Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian
- Ellen C. Perrin, MD, MA,
- Benjamin S. Siegel, MD,
- the COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH
Extensive data available from more than 30 years of research reveal that children raised by gay and lesbian parents have demonstrated resilience with regard to social, psychological, and sexual health despite economic and legal disparities and social stigma. Many studies have demonstrated that children's well-being is affected much more by their relationships with their parents, their parents' sense of competence and security, and the presence of social and economic support for the family than by the gender or the sexual orientation of their parents. Lack of opportunity for same-gender couples to marry adds to families’ stress, which affects the health and welfare of all household members. Because marriage strengthens families and, in so doing, benefits children’s development, children should not be deprived of the opportunity for their parents to be married. Paths to parenthood that include assisted reproductive techniques, adoption, and foster parenting should focus on competency of the parents rather than their sexual orientation.
- civil marriage
- foster care
- nurturing children
- gay parents
- lesbian parents
- health disparities
- legal disparities
- same sex
- same gender
- marriage equality
The mission of the American Academy of Pediatrics (AAP) is to promote optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. Historically, the AAP has worked, through its educational, research, advocacy, and policy efforts, to highlight the powerful connection between children’s well-being and the functioning of their most enduring source of support and influence—their parents. It is vital that pediatricians understand the unique and complex characteristics of their patients’ families and support them to ensure optimal development of children.
All children have the same needs for, and the right to, nurturing, security, and social stability. Children whose parents are gay and lesbian have historically been subjected to laws, social policies, and disapproving attitudes that create social distance and ostracism and challenge the stability of their families as well as their optimal social and psychological development. This technical report provides the scientific rationale, based on the current available evidence, to support the recommendations outlined in the policy statement “Promoting the Well-Being of Children Whose Parents are Gay or Lesbian”1: support for marriage equality, including repeal of the federal Defense of Marriage Act and similar public policies that limit access to federal benefits associated with civil marriage for gay and lesbian couples, and the right of gay and lesbian adults to adopt and provide foster care for eligible children.
Children depend on their parents for guidance, nurturing, protection, support, and love. Their resiliency derives from their sense of permanence, security, and unconditional attachment. As a consequence of this central value to their children, modern societies have developed the legal and social contract of marriage to ensure the permanent commitment of parents to each other and to their children, and thus to provide an optimal environment for children to thrive. The value of children to society is reflected also in the many public policies and programs that are designed to ensure adequate resources and support to parents who are raising a child alone, by choice or circumstance, and to families that because of physical or mental illness, abuse, neglect, and/or financial difficulty, cannot function successfully in their capacity as parents. Families created by gay and lesbian adults are no exception to these broad social policies.
Because of the value of marriage to the society, there are few legal restrictions on who can marry. The only legal limitations to marriage equality for consenting adults in the United States are for adults who are certified as mentally/emotionally incompetent, for whom marriage would lead to a polygamous relationship, who are of minor age, who are related by blood, or who are the same gender (in a majority of the states). Even a history of child abuse, domestic violence, or other criminal activity does not disqualify adults from civil marriage. Despite conflicts based on individuals’ political and religious beliefs, it is important to recognize that laws restricting competent adults of the same gender from codifying their commitment to each other and their children via civil marriage may result not only in pain and hardship for their children but also in legal, economic, psychological, social, and health disparities that can no longer be justified.
The 2003 report of the AAP Task Force on the Family stated that: “No particular family constellation makes poor or good outcomes for children inevitable.”2 The report continued: “A stable, well-functioning family that consists of 2 parents and children is potentially the most secure, supportive, and nurturing environment in which children may be raised. That children can be successfully brought to adulthood without this basic functioning unit is a tribute to those involved who have developed the skill and resiliency to overcome a difficult and fundamental challenge.”2
Families are diverse, complex, and changing. Most US public policy is built on the presumption that the majority of families are composed of a married mother and father raising their biological children. In contrast, the 2010 US Census revealed that the proportion of children living with 2 married biological parents had declined to 65.3%, down from 69.2% in 2001.3 See Table 1 for further elucidation of family types based on the 2010 Census.
