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Guest Editorial
Psychotherapy Education: Innovation and Evolution
Daniel H Greben, Zindel V Segal
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In Review
Implications of Psychotherapy Research for Psychotherapy Training
William E Piper
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Advances in Psychotherapy Education
Paula Ravitz, Ivan Silver
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Integrative Dimensions of Psychotherapy Training
Daniel H Greben
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Original Research
Forty Years of Deinstitutionalization of Psychiatric Services in Canada: An Empirical Assessment
Patricia Sealy, Paul C Whitehead
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Comparisons Between the South Oaks Gambling Screen and a DSM-IV-Based Interview in a Community Survey of Problem Gambling
Brian J Cox, Murray W Enns, Valerie Michaud
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Spirituality and Psychiatry in Canada: Psychiatric Practice Compared With Patient Expectations
Marilyn Baetz, Ron Griffin, Rudy Bowen, Gene Marcoux
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Differences Between Only Children and Children With 1 Sibling Referred to a Psychiatric Clinic: A Test of Richards and Goodman's Findings
Jacques D Marleau, Jean-Jacques Breton, Gisèle Chiniara, Jean-François Saucier
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Book Review
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The Infant and Family in the Twenty-First CenturyReviewed by
Pratibha N Reebye

Letters to the Editor
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High Frequency of Bipolar Spectrum in Outpatients With Depression

Long-Term Lamotrigine Adjunctive to Antipsychotic Monotherapy in Schizophrenia: Further Evidence

Evidence for Early Intervention in First-Episode Psychosis

D₂ Antagonist Augmentation in Patients With a Partial Response to Atypicial Antipsychotics

Original Research

Differences Between Only Children and Children With 1 Sibling Referred to a Psychiatric Clinic: A Test of Richards and Goodman’s Findings

Jacques D Marleau, PhD¹, Jean-Jacques Breton, MD, MSc², Gisèle Chiniara, MD³, Jean-François Saucier, MD, PhD⁴

Since early in the 20th century, when G Stanley Hall stated that being an only child was a disease in itself (1), many theorists and researchers have investigated whether only children differed from nononly children with regard to mental health. In general, data from community samples have been contradictory. In Quebec, Bergeron and colleagues reported that only children, especially those aged 6 to 11 years, were more at risk for mental disorders than were children with at least 1 sibling (2). In a Finnish study, only children were found to be significantly more likely to have a psychiatric disorder, compared with nononly children (3). Moreover, only children in Korea posted a higher deviance rate at school than did children with at least 1 sibling. In contrast, no differences emerged from data in Japan and China (4). Several studies have been conducted in China since the Chinese government began encouraging couples to have only 1 child. Many people believed that only children would be overprotected, potentially leading to negative psychological development. However, results of recent studies suggest that no marked differences exist between only children and nononly children with respect to personality traits (5,6).

Information from community samples concerning children using mental health services clearly shows that only children are no more likely to be referred to mental health services than are non only children (7–9). More specifically, Verhulst and van der Ende in Holland found that the presence of siblings lessened the chance of parents perceiving their child’s behaviour as problematic (9). In Quebec, Breton and colleagues found that parents of only children aged 6 to 14 years used more services outside the school setting than did those with at least 2 children (JJ Breton, personal communication, 2000).

Findings concerning only children in psychiatric and other clinical settings have been equally inconsistent. Some studies report that only children are underrepresented in clinical groups (10–15), while others have found that only children are more likely to be referred to clinical settings (16–20). This contradiction suggests that certain child or family variables influence referral.

Few authors have compared only children and nononly children in the same clinical setting (21,22). Howe and Madgett compared only children (n = 115) with children from multi- sibships (n = 115) aged 5 to 12 years seen from 1953 to 1968 in a Canadian mental health clinic (22). They presented data indicating that male only children showed more preneurotic and psychosomatic disturbances than did male nononly children. They also found 2 significant differences between the 2 subgroups of children: 1) male only children were more likely than male nononly children to return to the psychiatric clinic, and 2) mothers of only children (1 girl and 1 boy) were more often described as overprotective than were mothers of nononly children.

