1. Grandparents as Caregivers Amanda Soong, MD Assistant Professor of Pediatrics, General Pediatrics and Adolescent Medicine University of Alabama at Birmingham

2. Objectives  Define Grandparent Caregivers  Review the current demographics for this population  Identify factors contributing to the increasing prevalence of grandparent caregivers  Review the impact of being a Grandparent Caregiver on the older adults’ health, as well as the children  Explore the implication of Grandparent Caregivers on how we practice

3. Grandparent Caregivers  For today’s talk, Grandparent Caregivers are defined as grandparents that provide the majority of care for their grandchildren under the age of 18.  This may include grandparents with formal or informal custodial arrangements, or grandparents that provide childcare for working parents.  Also included are other older relatives that may have custody/provide care.

5. Grandparent Caregivers  Role of Grandparents in the US  In other countries, Grandparent Caregivers are an integral part of society.

6. Grandparenting in the US  According to an article by Gratton and Haber published in Generations, the role of grandparents have had 3 distinct phases over the history of the US.  Authority  Burden  Companion

7. Residency of Older Adults

8. Grandparenting in the US  There are currently 2 trends changing the role of grandparents in the family.  Longer life spans  Increasing number of grandparent caregivers

9. The Numbers  According to the 2000 US Census:  5.8 million people were identified as co-resident grandparents  2.4 million were Grandparent Caregivers.  Among the caregivers, 39% had cared for their grandchildren for 5 or more years  In 2011 the number had increased to:  7 million co-resident grandparents  Over 2.8 million Grandparent Caregivers

11. Children in the Care of Grandparent Caregivers (% by state)

12. Percentage of Children Cared for by Grandparent Caregivers

13. Why it Matters to Us….  This trend is important to any healthcare professional who works with either older adults or children.  Caring for grandchildren can affect the grandparent’s health as well as the child.  These patients have special challenges that other patients may not face.

14. Who Becomes Grandparent Caregivers  A study published by Minkler and Fuller-Thomson in 2000 found that Grandparent Caregivers were most likely to be:  Female  Younger  African American  Not have completed high school

15. Etiology of Grandparent Caregivers  Awareness of Grandparent Caregivers grew in the 80s-90s with the crack cocaine and AIDS epidemics.  More recently, the economic downturn has increased the number of Grandparent Caregivers.

16. Etiology of Grandparent Caregivers

17.  As more children have been removed from parental custody, DHR and state agencies have come to prefer family placements for a variety of reasons.

18. Etiology of Grandparent Caregivers  In September of 2010, the Pew Research Center released a report showing that the number of grandchildren cared for by their grandparents rose sharply from 2007-2008, the first year of the “Great Recession”.  The increase was greatest among Caucasians.

19. Health Consequences for Grandparent Caregivers  Being a Grandparent Caregiver has been shown in multiple studies to have a negative impact on the caregiver’s health.  Caregivers have higher incidences of:  Depression  Diabetes  Hypertension  Insomnia

20. Health Consequences for Grandparent Caregivers  In the study mentioned previously in Harlem, NY, Grandparent Caregivers were found on medical exam to have frequent medical issues:

21. Health Consequences for Grandparent Caregivers  While caring for a young child takes a definite physical toll, it also can lead grandparents to neglect their own health.  A study published in 2008 showed that grandmothers who had recently taken custody of their grandchildren were more likely to skip their own preventative services.

22. Health Consequences for Grandparent Caregivers  The disparity of health in Grandparent Caregivers vs. their non-caregiving peers is felt to be due to several reasons:  Not making/having time to tend to their own health  Increased exhaustion  Stress and depression  Lack of respite care  Limited financial means

23. Health Consequences for Grandparent Caregivers  Despite the negative impacts on grandparent’s health and the challenges that these families might face, 90% of grandparents report that they would do it again.

24. Health Consequences for Children  Children in their grandparent’s custody exhibit greater rates of academic and behavioral problems.

25. Health Consequences for Children  These children may also be at higher risk for chronic diseases such as asthma and anemia since they are more frequently from lower income environments.  The children may be behind on preventative care measures such as vaccines due to poor or disjointed medical care.  Families may have difficulty obtaining medications due to financial issues.