Determining the number of children being raised by lesbian and gay parents is challenging, because most surveys do not ask about parents’ sexual orientation. Starting with the 2000 Census, gay and lesbian couples have had the option to identify themselves as spouses.4 The 2010 Census identified 131 729 self-reported married same-gender households and 514 735 same-gender unmarried partner households located in essentially all counties of the United States.4–6
Thirty-one percent of same-gender couples who identified as spouses and 14% of those who identified as unmarried partners indicated that they were raising children, more than 111 000 in all.5 In addition to these parents, many single gay men and lesbians are also raising children. Combined, current estimates suggest that almost 2 million children younger than 18 years are being raised by at least 1 gay or lesbian parent in the United States.6,7
Families with a gay or lesbian parent (or parents) are, themselves, a diverse group.8,9 For example, 55% to 59% of same-gender couples with children identify as white compared with 70% to 73% of married heterosexual couples with children.7 Same-gender couples, like heterosexual couples, may become parents by having children in previous heterosexual relationships or through fostering, adoption, donor insemination, and/or surrogacy.10
Legal Disparities Created by State Laws
Regulations and laws about the rights and responsibilities of parenthood are primarily state specific, resulting in great variability among the states. Many legal and social disparities exist for same-gender couples and their children.11
A critical disparity for children of unmarried parents is the absence of the protections reflected in divorce law. Thus, in the event of the dissolution of the couple’s relationship, these families lack the protections that exist for children whose parents are married, such as:
Access to the courts for a legally structured arrangement for dissolution of the relationship;
A court-approved legal arrangement for visitation rights and/or custody of children; and
Entitlement for children to financial support from and ongoing relationships with both parents.
The majority of states prohibit, by statute or state constitutional amendment, recognition of same-gender marriage.12 A few states extend other forms of relationship recognition, such as civil union or domestic partnership.
A few states, either by statute, regulation, or legal interpretation, restrict or prohibit foster parenting by same-gender couples and/or lesbians and gay men.
Laws regarding joint adoption by same gender couples, wherein both individuals become the legal parents of a biologically unrelated child, vary from state to state.13 Joint adoption by lesbian and gay couples is expressly prohibited in a few states, granted by law in fewer than half, and not addressed by statutes in most states.
Only in states that recognize civil marriage or other forms of domestic relationships can a lesbian or gay spouse or partner be recognized as a legal parent or step-parent to the child(ren) she or he is helping raise. In the majority of states, this is not a legal option.
In the United States (but not in much of Europe), sperm and egg donors may choose to remain anonymous and take on no legal responsibility for any children born. In a few states, a donor may be considered a legally recognized parent and have related responsibilities. A few states have laws ensuring that both parents are legally recognized as “presumed parents” of the child.
Most states lack a formal mechanism to ensure basic rights and responsibilities to nonbiological, nonadoptive coparents. Such laws are important to children when adult couple relationships are in dissolution and appropriate custody is under consideration.
Legal arrangements with a surrogate carrier are available in only a few states to gay men who wish to have a biologically related child.
In the event of death of a spouse, partner, or parent, state laws do not provide for Social Security or veteran’s survivor benefits for the surviving spouse/partner and children.
Legal Disparities Created by Federal Laws and Regulations
Restrictions against civil marriage for same-gender couples, such as the federal Defense of Marriage Act (Pub L No. 104-199 ) and replications of it in state statutes and constitutions, deny these couples and their children numerous other protections and benefits deemed valuable by society and government to which heterosexual married couples and their children have access. Under the Defense of Marriage Act, these benefits are not available to couples of the same gender even if they are legally married in a state that recognizes same-gender marriage. The US Government Accountability Office has identified a total of 1138 federal statutory provisions in which marital status was a factor in determining or receiving rights, benefits, and protections. These have been outlined elsewhere in detail14; a few examples are presented here:
Legal recognition of a couple’s commitment to and responsibility for one another and legal recognition of a child’s relationship to both parents and joint parenting rights;
Tax-exempt employer-sponsored health and other insurance benefits for spouse/partner and nonbiological/not jointly adopted children;
Ability to consent to medical care or authorize emergency medical treatment of nonbiological/not jointly adopted children;
The ability to travel with a child if it will require proof of being a legal parent;
The ability to file joint income tax returns and take advantage of family-related deductions, including the ability to use the child tax credit, child and dependent care tax credit, dependency exemption, earned income tax credit, and gift and estate tax exemption; and
A surviving parent’s right to the custody of and care for, and children’s right to maintain a relationship with, a nonbiological or not legally recognized parent in the event of the death of the other parent.
