Ella said, "Here 1 am, 63 years old, finally retired from my secretarial job, and I wake up today and have to start raising my 4year-old granddaughter." Ella's 19year-old daughter just left home to attend college, leaving Ella to care for her daughter, Brittany. Being the only relative living nearby and believing in family values and unity, Ella had no other option than to keep Brittany and begin parenting for the second time. Names changed for anonymity purposes.
Grandparenthood has not turned out the way many maturing Americans expected because most did not envision being primary caregivers at this stage in their lives. Casper and Bryson (1998) reported 2.4 million families in the United States were maintained by grandparents, an increase of approximately 400,000 (19%) since 1990. These families comprised 7% of all families with children younger than age 18, and a singlegrandmother with limited financial resources heads almost half of these families (Casper & Bryson, 1998).
Although social ties are strong within most American families, grandparents caring for their grandchildren report decreased social networking and diminished marital satisfaction (Minkler, Roe, & RobertsonBeckley, 1994). This new role causes caregiver stress, adversely affects child health, and ultimately diminishes family functioning (MorrowKondos, Weber, Cooper, & Hesser, 1997). Nurses and other health care providers are in a strategic position to assist grandparents and their grandchildren develop coping mechanisms to enhance resource use and healthy family systems (Dowdell, 1995; Minkler, Driver, Roe, & Bedeian, 1993). The purpose of this article is to explore the changing role of grandparenthood and provide strategies nurses can use to help this community support and cope with tlieir unanticipated parenting role.
ASSESSMENT INDICATORS FOR G RAN D PARE NTI NG
THE CHANGING ROLE OF GRANDPARENTHOOD
Divorce, unemployment, abandonment, teen pregnancy, death of a grandchild's parent, incarceration, mental and physical illnesses, grandchild maltreatment, and a growing number of AIDS cases have left increasing numbers of grandparents with the task of raising their grandchildren on a full-time basis (Ward & Brown, 1994). Additionally, dualincome families, the need for a single parent to work, single parenthood, and observed inadequacies in the parenting of children has led many grandparents to assume responsibility for at least part-time care of their grandchildren. For many grandparents, assuming parenting responsibilities has occurred at a time when relief from parenting was expected, and more relaxing and enjoyable activities were planned.
For some grandparents, the role of parenting has been promoted by state law mandating child welfare agencies to place foster children with relatives whenever possible. If the parents are deemed unfit or abdicate their parenting responsibilities, grandparents may feel a duty to accept the parenting role. Grandparents also may assume the parenting role because of feelings of personal responsibility when their children cannot or elect not to provide basic and safe care. In these cases, grandparents may be very reluctant to disclose less than satisfactory living situations for fear of welfare agency intervention or because of difficulty adhering to housing regulations (Kelley, 1993).
The increase in grandparent caregiving is particularly pronounced in Black families. The 1990 census estimated more than 12% of Black children lived with their grandparents, compared to 5.8% of Hispanic children and 3% of White children (Casper & Bryson, 1998). Some estimates indicate low-income Black communities with a high incidence of AIDS, illicit drug use, and violence may have as many as 50% of the children living with grandparents (Roe, Minkler, & Barnwell, 1994).
For some grandparents on a fixed income, the financial responsibility of parenting presents significant stress. These grandparents often are at significant risk for depressive symptomatology and other social and emotional problems (Minkler, Fuller-Thomson, Miller, & Driver, 1997). A number of studies have noted substantial problems including depression, poor health, and increased psychological stress when family members assumed significant and time-consuming caregiving roles (Hall, 1998). Children left to be cared for when substance abuse is involved often are very young and vulnerable and may suffer from neglect, abuse, and exposure to other traumatic stresses (Caliandro, & Hughes, 1998; Grant, Gordon, & Cohen, 1997). A recurring theme in all these studies is die stress of caring for grandchildren is significant and culturally determined (Hurme, 1997). Health care providers should be knowledgeable of potential areas of stress and identify resources and strategies to assist caregiving grandparents in their second parenting role.
