The Journal of School Nursing2024, Vol. 40(4) 421–430© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221115700journals.sagepub.com/home/jsn
Abstract
This study identified custodial grandparents’ perception of sources of stress that may affect their health and better understand their needs. Findings from this qualitative study are based on thematic analysis of interviews with 10 custodial grandparents. The following themes emerged: 1) grandparents’ stress from perceived lack of readiness to care for grandchildren; 2) need for effective communication between and among family members; 3) sufficiency of financial and legal resources; 4) access to community resources, and 5) raising grandchildren reenergizes and revitalizes grandparents’ physical and mental health. These findings provide insight into the stressful aspects of the role of raising grandchildren. Understanding stressors affecting custodial grandparents and their grandchildren will help school nurses, social workers, teachers, school administrators and other professionals collaborate to address their challenges.
Keywordsgrandparents raising grandchildren, caregivers, mental health, school nursing, school health services and qualitative research
In the United States, more grandparents are becoming primary caregivers to their grandchildren. Almost three million children in the United States (U.S.), or 4% of all children, are raised in kinship care in parent-absent households in non-foster care (The Annie E. Casey Foundation Kids Count Data Center, 2021). The vast majority of these children are being raised by grandparents, and to a much lesser degree, by other relatives (Vandivere et al., 2012). Furthermore, grandparent caregivers are most often women of racial minority status (Ellis & Simmons, 2014). These families are often known as grandfamilies and the caregivers as custodial grandparents, grandparents raising grandchildren (GRG) and grandparent caregivers (Dolbin-MacNab & O’Connell, 2021). While it is generally considered better for children to be raised by relatives than by non-relative foster care parents (Denby et al., 2017; Xu & Bright, 2018), concerns over the role of parenting later in life have not been fully addressed. Grandparents find themselves at a crossroads in life where they may accept their new parenting role but are often unprepared financially and emotionally to raise grandchildren (Lent & Otto, 2018). This qualitative study focuses on the needs and stressors of grandparents who assume the role of full-time caregiver.
Because federal policy prioritizes placement with extended family members over non-relatives when children are removed from birth parents, children often end up in the care of grandparents (Xu & Bright, 2018). Children may be placed with grandparents through formal foster care placement by child welfare officials or informally through arrangements made among family members, with the latter occurring much more frequently (Kelley et al., 2013a). These children, who have often been traumatized while living with their birth parents (Generations United, 2016), are rarely offered professional support to help them cope with past stressful living experiences or their new living arrangements with grandparents. Similarly, their grandparents are given little if any parenting education or emotional support to help them raise distressed children (Dolbin-MacNab, 2006). Many grandchildren have behavioral issues and developmental delays making them more challenging to parent (Dolbin-MacNab & O’Connell, 2021; Kelley et al., 2011; Kresak et al., 2014). Furthermore, most grandparents are parenting again at a stage in their lives when they should have few, if any, parenting responsibilities.
The context in which grandparents come to raise children is essential to understand in order to fully appreciate their caregiving experiences. While the primary or most common reason for GRG is substance use disorder (SUD), other factors include child neglect and abuse, including abandonment; mental health issues; incarceration; interpersonal violence; and death (Hayslip et al., 2017; Kelley et al., 2021). These precursors to raising grandchildren are often interwoven. Given the antecedents to children being raised by grandparents, the transition from one’s parent’s home to one’s grandparent’s home often is a complex transition for all three generations. It is also essential to recognize that the change to becoming a full-time caregiver can occur abruptly with little or no time for the grandparents to prepare. Regardless, the time of transition is often one of crisis for the grandparents who need time and financial resources to provide essentials such as adequate housing, furniture, clothing, and food.