Because children cannot legally consent to medical treatment, the lack of uniform legal recognition of lesbian and gay parents results in parents being prohibited from accompanying their child(ren) and making medical decisions for them in routine and even emergency situations. Parents may even be barred from visiting their child in the hospital if their parental status is ambiguous.
Another challenge for same-gender couples and their families is obtaining health insurance. As a result of the federal Defense of Marriage Act, employers are not required to, although some choose to, offer health benefits to same-gender spouses or partners or children of lesbian and gay employees, even if those workers are legally married in their state. As a result, same-gender couples are 2 to 3 times less likely to have health insurance than are heterosexual couples.7,15 This disparity affects children directly, because the vast majority of children (more than 84%) have the same health insurance status as their parents (public or private insurance or uninsured16). Evidence that health insurance coverage is directly associated with health status is undeniable.17
Even when employers do make health insurance benefits available to same-gender spouses, partners, and related children, these families are faced with an economic disadvantage compared with their heterosexual counterparts. Such benefits are considered by the Internal Revenue Code to be taxable or “imputed” income to the employee unless the spouse or partner or child qualifies as a legal dependent. In addition, employers must also pay taxes on this imputed income for their share of the employee’s payroll tax.
Lesbian- and gay-headed families are at greater peril than heterosexual-headed families when a parent loses a job or takes a cut in pay. The Consolidated Omnibus Budget Reconciliation Act of 1995 (COBRA [Pub L No. 99-272]) provides workers and their families who lose their health benefits the capacity to continue group health benefits provided by their employer group health plan for limited periods of time. However, the COBRA, as federal legislation, does not require employers, even those who provide benefits for same-gender spouses/partners and their dependents, to offer lesbian and gay employees the opportunity to enroll their spouses, partners, or children.
Additional challenges exist in the provision of health care. Physicians, hospitals, and other health care professionals and environments may not offer a welcoming environment for same-gender parents and their children. The reaction a family may encounter ranges from acceptance to disdain: sometimes pediatricians and others encountered in health care settings or institutions may express stigmatizing attitudes or refuse to recognize an unmarried parent, especially when that parent is part of a gay or lesbian couple. Among respondents in a survey of gay and lesbian parents in New York, 42% reported that dislike of lesbian and gay people was a barrier to accessing health care and reported a lack of appropriately trained, competent professionals to deliver health care to lesbian and gay people.18 According to the October 2011 report, All Children Matter: How Legal and Social Inequalities Hurt LGBT Children, “a family may shy away from scheduling a child’s doctor’s visit in an effort to shield him or her from hostile questions or misunderstandings. For parents who must rely on medical professionals with unknown attitudes toward lesbian and gay patients, concerns linger about treatment of them and their children, which can make care more difficult to obtain.”7 Some parents report worries about being blamed for their child’s physical or emotional disorders because of their sexual orientation or family constellation.19
Children’s Developmental Trajectory and Psychological Outcomes
Many factors confer risk to children’s healthy development and adult outcomes, such as poverty, parental depression, parental substance abuse, divorce, and domestic violence, but the sexual orientation of their parents is not among them. Many studies have assessed the developmental and psychosocial outcomes of children whose parents are gay or lesbian and note that a family’s social and economic resources and the strength of the relationships among members of the family are far more important variables than parental gender or sexual orientation in affecting children’s development and well-being.20 A large body of scientific literature demonstrates that children and adolescents who grow up with gay and/or lesbian parents fare as well in emotional, cognitive, social, and sexual functioning as do children whose parents are heterosexual.21–37 Although the methodologic challenges are daunting in addressing phenomena as complex and multifactorial as children’s long-term developmental and psychosocial outcomes, the literature accumulated over more than 30 years, taken together, provides robust, reliable, and valid assurance about the well-being of children raised by parents of the same gender.28,29
The first review of available data regarding the well-being of children living with lesbian or gay parents concluded that “While research on these topics is relatively new….there is no evidence that the development of children with lesbian and gay parents is compromised in any significant respect relative to that among children of heterosexual parents in otherwise comparable circumstances.”30
Another early review summarized 23 articles published before 2000 that, together, described 615 offspring of lesbian mothers and gay fathers and 387 controls by using a variety of psychological tests and interviews. The conclusion drawn from these studies was that children raised by gay and lesbian parents did not systematically differ from other children in emotional/behavioral functioning, sexual orientation, experiences of stigmatization, gender role behavior, or cognitive functioning.31
A more recent comprehensive review of the experiences of gay and lesbian parents and their children reaffirmed that most children raised by lesbian and gay parents are developmentally and socially well-adjusted and that the societal presence of stigma, heterosexism, family circumstance, structure, and process are more important influences on children’s developmental trajectory than is the gender or sexual orientation of their parents.32