In 1996, Richards and Goodman compared 683 only children with 2364 children from 2-child families seen in a psychiatric clinic in England since January 1, 1974, for the presence of a psychiatric diagnosis (diagnoses were measured using the ICD-9 system) (21). Collected through standardized “item sheets,” the data for this study showed no statistically significant differences between only children and nononly children. The authors also investigated the possibility that only children were more likely to be referred for minor problems. First, Richards and Goodman’s results indicated no difference in the proportion of children aged 5 to 16 years with no diagnosis among only children and nononly children referred (21). Second, they reported that only children under age 5 years referred were significantly more likely to have no disorder (29%; 41/141), compared with children with 1 sibling (13%; 32/239).

In this sample, the higher proportion of only children with no disorder may suggest a function of the parent’s differential sensitivity rather than a function of the child’s behaviour. Multivariate logistic regression analysis showed that 2 variables had a statistically significant impact: only-child status and parenting situation. Only children and children living with 1 birth parent were more likely to have no disorder. The variable “overprotectiveness” was not statistically significant (this measure was not defined in the authors’ text). Their findings indicated that parents of only children are quicker to seek medical advice than are parents with 2 children. Richards and Goodman write:

Though our study does suggest that the parents of young only children are more likely to seek help with subthreshold problems, we believe this behaviour could as easily be labeled more caring as over-protective (21; p 757).

Initially, our study aimed to verify Richards and Goodman’s findings and to explore differences between only children and children with 1 sibling regarding the presence or absence of a psychiatric diagnosis. We use a sample of 169 children under age 5 years seen in the outpatient psychiatric clinic of a large pediatric hospital in Montreal, Quebec. We then assess the contribution of certain variables (such as age and sex of child, ordinal position, parenting status, and mother’s child-rearing attitudes) to the absence of a psychiatric diagnosis, using logistic regression analysis. It is important to gain a better understanding of the link between maternal attitudes and the suggested variables to gain a firm grasp on the process of clinical referral. Compared with Richards and Goodman’s study, which focused solely on the concept of overprotectiveness, we examine various facets of maternal behaviour.

Methodology

Design
This is a retrospective study based on a sample of children under age 5 years referred to child psychiatry services. We garnered clinical record data from 2 time periods for analysis: 143 consecutive files in 1985 to 1986 and 95 consecutive files in 1990 to 1991, for a total of 238 files (23). The sample in this study consists of 169 children: 85 only children and 84 children with 1 sibling.

Procedure
At the beginning of the first data-collection period, 2 of the article authors reviewed about 10 files to compare the codification of each variable. A predefined grid of 54 child- and family-related variables, developed by Valla and Houde (24), was used to analyze the files. The child psychiatrist who evaluated the child coded mental disorders according to the ICD-9. Five categories of mental disorders were used for data analysis. Three ICD-9 categories were modified slightly: 1) transient conditions because of a stressful situation were grouped with adjustment disorders; 2) cases of autism under the category of psychotic disorders were classified under developmental disorders; and 3) prolonged depressive reaction and affective immaturity were added to the category of anxiety disorders (that is, phobias, separation anxiety, hyperanxiety, and avoidance). Also, 2 categories were created: family relational disorders and externalizing disorders (23). Externalizing disorders grouped attention- deficit disorders, behavioural disorders, and conduct disorders.

Variables
The dependent variable was the presence or absence of a psychiatric disorder, according to the following 5 categories: 1) adjustment disorders, 2) developmental disorders, 3) anxiety disorders, 4) family relational disorders, and 5) externalizing disorders.

The independent variables were child’s age (0 to 2 years vs 3 to 4 years), sex of child, sibling status (only child vs child with 1 sibling), parenting situation (2 birth parents vs 1 birth parent), and mother’s child-rearing attitudes (attitudes are termed adequate or inadequate). We defined inadequate child-rearing attitudes as significant impatience, rejection, stubbornness, neglect, or overprotectiveness.

Analysis
We performed chi-square tests to measure the association between each independent variable and the dependent variable. We then constructed a multivariate logistic regression model using the 5 independent variables as predictors of no-disorder status. We used a hierarchical backward elimination strategy for each model and assessed goodness-of-fit with the Hosmer–Lemeshow statistic (P > 0.05) (25). We computed odds ratios and 95%CIs as estimates of strength of association.

Results

Of the total sample, 57% of children were aged 3 to 4 years, and 43% were aged 0 to 2 years (boys 59%; girls 41%). Most (79%) were referred by a physician. The percentage of children living with 1 birth parent was 32%. Regarding diagnoses, 84% of the children presented at least 1 mental disorder, and 16% had no disorder. The most frequent disorders were adjustment (32%) and developmental (27%) disorders.