Substance use disorder (SUD), which includes use of alcohol, prescription and illegal drugs, has long been a significant reason for children to be removed from their birth parents and placed in substitute care. Undoubtedly, the “opioid epidemic” has impacted the number of GRG as the number of parents affected by opioid addiction has increased over the past two decades (Davis et al., 2020; Dolbin-MacNab & O’Connell, 2021; Lent & Otto, 2018). One study found that after controlling for several demographic characteristics, the states with the largest proportions of custodial grandparents were also those with the highest opioid prescribing rates (Anderson, 2019). Furthermore, opioids contribute to almost 70% of all drug overdoses (Centers for Disease Control and Prevention, 2019), likely contributing to the number of children losing parents to drug-related deaths and subsequently raised by grandparents. This widespread phenomenon of GRG due to the opioid crisis has received recent recognition in the popular press (Fleming, 2019).
Dealing with an adult child with a SUD is a severe and chronic source of stress for grandparents before and after their grandchildren’s placement (Dolbin-MacNab & O’Connell, 2021). In addition to childcare responsibilities, they are dealing with feelings they have toward the adult children and the impact that their behavior on the grandchild. The grandparent are faced with monitoring the relationship between the parent and child if they continue to to suffer with substance abuse. (Lent & Otto, 2018).
Grandfamilies are usually considered a better option than non-relative foster care because they enable children to remain connected to their families, community, culture, and religion, while also allowing more stable living arrangements (Dolbin-MacNab & O’Connell, 2021; Goulette et al., 2016; Kelley et al. 2011). They are also more likely to allow siblings to remain together, resulting in better emotional and behavioral outcomes for the grandchildren (Kelley et al., 2011). In another study, researchers found that children in the care of grandparents had better behavioral and adaptive functioning compared to those in non-relative foster care (Harnett et al., 2014). However, researchers also found that grandparents had higher stress in the role when compared to foster caregivers (Harnett et al., 2014). While residing with grandparents may be more desirable for grandchild outcomes, the impact on the caregiver may be disadvantageous or have mixed results (Goulette et al., 2016).
While they clearly represent a demographically heterogeneous population, GRG tend to be economically disadvantaged (Dolbin-MacNab & O’Connell, 2021; Whitley & Fuller-Thomson, 2017). Compared to grandparents not residing with grandchildren, those raising grandchildren are more likely to be living in poverty even though the majority still participate in the workforce (U.S. Census Bureau, 2020). They also are more likely to be single, female, younger, and less well-educated than other family arrangements (Ellis & Simmons, 2014; Whitley & Fuller-Thomson, 2017). Furthermore, racial minority groups are more likely to be overrepresented in GRG (Whitley & Fuller-Thomson, 2017; U.S. Census Bureau, 2020). Therefore, grandmothers face an increased likelihood of social disadvantage (e.g., economic burden, single parenthood) when raising grandchildren.
Though much of the previously published research has shown that custodial grandparents have a propensity for compromised mental health well-being, the results are somewhat mixed, possibly due to the varying quality levels in research methods (Bundy-Fazioli et al., 2013; Mansson, 2014). A systematic review and meta-analysis (SRMS) that examined the mental health well-being of custodial grandparents provided some insight (Kelley et al., 2021). Inclusion criteria included studies of grandparents raising grandchildren in parent-absent homes, designs using at least one comparison group of adults with comparable backgrounds who were not raising grandchildren, and one or more standardized measures of mental health well-being. The meta-analysis results indicated that GRG are overall at increased risk of adverse mental health well-being outcomes, including depression and stress, compared to non-parenting counterparts (Kelley et al., 2021).
In addition to diminished mental health well-being, GRG also are more likely to report impaired physical health. The majority of studies examining their physical health status indicated they are at increased risk for physical health challenges, including chronic health diseases (Kelley et al., 2013b; Musil & Ahmad, 2002; Whitley & Fuller-Thomson, 2017). Undoubtedly, the increased likelihood of diminished mental and physical well-being experienced by GRG contributes to the stress they experience in their parenting roles (Smith & Dolbin-MacNab, 2013).