Much of this early research about children with gay and lesbian parents was, by necessity, based on relatively small convenience samples. Nevertheless, more than 100 scientific publications over 30 years, taken together, have demonstrated that children's well-being is affected much more by their relationships with their parents, their parents' sense of competence and security, and the presence of social and economic support for the family than by the gender or the sexual orientation of their parents.20,33,34
Increasing recognition and acceptance of lesbian and gay parents has allowed for larger, community-based and national studies in the United States and Europe. Three studies are of particular note. Using data obtained in a large US population-based survey, the National Longitudinal Study of Adolescent Health, the 44 adolescents who reported being raised by 2 women in a “marriage-like” family arrangement were compared with a random sample of 44 adolescents raised by heterosexual parents.35,36 There were no differences noted in measures of self-esteem, depression, anxiety, school connectedness, and school success. The authors concluded that “adolescents were functioning well and their adjustment was not associated with family type.” In both groups of adolescents, those who described a “closer relationship with their parents” reported less delinquent behavior and substance abuse; that is, the quality of parent-adolescent relationships better predicted adolescent outcomes than did family type.
Another community-wide study was based on data from a cohort of 14 000 mothers of children born within a particular county in England during 1 year.37 The study examined the quality of parent-child relationships and socioemotional and gender development in a community sample of 5- to 7-year-old children with lesbian mothers. Thirty-nine lesbian mother families were compared with 74 two-parent heterosexual families and 60 families headed by single heterosexual mothers. No differences were found in maternal warmth, emotional involvement, enjoyment of motherhood, frequency of conflicts, supervision of the child, abnormal behaviors reported by parents or teachers in the child, children’s self-esteem, or psychiatric disorders. Both mothers and teachers reported more behavioral problems among children in single-parent families than among children who had 2 parents in the home, irrespective of their sexual orientation.
A recent publication was based on a large national sample of US adults who were asked whether their parents had ever had a relationship with a person of the same gender while they were growing up and whether they had ever lived with that parent while the parent was involved in such a relationship.38 Parents who were said to have had a same-gender relationship were categorized as lesbian or gay parents, although their sexual orientation was not directly determined. In comparison with those who did not report that a parent had had a same-gender relationship, a number of adverse outcomes were identified, including being on public assistance, being unemployed, and having poorer educational attainment. Extensive critique of this study39–44 has pointed out that:
It is well known that family instability, and in particular divorce, is a risk factor for children,45,46 and almost all of the respondents whose parent had had a same-gender relationship had also experienced the divorce of their parents.
These data reflect an era when stigmatization and discrimination toward same-gender couples and their children were strong and were likely to have contributed to less-than-optimal child-rearing environments.40
The great variability in the form and characteristics of both same-gender and heterosexual relationships, combined with the small number of those relationships, even in a large data set like this one, makes it impossible to sort out true evidence of causality.43
A longstanding longitudinal study of children born to lesbian parents in the United States provides further insight into the well-being of children raised from birth by lesbian parents. The National Longitudinal Lesbian Family Study began in 1986, enrolling 154 lesbian mothers who became pregnant through donor insemination (70 birth mothers, 70 comothers, and 14 single mothers). These mothers have been enrolled in the study for more than 17 years, maintaining a retention rate of 92%. Recent publications describe the outcome of 78 adolescent offspring at age 17 (39 girls and 39 boys) on the basis of mothers’ and adolescents’ reports and comparing them with national standardization samples. The mothers’ reports about their 17-year-old sons and daughters indicated that they had high levels of social, school/academic, and total competence and fewer social problems, rule breaking, and aggressive and externalizing behavior compared with their age-matched counterparts in the Achenbach Child Behavior Checklist’s standardization sample. There were no differences between offspring who were conceived by known or anonymous donors or between offspring whose parents were still together and those whose mothers had separated.47 An accompanying editorial noted, “Can these data reassure those who fear that homosexual relationships with or without children will herald the end of the family as we know it? Our experience tells us of the resilience of children who are loved and know that love. … And when we see these moms or dads with their kids in our practice, we call them families.”48
The self-reported quality of life of the adolescents in this sample was similar to that reported by a comparable sample of adolescents with heterosexual parents.49 Lesbian parents reported that they planned to expose their children to male role models as an important child-rearing strategy. Half of both the girls and the boys had identified a male role model in their lives. There were no significant associations between gender role traits, adolescent psychological adjustment, gender of the adolescent, and the presence or absence of male role models.50