ASSESSING THE STRESSES OF CAREGIVING GRANDPARENTS
While the literature on caregiver stress in grandparents raising grandchildren is limited, there are reoccurring themes that predominate and provide a basis for assessment and intervention in the home. While older grandmothers tend to perceive themselves as being stronger and less frustrated with their grandchildren than do younger grandmothers (Watson, 1997), adjustment problems remain among many grandparents who must assume unanticipated responsibilities during the latter portion of their lives. These include adjustment to the caregiver role, financial stress, lack of living space to accommodate grandchildren, role restriction, and special childhood problems.
Adjustment to the Caregiver Role
The caregiving grandparent role may be thrust on an individual suddenly, be a negotiated assumption, or reflect an inevitable resolution. With each circumstance, different dynamics are involved and include the nature and length of forewarning, the circumstances and emotions related to the triggering event, the grandparent's goal, the length of time involved in the role, and the perceived influence on personal destiny (Roe et al., 1994). Depending on the family dynamics, psychological and parenting stresses may vary significantly. The grandparent may feel ill equipped to address the tantrums of a 3-year-old or an incidence of shoplifting which may occur in the preteen years. The social norms and acceptable behavioral standards, which applied to their own children, may no longer seem to be appropriate, and there are few sources of advice for elderly parents. An intergenerational approach to reconciling differences in perceptions between grandparents and grandchildren is one avenue nurses can take to nurture family unity (O'Reilly & Morrison, 1993). Table 1 identifies assessment questions nurses can ask to ascertain information to plan appropriate care for both grandchildren and grandparents.
Another area of concern for grandparents who assume full-time caregiving responsibilities for young children is that they will not live long enough to assist the child to adulthood. Fears of what may happen to the child if the grandparents die or become unable to care for the child can seriously aggravate caregiver stress (Kelley, 1993). Some grandparents who have living children may fear their children will return and attempt to assume parenting duties in an unfit state. This scenario has prompted some grandparents to take the grandchild and relocate to an area away from the parents.
A majority of grandparents report financial difficulties in raising grandchildren are a major concern (Ahmann, & Shepherd -Vernon, 1997; Kelley, Yorker, & Whitley, 1997). The addition of children to the household may cause grandparents to lose subsidized senior citizen housing, which further increases cost of living. Occasionally, some lease agreements restrict the number and age of occupants, thereby forcing grandparents to choose between their grandchildren and their residence.
In some cases, grandparents' benefits of caring for a grandchild are less than a foster parent would be paid caring for the same child. Health care for a growing child may become a critical issue because many grandparents raising grandchildren do not seek financial assistance. Instead, they attempt to manage the child's health needs out-of-pocket. This management strategy often forces grandparents to choose between a health maintenance visit for the grandchild, purchasing their own medication, or buying food for the family. The most necessary expense tends to be food, which would benefit everyone. However, this places both the grandchild and grandparents at further risk for illness.
Space to Accommodate Grandchildren
A grandchild moving in with grandparents often causes crowding in the present living space. If the grandparents are living in a smaller space since their children left, making room for a grandchild can present major obstacles, often leaving both child and grandparents with little privacy or personal space. This may compound both depressive reactions and anxiety, especially among grandmothers who already experience greater levels of stress and less social support when providing primary care to grandchildren (Musil, 1998).
Role restriction can lead to a sense of resentment associated with the loss of anticipated freedom from parental responsibilities. For example, while a grandparent may enjoy being a grandparent when the child visits for only a short time, finding they are required to provide full-time care may be considered an infringement on their ability to perform the activities expected for that stage of life.
Some grandmothers quit their jobs to provide care for grandchildren who need a caregiver. The grandparents may perceive this as a negative move because jobs provide identity, dignity, income, and an opportunity for a comfortable retirement. Diaper washing, midnight feedings, infant and childhood illnesses, or the need to relinquish a car because of the expense may provoke personal hardship and aggravate an already stressful situation.