Raising grandchildren can be stressful, with increased time and energy demands related to parenting (Mendoza et al., 2020). In addition to these parenting demands, GRG often experience inadequate financial and social support, thereby increasing their susceptibility to anxiety and depression (Doley et al., 2015; Kelley et al., 2013). This qualitative study sought to identify GRGs’ perceived sources of stress and recognize their perceived needs related to physical and psychological health to better understand their concerns.
A qualitative exploratory study was conducted focusing on the needs and stressors of grandparents who assume the role of fulltime caregiver for their grandchildren. The founders of a statewide organization in the southeast that provides information to grandparents raising grandchildrenwerecontactedbytheprincipal investigator (PI) to identify potential study participants. The PI held meetings with the center’s founders to discuss conducting qualitative interviews with GRG.
The Grandparents Raising Grandchildren Information Center of Louisiana is a a non-profit organization serving grandparents and kinship caregivers. The GRC’s mission is “dedicated to offering both information and support to grandparent and other kinship caregivers and their families” (Grandparents Raising Grandchildren of Louisiana). The support group meets every month and consists of grandparents and kinship caregivers. The group is led by a grandparent who is part of the organization. The founder started the organization as she raised her grandchild and recognized the need for an organization to help these families. identified. These grandparents were contacted and invited to attend an in-person discussion about the study following a regular support group meeting. Grandparents who were interested and grandparents who attended the regular support group meeting that day were also invited to stay and attend the in-person discussion. A purposive sample of five recommended grandparents and five volunteer grandparents was recruited. The inclusion criteria were: (1) communitydwelling custodial grandparents responsible for full-time care of at least one grandchild younger than 18 years old for at least 12 months or longer, (2) head of household with no biological parent present, and (3) living within a 20-mile radius of the GRG Information Center.
The sample consisted of nine women and one man ranging in age from 46–69 years. The mean age was 55 (SD = 6.9) years. Five grandparents were African American and five were Caucasian. Two grandparents were a married couple. The grandchildren of participants ranged in age from 1–16 years, and the average age was 6 (SD = 4.4) years. The average number of grandchildren raised was 1.6 (SD = 1.5).
The PI developed a demographic form that included background variables and an interview guide. Based on the literature, a semi-structured interview guide had open-ended questions used to assess: (1) needs encountered while raising grandchildren, (2) how raising grandchildren affected their health, (3) challenges faced raising grandchildren, (4) primary sources of stress related to raising grandchildren, (5) ways to cope with stress, (6) benefits of raising grandchildren and (7) types of support needed. The PI and founder of the organization reviewed the interview guide to ensure the clarity of the questions.
Following approval from the University of Missouri Columbia Institutional Review Board, recruitment began. At the first meeting held after a regular support group meeting, interested grandparents consisting of the ones recommended by the founder and other grandparents who attended the support group meeting that day were told about the study and questions were answered. At the second meeting, all grandparents contacted agreed to be interviewed and were given a copy of the waiver of documentation consent and completed the demographic information form.
Times were scheduled to meet at the center or a mutually convenient place for interviews. The PI conducted all face-to-face, audio-recorded interviews that lasted 30–45 min. The PI is of African-American ethnicity and was guided by faculty committee members with expertise in qualitative methods. Four participants were interviewed privately and three meetings were held with pairs of respondents.
All transcripts were imported into NVivo, a qualitative software package, before data analysis. The transcribed data were analyzed using a descriptive thematic analysis based on Braun and Clarke’s (2006) six phases: familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and production of a report. The PI and a faculty member experienced with qualitative datareviewed transcripts and coded data individually, then compared analyses. One meeting was held with the participants to discuss the identified themes.
Steps were taken to ensure the trustworthiness of the study. An interview guide was used to maintain consistency during interviews. No names were used on the audiotapes. Interviews were transcribed verbatim into Microsoft Word 2016 by a professional transcriptionist within 72 h of the discussions. Participants provided feedback on developing the key themes and ideas from the content coding and changes were made. Member checking with the participants supports the validity and credibility of study findings (Lincoln & Guba, 1985).