More data are available to document the well-being of children whose parents are lesbian than of those whose parents are gay men, because the numbers of gay men parenting have, until recently, been small. Recent studies affirm that families created by gay men resemble closely those created by lesbians.51 For example, a recent study assessed child development and parenting among 27 lesbian, 29 gay, and 50 heterosexual couples who had adopted a child.52 Lesbian and gay parents were similar in a variety of parenting characteristics to their heterosexual counterparts. Children in all family types were functioning similarly and had few behavior problems. Average scores for internalizing, externalizing, and total behavior problems reported by parents and teachers were similar to population averages for the child development instruments. In particular, there were no differences among the family types in children’s adjustment, parenting stress, parent discipline techniques, and couple adjustment. As in previous studies, teachers’ ratings of behavior noted that behavior problems were more likely in children with single parents than with 2 parents, irrespective of their sexual orientation. Instead, “parents who reported less parenting stress, use of more effective disciplinary techniques and who had greater happiness in their couple relationships had children who were described as well off.”51
Some authors have investigated children’s academic performance as an indicator of their well-being. Two articles compared the academic achievement of children whose parents were gay or lesbian with children whose parents were heterosexual. Although the studies were performed with different methodologies and in different population groups, both revealed similar academic achievement in the 2 groups. Using an analysis of US Census data to perform the first large-sample, nationally representative analysis of educational outcomes, the author concluded that “children of same-sex couples are as likely to make normal progress through school as the children of most other family structures.”53 Another study demonstrated that lower academic achievement was related more to the number of family transitions experienced by children than to the sexual orientation of their parents.54
A few publications have suggested less positive outcomes for children raised by same-gender parents. For example, a small study from Australia55 has sometimes been cited in support of the proposition that children raised by lesbians and gay men are less well-adjusted than those raised by heterosexual couples. The study was based on a comparison of teachers’ reports about 58 children in each of 3 groups of parents: married, heterosexual cohabiting, and gay or lesbian cohabiting. A primary goal of the study was to understand possible disadvantages to children’s school and social performance on the basis of the marriage versus cohabitation of their parents. It is critical to note that:
At the time of the research, marriage was available only to heterosexual parents, and therefore, all gay or lesbian couples were, by definition, cohabiting.
There is strong evidence provided in the article that the children with gay or lesbian parents were severely stigmatized in their schools and communities.
Most of the children with gay or lesbian parents had experienced the divorce of their heterosexual birth parents, in many cases shortly before the time of study, thus potentially adding to the children’s stress.45,46
The study’s findings included considerable variation in the ratings given by teachers with regard to the children’s school behavior and performance. For example, children with gay or lesbian parents were rated as performing less well in language and math but better in social studies and as having a better attitude toward learning, compared with the children being raised by cohabiting or married heterosexual parents. The deleterious effects of divorce and of stigmatization on children’s development are described by the author as likely contributors to the areas of poorer performance of the children with gay or lesbian parents. Overall, the author’s conclusions emphasized the benefits of marriage: “married couples seem to offer the best environment for a child’s social and educational development.”55 In another article, the same author reported a comparison of cohabiting adults of the same and of different genders and concluded that, in substantial ways, the relationships of cohabiting adults are similar, whether the partners are of the same or different genders.56
A 2012 commentary has described various shortcomings of the aforementioned research in support of adoption rights and marriage equality for same-gender couples.57 In general, this critique pointed out that most studies have included small and selective samples; have rarely reported longitudinal data and, therefore, have reported only short-term outcomes; and often have not included a comparison group. While agreeing with the imperfections of past research in this area, others have pointed out the intrinsic complexities of this research agenda40 and commented that, despite these imperfections, it is likely that the extensive research efforts that have been carried out would have documented serious and significant damages if they existed. In addition, it is important to note that all past research about children growing up with gay or lesbian parents has taken place in the context of pervasive social stigma and includes a majority of children whose parents were either single or divorced, each of which can be expected to contribute to poor outcomes for children.39
Although studies of uncommon and varied phenomena are difficult to perform and yield incomplete and imperfect results, there is an emerging consensus, based on an extensive review of the scientific literature, that children growing up in households headed by gay men or lesbians are not disadvantaged in any significant respect relative to children of heterosexual parents. Indeed, the fact that most data suggest that children grow up successfully in families created by gay and lesbian parents despite the almost-universal family disruption and social stigma they have experienced attests to the resilience of these families. Greater acceptance and support of these families will provide an environment even more conducive to successful social and emotional development.