Social isolation may be experienced when grandparents assume the responsibilities of raising their children's children (Kelley, 1993). Their friends who do not have similar parenting problems are much less likely to share in the same activities. Further, grandparents may have difficulty relating to parents involved in the grandchildren's school and social activities.
WORLD WIDE WEB RESOURCES FOR GRANDPARENTS AND GRANDCHILDREN
Special Childhood Problems
Grandparents may need to be informed about childhood problems and solutions tliat currently exist but did not exist during their years of first parenting (e.g., child prostitution, cyberporn). Additionally, grandparents who suddenly are confronted with health problems of grandchildren may minimize their own health care needs (Joslin & Brouard, 1995). Thus, nurses providing care in this environment should place additional emphasis on holistic family care to ensure the health concerns of everyone are met and the grandparents become responsible caregivers during this potentially stressful period (SmithBattle, 1997).
The grandchildren may suffer from bitterness and depression as a result of early childhood trauma, parental loss, or physical relocation, for example. While these can lead to grandparents feeling insecure, the grandchildren also may express hostility at not having traditional parents like other children. Grandparents may need particular support and assistance if these conditions are manifested in acting-out behaviors because often no action will be taken if symptoms are not recognized or perceived as serious (Kunstadter, 1991).
ADJUSTMENT TO THE CAREGIVER GRANDPARENT ROLE
Adjustment to the caregiving role can be enhanced if an adequate social network is present which facilitates knowledge of existing social systems (Minkler et al., 1993). The caregiver grandparent role can provide a challenge, offering new meaning and renewal to life if such supports are available and used readily. Table 2 highlights some relevant Internet resources available to assist nurses to help grandchildren and grandparents work through multiple potential problems.
As the number of caregiving grandparents increases, awareness of the needs of individuals in this group grows. Many states have chapters of organizations for grandparents raising grandchildren with the goal of providing support and information. The American Association of Retired Persons (AARP) is addressing this topic increasingly in its bimonthly magazine, Modern Maturity, and its monthly newsletter, the AARP Bulletin. Just as parents need relief from the stress of constant caregiving, grandparents also need relief from constant caregiving the second time they do it.
In 1993, the AARP and The Brookdale Foundation Group, a philanthropic organization that focuses on meeting the needs and challenges of America's older population, joined to found the AARP Grandparent Information Center. This center functions as a clearinghouse of information and provides a vital link between grandparents and social service agencies. Resources are available to assist in caring for grandchildren. In its first year, the Center responded to more than 4,700 telephone calls and letters from grandparents, professionals, researchers, and the media (Lehrmann, 1995). The Center also offers a newsletter, provides tip sheets on a variety of topics related to grandparents raising grandchildren, and suggests other helpful publications. While the availability of support is growing rapidly, many grandparents have little knowledge of accessible services. While some support groups are in place, one study determined only 12% of caregiving grandparents surveyed ever had attended a support group meeting (Kelley, 1993). Because many caregiving grandparents have low incomes, financial restraints can be an additional obstacle to accessibility of support (Ahmann & Shepherd-Vernon, 1997). Overcoming institutional barriers and cultural obstacles is essential if grandparents are to successfully negotiate a system that tends to be inflexible in meeting their demands as second-time parents.
Negotiating the System
Assisting a child through the educational, health prevention, and legal systems is a challenge for traditional parents. Because caregiving grandparents are elderly, this can present a challenge for which professional assistance is required. This is especially true if the child has special health needs. For example, the caregiving grandparent may be required to function as a case manager if the child is diagnosed with a chronic illness.
Because grandparents may be raising several grandchildren with complex problems, there may be competition for scarce resources. Professional assistance may be needed if those resources are to be obtained and used appropriately. Grandparents must be instructed where to go within the health care and social welfare system to obtain the consistent support necessary to provide safe and adequate care to the children they are raising.