Five major themes emerged from the data:
(1) Grandparents’ stress from perceived lack of readiness to care for grandchildren.
(2) Need for effective communication between and among family members (grandparents, adult children, and grandchildren) related to expectations, roles, authority, and family structure.
(3) Sufficiency of financial and legal resources to ensure the viability, sustainability, and security of grandfamilies.
(4) Access to community resources to support grandparents raising grandchildren.
(5) Raising grandchildren reenergizes and revitalizes grandparents’ physical and mental health.
Factors contributing to custodial grandparents’ perceived readiness to become the primary providers of care for their grandchildren are multifactorial and interwoven with the underlying reason(s) for the transition in custodial care responsibilities, length of time available to prepare for the role transition, prior relationship with their adult child and grandchild, and other characteristics of the grandparents, their adult child and grandchild.
The processes of decision-making and the amount of time needed for transitioning to the grandparenting role vary widely and depend on the circumstances surrounding the transition. Circumstances include the death of a parent, parental incapacity (substance abuse, physical and/or mental illness), child abuse and/or neglect, incarceration, irresolvable relationship conflicts involving parent(s) and child, distance employment of the parent including military deployment.
One grandmother (early ‘60 s) lamented,
“Children have been born addicted to drugs and parents are still on drugs, you know what I mean kind of in and out.”
Another grandmother (late ‘60 s) voiced,
“They [Department of Child Services] should really make sure you have some type of resources, have someone to help you transitions, that you should have someone you can call…”
Another grandmother (mid-50 s) expressed,
“My daughter doesn’t see anything wrong with it and that [my grand]child is 16 years old, a teenage girl go in the streets and you don’t know if she is living or dead.”
Several participants reported that their adult children’s mental health issues were a significant stressor. Grandparents described interacting with their biological children and the conflict in the family environment. “My child is not allowed to see my grandchildren. I don’t allow her. It’s better for them; it is healthier for them not to even see her.” Others explained the relationship with the biological parents, their drug use and the stress it caused on raising the grandchildren. Grandparents often experience feelings of guilt and shame because of their adult children’s addictions and are left to deal with their emotions.
One grandmother (mid-50 s) discussed her relationship with her biological daughter who did not live in the home with her:
“My daughter is schizophrenic and when she is at her lowest, she is really, really low, …and I just can’t get any sense into her at all. She will just walk and walk….I have been dealing with her for a while and I am beginning to see the same patterns with her daughter.”
Another grandmother (early ‘60 s) discussed the stress caused by drug use in the family:
“Custody issues, psychological issues that the children had when they came to you. Mental, lots of mental issues.…You know, it is kind of a love-hate relationship at times, if that makes any sense. You will always love your children and you will always believe tomorrow will be better …”
Although biological parents may not live in the home, they may add to the conflict within the family environment. Grandparents may feel divided loyalties in caring for grandchildren and still supporting their biological child.
Grandparents need adequate financial and legal resources to provide their grandchildren with a safe, comfortable environment to live, foster their age-appropriate growth and development, promote learning and educational advancement, and prepare them for a meaningful and productive occupation and/or career.
One grandparent (late ‘60 s) cited the lack of financial and legal resources available to grandparents. “Financial, legal, and resources. There are very, very few that are geared toward grandparents.” Another grandmother (early ‘50 s) indicated the need for assistance with daycare to get a break from daily child care responsibilities.
The grandparents viewed not having enough financial assistance to care for their grandchildren as a struggle. Furthermore, grandparents identified having to provide extra food, educational expenses, and possible childcare as stressors. Many grandparents were retired or near retirement, and this financial burden was not included in their retirement plans. Custodial grandparents may experience limited options for obtaining financial or housing assistance.