Over the past decade, 11 countries have recognized marriage equality and, thus, allow marriage between 2 partners of the same gender: Argentina, Belgium, Canada, Denmark, Iceland, Netherlands, Norway, Portugal, Spain, South Africa, and Sweden. There has been no evidence that children in these countries have experienced difficulties as a result of these social changes.
When Marriage Is Not an Option
The AAP recognizes that some children are members of families headed by a single parent or by 2 parents who do not choose to be legally married and that it is possible for these parents to overcome the challenges involved in raising children in these circumstances. The AAP also acknowledges that some children have been removed from severely challenged families and are in temporary custody of a state agency or a related adult. There is no evidence that restricting these children’s access to loving and nurturing adoptive or foster care homes on the basis of gender or sexual orientation of the parents is in their best interests.52,58
The AAP Task Force on the Family reported that “married men and women are physically and emotionally healthier and are less likely to engage in health risk behaviors, such as alcohol or drug abuse, than are unmarried adults.”2 Both men and women live longer when married, presumably in part because they have healthier lifestyles, eat better, and monitor each other’s health.2 They tend to have relationships with more people and social institutions, which increases their level of social support. It has been well established that permanently married parents can create the best environment for children’s development.2,59
Marriage supports permanence and security (the basic ingredients for the healthy development of children). Marriage is also the official societal mechanism for conferring rights, benefits, and protections that support couples as spouses and parents and their children financially and legally. In a survey of married same-gender couples in Massachusetts, the first state to allow civil marriage for same-gender couples, 24% of the respondents noted that their children had previously been explicitly teased or taunted about having a gay or lesbian parent, but 93% of respondents stated that marriage has made their children happier and better off.60 Eighty-four percent of parents stated that their being married made them feel more comfortable working with their child(ren)’s teachers at school.
On the basis of this comprehensive review of the literature regarding the development and adjustment of children whose parents are the same gender, as well as the existing evidence for the legal, social, and health benefits of marriage to children, the AAP concludes that it is in the best interests of children that they be able to partake in the security of permanent nurturing and care that comes with the civil marriage of their parents, without regard to their parents’ gender or sexual orientation.
Marriage equality can help reduce social stigma faced by lesbian and gay parents and their children, thereby enhancing social stability, acceptance, and support. Children who are raised by married parents benefit from the social and legal status that civil marriage conveys to their parents.
When marriage of their parents is not a viable option, children should not be deprived of the opportunity for temporary foster care or adoption by single parents or couples, irrespective of their sexual orientation. Public policy and community support are vital to the success of children in these circumstances.
Pediatricians working to eliminate disparities and establish support, stability, and security of all families through marriage equality and legal parental recognition honor the AAP mission to promote the optimal physical, mental, and social health and well-being of all infants, children, adolescents, and young adults.
Ellen C. Perrin, MD, MA
Benjamin S. Siegel, MD
Committee on Psychosocial Aspects of Child and Family Health, 2012–2013
Benjamin S. Siegel, MD, Chairperson
Mary I. Dobbins, MD
Arthur Lavin, MD
Gerri Mattson, MD
John Pascoe, MD, MPH
Michael Yogman, MD
Ronald T. Brown, PhD – Society of Pediatric Psychology
Mary Jo Kupst, PhD – Society of Pediatric Psychology
D. Richard Martini, MD – American Academy of Child and Adolescent Psychiatry
Barbara Blue, MSN, RN, CPNP, PMHNP-BC – National Association of Pediatric Nurse Practitioners
Terry Carmichael, MSW – National Association of Social Workers
George J. Cohen, MD
Stephanie Domain, MS, CHES
The authors and the committee thank James G. Pawelski, MS, for his valuable contributions to the development of this technical report.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
- Copyright © 2013 by the American Academy of Pediatrics