD Diagnoses: Evidence Based on Exact Birth Dates" Of all the studies reviewed, this study from the USA shows the highest increase in risk for diagnosis and medication of ADHD for the youngest children in a class. The study utilized data from 11,784 children in the Early Childhood Longitudinal Study-Kindergarten longitudinal survey that tracked kindergartners in the fall of the 1998–1999 school year through the next nine years. Children born 1 month prior to the September 1st class grade cutoff date were 122% more likely to be diagnosed with ADHD and 137% more likely to be medicated for ADHD. The study concludes by noting a point applicable to all included studies, "Whether relatively young children are overdiagnosed, relatively old children are underdiagnosed, or both, current efforts to define and diagnose ADHD evidently fall short of an objective standard." (Note: Data from this study was approximated from graphics included in the published version.)

  5. USA, 2010 (Evans)Evans, et al. "Measuring Inappropriate Medical Diagnosis and Treatment in Survey Data: The Case of ADHD among School-Age Children" This study used a sample of 35,343 children from the National Health Interview Survey and 18,559 children from the Medical Expenditures Panel Survey. Children born 1-3 months prior to the grade cutoff date were 27% more likely to be diagnosed for ADHD and 24% more likely to be medicated for ADHD compared to children born 10-12 months prior to the grade cutoff data. The study does a nice job of relating its findings to the "real world" scale of the problem when it states, "To put our estimates into perspective, an excess of 2 percentage points implies that approximately 1.1 million children received an inappropriate diagnosis and over 800,000 received stimulant medication due only to relative maturity."

COUNTER EVIDENCE

In this post we concentrated on studies that have been consistently finding evidence of increased risk of ADHD in the youngest children in a class as evidence for the misdiagnosis and potential over-medication of this population. However, a 2014 Danish study, Pottegard et al. "Children’s relative age in class and use of medication for ADHD: a Danish Nationwide Study" did not support these findings. Although the authors had hypothesized that they would find results consistent with those of other international studies, this did not prove to be the case. In explaining the difference, the researchers postulate, "...that this may be due to the high proportion of relatively young children held back by 1 year in the Danish school system and/or a generally low prevalence of ADHD medication use in the country."

ADVICE FOR PARENTS

Although many of these studies urge "caution" in diagnosing and medicating children for ADHD, they do not provide prescriptive advice to parents. However, using the evidence, it is possible to begin to construct a road map for parents challenged by a child that may have ADHD.

  1. Consider the Age of Your Child - Is your child one of the youngest children in his/her class?  If so, is his/her behavior outside the norm for not just his/her grade level, but for kids of his/her specific age? Consider a school with a class cutoff date of September 1st. A child born on August 31st will be in the same class as children born on September 2nd, but will be nearly an entire year younger. This may not seem like a big difference to an adult, but for seven and eight-year-olds, the oldest children in the class will have had a 14% longer life compared to the youngest children in the class. This is no small amount in the context of rapid development in young children and behavior expectations in schools.

  2. Weigh Behavior Outside of School - Is your child also experiencing problems in the home or at play? Do problems seem to manifest in the school disproportionately to other environments? As recommended by the Canadian paper included above, "Greater emphasis on a child’s behavior outside of school may be warranted when assessing children for ADHD to lessen the risk of inappropriate diagnosis." This increases the likelihood that the child's behavior will be based on its own merits and not relative to students that may have a significant age advantage.

  3. Consider Holding a Young Child Back a Year - The possibility that "the high proportion of relatively young children held back by 1 year in the Danish school system" is one of the reasons that the Danish study did not find results consistent with other countries is very intriguing. Parents should carefully consider this option if they suspect that some of a child's school behavior issues may be due to immaturity relative to other classmates.

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