Grandparents who do not have legal custody of their grandchildren or participate in state-administered programs such as kinship care may find it more difficult to access financial resources. One grandmother (late ‘50 s) expressed her frustration with dealing with the state system in order to get food stamps to feed her grandfamily.
“After I got my grandson…. I applied for food stamps and when they called me and told me I make $200 too much a month….I don’t understand,….people who make these decisions must not have any children. I cannot feed him and clothe him on $200 a month.”
Others expressed issues related to their finances.
“I …. there is an additional mouth to feed, clothing being that she is a young lady, daycare, and transportation. Now that she is going to be going to elementary school, …after school care because we both work.
Another grandmother (late ‘40 s) commented about the financial burden.
“…her biological parents are not financially set because the father is incarcerated and her mom she doesn’t remain gainfully employed for long periods of time…”
Another grandmother (late ‘60 s) described how difficult it is to get financial assistance from the biological parents.
“… these are my daughter’s children and I cannot get help from anyone, anybody, anywhere. I had to take the mother and the father to court to declare all of them unfit;…. now that I am a retiree I have to rear these two children on my income …I just do what I have to do with my retirement check…”
Grandparents described the challenges of acquiring the financial and legal assistance often needed to establish a legal relationship with the grandchildren in their care. This legal relationship can involve obtaining guardianship, custody, or adoption.
Participants identified a lack of illegal support as a barrier to their successful navigation of the legal system prior to assuming car for their grandchildren. Most do not have the knowledge or finances to retain an attorney, which leaves many feeling discouraged. One grandmother (late ‘40 s) stated:
“If you have the children, you cannot get legal custody, you cannot put them in school without legal custody, they have to go in as homeless which is horrible.”
Another expressed dismay with their experience with the legal system, a process that resulted in less financial support.
…they pulled the kids out of the home and told me that the only thing is there is no help for grandparents.… now that they turned it over to the two lawyers, they are going to court and OCS [Department of Children and Family Services] said there wouldn’t be any help for me at all.”
Grandparents expressed frustration because of their inability to access various resources from education to mental health support. Grandparents reported a lack of social support leading to isolation. Lack of access to resources can lead to poor psychological outcomes. One grandmother (early ‘60 s) acknowledged her frustration about the inability to get help for her grandchild.
“I think when they give you the children from the Department of Child Services, they should really make sure you have some type of resources, have someone to help you transition, that you have someone you can call ….”
Another grandmother (late ‘60 s) expressed needing help to care for her granddaughter.
“When I got my granddaughter, ….she was one year old, and I was already raising six children when I got custody of her, so it was like starting all over… she may have a learning disorder, but because of our income, she can’t really get support services….”
Not having time for themselves was a common thread for these grandparents.
“…finding time for ourselves and in doing so making sure that our childcare is not someone that is going to contribute to delinquency … I would rather keep her with me than put her in harm’s way…”
“You will find a lot of your friends say, well I would not do that I would just send them home. Send them where? You don’t have anywhere to send them so you kind of get isolated.”
“…It has been stressful for me because I have been raising him every day of his life …. I have never had someone say, let me take him off your hands for a little while and let him come spend a night or anything. So, I’m like Lord; I need some help.”
Custodial grandparents were quick to discuss the positive impact of raising their grandchildren. Grandparents described how their grandchildren make them feel and the satisfaction they received from caring for their grandchildren. They commented on how raising grandchildren helped them keep their minds sharp and stay young. Participants expressed that although there are challenges related to caring for their grandchildren, they would not change their situation. One grandmother commented on how she felt the role to be of psychological benefit.
“It keeps you young, keeps you going. I have to do homework and everything with mine, so it keeps me smart because I have to go to school in order to learn what he is learning in order to help him with his homework.”
One grandmother discussed how raising her grandchild makes her want to be physically active and healthy.
“… it kind of makes me want to be more cautious of what I eat and what she eats because now I feel a totally different responsibility, so I want to be here longer in good health, still able to move around and be active with her.”
And another discussed how her grandson helps to keep her healthy.