One such regional effort has been established in the state of Georgia. Project Healthy Grandparenting currently is in four sites across the state and represents a collaborative project between nursing and social services. The ultimate purpose of this project is to keep grandparents who are raising grandchildren physically and emotionally healthy and to support intergenerational families, thereby keeping the children out of the foster care system. To accomplish these goals, support groups, educational efforts, and legal, financial, and psychological assistance are available. The program functions as a research and service project, and data currently are being collected to make comparisons across the state (Woodring, 1998). Successful efforts to link these social services ultimately should serve to increase the meaning and life satisfaction of the experience.
Satisfaction in the Grandparent Role
While some grandparents who assume the caregiving role of their grandchildren are unhappy with the role reversal, others find it a rewarding role. For a grandparent who is unhappy with their own child, helping a grandchild overcome the scars of early abuse and neglect may be a source of great pride. Some grandparents have found having a child in the house again has had a positive effect on intimate relationships by increased communication between the partners. Raising a grandchild can renew a relationship that was abandoned by providing a challenging opportunity to renew life's goals. Brussoni and Boon (1998) found the closeness of the grandparent-grandchild relationships was related to the extent to which the two interacted and shared multiple aspects of their lives. Other positive outcomes of grandparents raising grandchildren include upholding the essence of family cohesiveness (Caliandro & Hughes, 1998) and providing an emotionally rewarding experience (Burton, 1992). Thus, nurses who understand the multifaceted nature of these complex households can facilitate both the grandparenting role and the positive growth experience for the grandchild.
Supporting a Teenage Mother
An interpretive phenomenological study of teenage mothering by SmithBattle (1997) found grandparents who facilitated mothering duties profoundly enabled the mothering role of the daughter. The mother's responsiveness was enhanced when the grandparent:
* Attended to the baby and the mother without taking over the responsibilities.
* Positively regarded the young mother's capabilities.
* Approached conflicts through dialogue.
* Shared caregiving responsibilities in a highly fluid manner.
Grandparents facilitated mothering when they did not act in ways to make the mother dependent but enabled her to become engaged responsively with the baby.
Providing support for grandparents raising grandchildren offers new opportunities and challenges for health care professionals. This may be particularly true for nurses who work with elderly families and who encounter caregiving grandparents during home visits and in other care delivery settings. Maintaining a functional grandparenting role includes identifying health promotion and risk reduction strategies, while enhancing the available support system for the family unit. Awareness of the potentially stressful aspects of this caregiver role is the first step in developing strategies that offer the opportunity for nurses to make an important difference in the life of an intergenerational family. Being knowledgeable of potential and actual areas of stress in these families and providing resources to assist caregiving grandparents can enhance their quality of life. Facilitating holistic health functioning of the grandparents also may lead to a positive experience for the grandchildren. Ultimately, health care providers should be knowledgeable of the potential problem areas and develop strategies to optimize social networks and available community resources. Grandparents raising grandchildren experience many rewards, including a renewed sense of purpose and connectedness with the children in their care. Support groups, community resources, and neighborhood organizations can assist grandparents greatly in overcoming a tangled bureaucracy and support myriad benefits of grandparents raising grandchildren.
- Ahmann, E., & Shepherd-Vernon, B. (1997). Kinship care: An emerging issue. Pediatric Nursing, 23, 598-600.
- Brussoni, M.J., & Boon, S.D. (1998). Grandparental impact in young adults' relationships with their closest grandparents: The role of relationship strength and emotional closeness. International Journal of Aging & Human Development, 46(A), 267-286.
- Burton, L.M. (1992). Black grandparents rearing children of drug-addicted parents: Stressors, outcomes, and social service needs. The Gerontología, 32, 744-751.
- Caliandro, G., & Hughes C. (1998). The experience of being a grandmother who is the primary caregiver for her HIV-positive grandchild. Nursing Research, 47(2), 107113.