Demographic characteristics of only children and children from 2-child families showed no statistically significant difference, except for family structure (Table 1). The data also indicated no difference between only children and children with 1 sibling in the categories concerning mental disorders, presence of at least 1 diagnosis, or presence of at least 1 psychiatric symptom (Table 2). The proportion of only children with no disorder was 14.8%, compared with 17.3% for children with 1 sibling. This difference was not statistically significant (c² = 0.183, P = 0.669).

We conducted a subsequent analysis comparing the 2 age groups. Among children aged 0 to 2 years, there was no significant difference in frequency of no disorder between only children (23%; 9/39) and children with 1 sibling (43%; 13/30) (c² = 3.20, P = 0.073). There was also no significant difference between those aged 3 to 4 years (only children, 7%; 3/42 vs nononly children, 2%; 1/51), respectively (c² = 1.50, Fisher’s P = 0.324). However, proportionally more younger children (that is, age 0 to 2 years) had no disorder diagnosed, compared with older children (aged 3 to 4 years) in each subgroup, that is, only children with no diagnosis (23%; 9/39 for younger children vs 7%; 3/42, for older children; c² = 4.07, P = 0.044) and children from 2-child families with no diagnosis (43%; 13/30 for younger children vs 2%; 1/51 for older children; c² = 22.62, P = 0.001).

When we added the variable “sex of child” to the analyses, the proportion of female only children with no disorder did not differ significantly from female children with 1 sibling (23%; 8/35 for female only children vs 17%; 5/30 for female nononly children; c² = 0.39, P = 0.534). The same was noted for males (9%; 4/46 for male only children vs 18%; 9/51 for male nononly children; c² = 1.67, P = 0.196). Also, the difference between female only children with no disorder and male only children with no disorder did not prove statistically significant (23%; 8/35 for girls vs 9%; 4/46 for boys; c² = 3.16, P = 0.076). As with the only children, the difference between female and male children with 1 sibling did not prove statistically significant (17%; 5/30 for girls vs 18%; 9/51 for boys; c² = 0.013, P = 0.910).

The result of the chi-square test indicated a significant association between ordinal position and absence of disorder (c² = 7.83, df 2; P = 0.02). Second-born children with no disorder constituted 26%, compared with 15% for only children and 3% for first-born children.

Results concerning parenting situation showed that children from families with both birth parents did not present a significantly higher rate of no disorder than did children from families with 1 birth parent (19%; 20/104 for children with both parents vs 10%; 5/49 for children with 1 parent; c² = 1.99, P = 0.159). Among children living with both birth parents (Table 3), the proportion of no disorder did not vary across only children, first-born children, and second-born children (c² = 5.98, df 2; Fisher’s P = 0.056). The same was true among children living with 1 birth parent (c² = 1.30, df 2; Fisher’s P = 0.637).

Mothers’ inadequate child-rearing attitudes were associated with the presence of a psychiatric diagnosis in only children, compared with mothers’ adequate child-rearing attitudes (97%; 35/36 vs 76%; 19/25, c² = 6.54, Fisher’s P = 0.016); this association was not found for children from 2-child families (89%; 16/18 vs 84%; 26/31, c²= 0.23, Fisher’s P = 1.000).

We entered the independent variables into the multiple logistic regression model: age of child (0 to 2 years vs 3 to 4 years), sex of child, sibling status (only child vs child with 1 sibling), parenting situation (2 birth parents vs 1 birth parent), and mother’s child-rearing attitudes (adequate vs inadequate). The analysis revealed that child’s age and mother’s child-rearing attitudes were significant predictors of no disorder. The odds of having no disorder were 16 times (95%CI, 3.1 to 77.3) as high among younger children (age 0 to 2 years) as among older children (age 3 to 4 years). Similarly, the odds of having a child with no disorder were 5 times (95%CI, 1.3 to 22.6) as high among mothers with adequate child-rearing attitudes as among those with inadequate attitudes (the Hosmer–Lemeshow adjustment test: c² (1) = 0.415, P = 0.481).