“I have a five-year-old great-grandson, and the benefit to that is he helps me eat healthy. He is not a fast food eater; ….He is health-conscious, so that helps keep me on the right track to be health conscious as far as my diet and everything…”
Several grandparents mentioned raising their grandchildren gave them purpose in life as expressed by these grandparents.
“Lots of love and hugs, and it helps keep you a little bit younger and on your toes. It gives you a purpose in life.”
“I try to look at the big picture. …which is the benefit of all this.”
“… I am kind of feeling like it is like a garden, we plant a seed, and we have to nurture it and ensure the seed grows and has what she needs.”
There was a general discussion on how the grandparents deal with stressors, financial limitations, lack of legal assistance, limited resources, and benefits. One grandmother (late ‘60 s) summed up the overall thoughts of how these grandparents deal with these situations daily:
“We pray, go to support group, and call one another where you can vent to someone who understands what you are going through…. There is really nothing out there because, like we told you, grandparents raising grandchildren is the best kept secret…. It is not addressed at all.”
Grandparents raising grandchildren are faced with multiple challenges in their roles as primary caregivers. While grandparents in this study may seem young with an age range of 50’s to late 60’s, numerous studies indicate that the average age of grandparents raising grandchildren is 56–60 years (Harnett et al., 2014; Kelley et al., 2013b; Sprang, et al., 2015). The marital status of grandparents raising grandchildren also has been reported as 20% (N = 119) marital status (Neely-Barnes et al., 2010).
This study adds to the understanding of grandparents’ concerns about their perceived sources of stress and physical and psychological health needs. Despite that fact that many current public policies have incorporated increased financial support for grandfamilies, most resources remain inadequate. Furthermore, the physical and health needs of grandfamilies often remain unaddressed. Policies are needed that expand access to Medicaid insurance. Exceptions to work requirements are needed for GRGs who are caring for children with special needs as many of them leave full-time employment to care for these children, thereby losing health insurance benefits. Studies have addressed the effects stressors have on the well-being of GRG which include emotional distress (Bundy-Fazioli et al., 2013), compromised physical health (Taylor et al., 2017), emotional strain (Conway et al., 2011), and psychological distress (Kelley et al., 2013a). In this study, grandparents reported that their most significant stress was their ability to meet legal and financial needs. Findings also show that although parenting grandchildren can contribute to physical and emotional distress, these grandparents stated that parenting grandchildren bring benefits that outweigh the adverse effects.
Grandparents described mixed feelings related to having to interact with their biological children. Although the biological parents of the grandchildren may not live in the home, they may still contribute to family stress. Their biological children experienced mental health issues, including substance use disorder and had inconsistent interaction with their children, which was particularly problematic. Grandparents reported wanting to help the biological children with their problems hoping they may assume care for their children again. Grandparents are left providing financial assistance for their biological children (e.g., substance abuse treatment, behavioral health services, living expenses) which leaves less money for the grandfamily and adds to an already stressful environment. In response to the growing number of grandparents impacted by the opioid crisis, the federal Supporting Grandparents Raising Grandchildren Act (2018) was passed to address the needs and help GRG of biological children with substance use disorders.
In this study, the grandparents reported financial strain, health challenges in the grandparents and grandchildren, lack of social and community support, legal obstacles, and barriers to education as primary needs for raising their grandchildren. Without access to adequate resources, raising grandchildren can be very burdensome. In many instances, grandparents do not get involved with the system because of a lack of confidence. Our findings supported previous research suggesting a need for more multi-faceted resources, especially those related to financial, social and legal support (Doley et al., 2015; Kelley et al., 2007, 2019; Polvere et al., 2018; Van Etten & Gautam, 2012).