- Casper, L.M., & Bryson, K.R. (1998). Co-resident grandparents and their grandchildren: Grandparent maintained families (Population Division Working Paper No. 26). Washington, DC: United States Census Bureau.
- Dowdell, E.B. (1995). Caregiver burden: Grandmothers raising their high risk grandchildren. Journal of Psychosocial Nursing & Mental Health Services, 33(0), 27-30, 52-53.
- Grmt, R., Gordon, S.G., & Cohen, S.T. (1997). An innovative school-based intergenerational model to serve grandparent caregivers. Journal of Gerontological Social Work, 28(1/2% 47-61.
- Hall, E.O.C. (1998). Literature review, 19851995, on grandparental roles in healthcare. Image, 30(2), 194.
- Hurme, H. (1997). Cross-cultural differences in adolescents' perceptions of their grandparents. International Journal of Aging & Human Development, 44(3), 221-253.
- Joslin, D., & Brouard, A. (1995). The prevalence of grandmothers as primary caregivers in a poor pediatric population. Journal of Community Health, 20(5), 383401.
- Kelley, S.(1993). Caregiver stress in grandparents raising grandchildren. Image, 25(4), 331-337.
- Kelley, S.J., Yorker, B.C., & Whidey, D. (1997). To grandmother's house we go...and stay. Children raised in intergenerational families. Journal of Gerontological Nursing, 23(9), 12-20, 58-59.
- Kunstadter, P. (1991). Social and behavioral factors in transmission and response to shigellosis. Review of Infectious Diseases, 7i(Suppl. 4), 272-278.
- Lehrmann, E. (1995). Help for the caregiving grandparent. Modern Maturity, J0(March/ April), 30.
- Minkler, M., Driver, D., Roe, K.M., & Bedeian, K. (1993). Community interventions to support grandparent caregivers. The Gerontologist, 33, 807-811.
- Minkler, M., Fuller-Thomson, E., Miller, D., & Driver, D. (1997). Depression in grandparents raising grandchildren: results of a national longitudinal study. Archives of Family Medicine, 6(5), 445-452.
- Minkler, M., Roe, K.M., & Robertson-Beckley, R.J. (1994). Raising grandchildren from crack-cocaine households: Effects on family and friendship des of African- American women. American Journal of Orthopsychiatry, 64(1), 20-29.
- Morrow-Kondos, D., Weber, J.A., Cooper, K., & Hesser, J.L. (1997). Becoming parents again: Grandparents raising grandchildren. Journal of Gerontological Social Work, 28(1/2), 35-46.
- Musil, CM. (1998). Health, stress, coping, and social support in grandmother caregivers. Health Care for Women International, 19(5), 441-455.
- O'Reilly, E., & Morrison, M.L. (1993). Grandparent-headed families: New therapeutic challenges. Child Psychiatry and Human Development, 2J(3),147-159.
- Roe, K., Minkler, M., & Barnwell, R. (1994). The assumption of caregiving: Grandmothers raising the children of the crack cocaine epidemic. Qualitative Health Research, 4(3), 281-303.
- SmithBatde, L. (1997). Change and continuity in family caregiving practices with young mothers and their children. Image, 29(2),145-149.
- Ward, D., & Brown, M. (1994). Labor and cost in AIDS family caregiving. Western Journal of Nursing Research, 16(1), 10-25.
- Watson, J.A. (1997). Grandmothering across the lifespan. Journal of Gerontological Social Work, 2S(4),45-62.
- Woodring, B. (1998). Healthy grandparenting: Supporting wellness in intergenerational families. (Available from Dr. Barbara C. Woodring, Department of Family-Child Nursing, Medical College of Georgia, Augusta, GA 30912)
ASSESSMENT INDICATORS FOR G RAN D PARE NTI NG
WORLD WIDE WEB RESOURCES FOR GRANDPARENTS AND GRANDCHILDREN