Discussion

Our findings do not support those of Richards and Goodman (21). In this sample, the percentage of children with minor problems not warranting a psychiatric diagnosis did not differ between only children and children from 2-child families. This result is somewhat surprising in that, (as with Richards and Goodman’s study), we limited the sample to children under age 5 years and used the ICD-9 to determine whether a child had a mental disorder.

The multivariate analysis conducted in this study indicates that child’s age and mother’s child-rearing attitudes are the most statistically significant variables. This contrasts with Richards and Goodman’s findings that parenting situation and ordinal position are the most significant variables (21). In this sample, younger children (age 0 to 2 years ) seem more likely than older children (age 3 to 4 years) to have no disorder. In addition, when only children were compared with first-born and second-born children, the latter more often had no disorder. This supports the hypothesis that parents are more sensitive to their children’s health at a younger age. Two points must be emphasized. First, many mental health professionals are reluctant to formulate a psychiatric diagnosis for very young children, which may lead to an underevaluation of mental health problems in this subpopulation. Second, in terms of the concept “psychiatric disorder,” a diagnosis is difficult to establish for young children, and it is more appropriate to focus on the number of symptoms that a child presents.

The other statistically significant predictor of no disorder is mother’s child-rearing attitudes. Mothers with adequate child-rearing attitudes may be more sensitive to the behaviour of their children and act accordingly. Mothers’ sensitive or preventive behaviour may explain why children with no disorder were referred in this sample. Some limitations must be considered when interpreting our results. The contents of the files vary according to information provided by parents and children and according to the personality, training, and experience of the clinician. Further, we did not investigate an interrater agreement on the analysis grid.

To explain their results, Richards and Goodman suggested that parents of only children may be more likely to seek help than parents concurrently caring for 2 children, especially when children are under age 5 years (21). They preferred this explanation to parental overprotectiveness. The over- protectiveness hypothesis is often used in clinical and epidemiologic research to explain why a higher percentage of only children are found in clinical settings and why children without siblings are more at risk for mental health problems (18,22,25). Richards and Goodman’s cost–benefit explanation fits well with the fact that it is harder to seek help for children over age 5 years because children are in school and mothers are more likely to work (21). They also suggested that the higher percentage of only children referred for subthreshold problems from nontraditional families (that is, single-parent and reconstituted families) could be explained by the cost–benefit argument, because mothers from non- traditional families receive less help from others. Because the parenting situation variable proved not statistically significant in the logistic model, our data do not support Richards and Goodman’s hypothesis. The opposite was observed: bivariate data show that preschool children living with both birth parents more often had no disorder than those who lived with 1 parent.

Conclusion

This study shows that child’s age (that is, under 2 years) and mother’s adequate child-rearing attitudes are associated with the greater likelihood of a child having no disorder. This differs from the findings of Richards and Goodman, who reported that parenting situation and only-child status are the most statistically significant predictors (21). Further research is needed to explain these conflicting findings and to determine whether other variables (for example, sex of siblings, socioeconomic status, urban vs rural living, parent–child relationship, and cultural settings) are linked to children with no disorders being referred to psychiatric services. Future studies must control for these variables to better understand the determinants of children with minor problems not warranting a psychiatric diagnosis being referred for professional help.

References

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19. MacKay J, Bigras J, Melvyn C, Bélair C. Analyse statistique et psychodynamique de la population canadienne-française qui consulte en pédopsychiatrie : étude préliminaire. Can Psychiatr Assoc J 1968;13:341–51.

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Author(s)

Manuscript received August 2002, revised, and accepted September 2003.

1. Anthropologist and demographer, Centre de recherche de l’Institut Philippe Pinel de Montréal, Université de Montréal, Montreal, Quebec.

2. Child Psychiatrist, Service de recherche, Hôpital Rivières-des-Prairies; Centre de recherche Fernand-Séguin, Hôpital Louis-H Lafontaine, Université de Montréal; Montreal, Quebec.

3. Child Psychiatrist, Centre hospitalier Monseigneur Ross, Gaspé, Quebec.

4. Child Psychiatrist, Hôpital Ste-Justine, Université de Montréal, Montreal, Quebec.

Address for correspondence: Dr JD Marleau, Centre de Recherche, Institut Philippe Pinel de Montréal, 10905 boulevard Henri-Bourassa Est, Montréal, Quebec. H1C 1H1

e-mail: marleauj@videotron.ca

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