Grandparents were frustrated with the inability to provide basic necessities to their grandchildren. Some described how they reached out for resources but felt they could not get assistance. Others indicated they did not know where to start looking for any information. These findings are consistent with other studies (Cox, 2009; Van Etten & Gautam, 2012). Grandparents also expressed challenges with establishing legal relationships with their grandchildren to receive more financial assistance. Grandparents may have access to financial and foster care programs. Still, because they are unfamiliar with the details, they usually decide not to participate in the foster care programs and find themselves at an economic disadvantage (Generations United, 2017). School nurses need to be knowledge about resources in their communities so that they can make appropriate referrals for grandfamilies at the local, county, and state level. For instance, many states have so called kinship navigators available through their local, county or state child protective service (CPS) agencies. These navigators are often very knowledge of resources available to grandparents and other relative caregivers (Casey Family Programs, 2018). Other potential resources include health care providers, churches, legal aid agencies, and support groups for GRGs. School nurses can provide support for the healthcare needs of the grandchildren and be the link to address lack of medical care (Willgerodt et al., 2018). Grandparents can also be referred to local support groups for GRG as these groups have been found to be beneficial to custodial grandparents (Strozier, 2012).
This study also found that grandparents were frustrated with the lack of mental health services and access to care for grandchildren with disabilities. This population can benefit from programs that support GRG who have grandchildren with disabilities. For example, Child Find is a nation-wide organization that can locate and evaluate children in need of special education and are not currently enrolled in school (Child Find). Brown et al. (2017) found that grandparents raising grandchildren with disabilities reported better overall health and home environment conditions after participating in a program that provides familycentered case management. Recommendations from a national advocacy organization include addressing barriers to licensing grandparents as foster parents and ensuring that grandfamilies that are not foster parents can access financial support (Generations United, 2017).
Our findings included grandparents experiencing positive benefits related to raising their grandchildren. This study provides insight into the positive benefits that grandparents receive from raising their grandchildren, consistent with Mendoza et al. (2020) who found that grandparents experienced life satisfaction when having reliable social support. If the grandparents perceive there are benefits to raising their grandchildren, it may mitigate some of the stress experienced.
Further research on the benefits of grandparenting can help healthcare providers use the information to provide more interventions focused on positive well-being. Future interventions should consider implementing an overall assessment of grandfamilies and providing resources for all members, which will promote healthy outcomes for this population.
This study had several limitations. First, the findings do not represent all GRG but rather a small group of GRGs from a specific geographical area and who participated in a community-based support group. A second limitation is the sample selection process. The sample was drawn from an organization that provides support to the grandparents. The founders identified the grandparents to be contacted resulting in bias in the sample. Third, the order and phrasing of interview questions may have predisposed the respondents to answer negatively. If the benefits questions had been asked first, it might have changed how some of the questions were answered. Fourth, the grandparents interviewing in pairs may have been less willing to answer honestly without confidentiality afforded in a 1:1 interview. Lastly, including a married pair in the sample resulted in 20% of the sample responding about the same family. Future research would benefit from a larger and more diverse sample, especially related to geographical location and socioeconomic status. Follow-up interviews to confirm the themes identified were not conducted and may have yielded additional data.
Parenting, financial, social support, legal, and health resources continue to be priorities for GRG. The entire family is at risk for poor outcomes making it imperative that potential stressors are identified early, and resources provided. As grandparents bring their grandchildren to health visits, it is vital for nurses and social workers to use this time to determine their greatest needs and make referrals accordingly. School nurses, teachers, and social workers can provide a team approach as they collectively have frequent contact with the grandchildren and their grandparent caregivers. As more grandparents become primary caregivers, many grandchildren will live with them until they reach adulthood (Davis et al., 2020; Dolbin-MacNab & O’Connell, 2021). Thus, the challenges faced by grandparents are ongoing for many years. Recommendations include elevating best practices for grandfamilies by developing and supporting a national technical assistance center on grandfamilies (Generations United, 2016) to assist with access to resources that may differ over time with GRG and their grandchildren. School nurses can also advocate for GRG when their grandchildren qualify for Medicaid yet experiencebarriers obtaining coverage.
The transition to living together presents difficulties for both grandparents and grandchildren. Findings from this study suggest a need for school nurses to understand and identify stressors encountered by the grandfamilies. GRG may benefit from referrals for mental health intervention when experiencing high levels of distress. School nurses can also advocate for GRG when their grandchildren qualify for Medicaid yet experience challenges obtaining this public benefit. Because many of the grandchildren have experienced adverse childhood events (e.g., abandonment, neglect, parental substance use) prior to living with grandparents, school nurses can provide referrals for behavioral health services for the children such as organizations focused on helping families dealing with traumatized children. School nurses can also help with education and support for grandparents about caring for traumatized children by providing a list of local mental health or support groups in the local area. The National Center on Grandfamilies at Generations United provides valuable information on resources available to GRC including mental health services for traumatized grandchildren. (See: https://www.gu.org/explore-our-topics/grandfamilies/). Grandparents raising grandchildren may benefit from participating in parenting education classes, especially when the grandchildren exhibit behavioral problems, which is common (Kelley et al., 2011). Home visitation services conducted by nurses and social workers have shown to be an effective strategy in improving access to resources and social support, decreasing psychological stress, and improving physical health in GRG (Kelley et al., 2007, 2013b, 2019). Furthermore, findings from this study may be used to develop a needs checklist or a validated tool for researchers and clinicians to assess the needs of GRG better. Although GRG face challenges, they also experience positive rewards. Understanding and screening for stressors experienced by custodial grandparents and their grandchildren will help school nurses, social workers, teachers, school administrators and other professionals collaborate to address these challenges.
This study identified custodial grandparents’ perceived stressors and needs that may affect their physical and psychological health and their ability to parent their grandchildren effectively. Until challenges with SUD, economic instability, and mental health disorders are addressed, GRG will likely continue to be a growing at-risk group. The increasing demands of caring for grandchildren affect the grandparent’s health and well-being, but it can also have detrimental effects on the grandchildren.
It is essential to ensure that custodial grandparents and their grandchildren have resources and know how to access the resources needed to parent their grandchildren and to maintain a positive well-being. To achieve this, professionals can provide a positive learning environment to implement interventions. Professionals can also help the families by advocating for them by speaking to policy makers. Grandparents can also be educated on how they can make changes by speaking to policy makers about their situation. Having the grandparents mentally healthy will improve the grandchildren’s well-being resulting in improved relationships at home and school which is crucial in helping these families adjust as they transition to grandfamilies.
The authors would like to thank Dr. Margaret Andrews for her thoughtful review of this manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding in the form of tuition assistance was provided by the University of Missouri-Columbia Sinclair School of Nursing and the Robert Wood Johnson Foundation Future of Nursing Scholars Program.
Karen C. Clark https://orcid.org/0000-0002-3186-5205
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Karen C. Clark, PhD, RN, assistant professor, Southern University and A & M College, College of Nursing and Allied Health.
Susan J. Kelley, PhD, RN, FAAN, professor, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA.
Patricia C. Clark, PhD, RN, FAAN, professor Emerita, Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University.
Kari R. Lane, PhD, RN, associate professor, University of Missouri, Sinclair School of Nursing.
1 Southern University and A&M College, PO Box 11784, Baton Rouge, LA, 70813, USA
2 Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, PO Box 4019, Atlanta, GA 30302, USA
3 University of Missouri, Sinclair School of Nursing, Columbia, MO, USA
The first author is currently an assistant professor at Southern University and A&M College; however, this work was completed while faculty at Georgia State University and the study for this paper was conducted as part of her doctoral study at the University of Missouri-Columbia.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Robert Wood Johnson Foundation, University of Missouri,
Corresponding Author:Karen C. Clark, PhD, RN, Southern University and A&M College, College of Nursing and Allied Health, Baton Rouge, Louisiana 70813, USA.Email: karen.clark@sus.edu