26. Health Consequences for Children  Grandparents may have difficulty obtaining health insurance for their grandchildren.  Many insurance plans will not allow grandchildren to be added as dependents without established legal custody.

27. Health Consequences for Children  Studies have shown that children tend to be safer when in the care of their grandparents.  However, small survey sample of grandparent caregivers in Birmingham, AL showed grandparents have some important deficits in their child safety knowledge.

28. Social issues  Becoming a Grandparent Caregiver can disrupt the expected trajectory of the older adult years.

29. Economic Implications  The unexpected arrival of a grandchild to the household can be difficult economically.  Courts now favor placing children with relatives (most often grandparents) and often relatives do not receive financial benefits as do foster placements.  GPs may have difficulty navigating the system to apply for benefits when they are available.  Since these arrangements often are not legal, GPs can’t apply for benefits on their grandchildren’s behalf.

30. Economic Implications  For grandparents that are employed, the addition of a child can strain finances.  The GP may not live in housing suitable for children, or not have adequate space.

31. Economic Implications  Economically it is in the interest of the state to place children with their grandparents.  A study in 1996 calculated the value of grandparent provided care to be between $23.5 and $39.3 billion annually in terms of current dollars.

32. Legal considerations  Studies estimate that only 20-50% of Grandparent Caregivers have legal custody of their grandchildren.  Lack of legal custody impedes the grandparent’s ability to seek medical care, enroll the child in school, and seek benefits that the child might otherwise qualify for.  Grandparents can request to become a grandchild’s guardian through the Probate Court as a means of gaining legal status without terminating the parent’s custodial rights.

33. Legal considerations  In some cases, children who are placed in a grandparent’s custody may no longer be eligible to receive food stamps due to the parent’s actions.  A child also may not be able to receive food stamps based on who signs the court order to take the child out of the parent’s custody.

34. DHR and Kinship Care  Grandparents may not receive any financial benefits when gaining custody of grandchildren.  Sometimes benefits are given in the form of:  Relative caregiver payment: 1 time payment to be used as needed.  Aid to Dependent Children may be available for these children (AFDC)- $164/month  Programs are being piloted in different states looking at ways to provide some financial relief to kinship care providers.

35. Impact to Our Practices  The growing incidence of Grandparent Caregivers impacts both pediatric and geriatric care.  Being aware of the issues that influence our patients’ lives can help us provide improved, family- oriented care.

36. Impacts to Geriatric Practice  When reviewing social history and noting who is in the household, if grandchildren are mentioned, ask a few more questions.  Is the grandchild there full time?  How does the patient feel about the arrangement?  Has the patient been able to keep up with his or her health needs?  Does the patient have any unmet needs?

37. Impacts to Geriatric Practice  Grandparent Caregivers should be encouraged to take care of their health so they can continue to care for their grandchild.  GP Caregivers should be asked about end of life plans.  The planning should include what will happen to the children in the case of illness or death.

38. Impacts to Geriatric Practice  When discussing or prescribing medications, it is important to stress medication storage. Grandparents might not be in the habit of child proofing and need a reminder of safe medication storage.

39. Impacts to Geriatric Practice  Special attention should be paid to the grandparent’s cognitive function.  Since the grandparent is caring for a young child, even mild cognitive impairments could cause significant problems.  If the grandparent lives alone with a young child, it may be difficult to identify mild impairments.

40. Impacts to Geriatric Practice  The grandparent’s physician plays an important role in assessing the grandparent’s health and level of function, and can provide advice on how to meet the challenges of raising a young child.  The physician may also identify factors which place either the grandparent or child in danger due to the current custodial arrangement.

41. Impacts to Geriatric Practice  Be aware of resources available in your community to support Grandparent Caregivers.  Studies have shown that Grandparents can benefit from having a network to help navigate challenges and share experiences.

42. Impacts to Pediatric Practice  First and foremost, pediatric care providers should be alert to patients cared for by Grandparent Caregivers.  Be aware of the challenges that can face these families.  Modify your history and guidance as needed to address the family’s specific situation.

43. Impacts to Pediatric Practice  What is the financial situation? Does the child have insurance?  Does the grandparents have the legal standing to provide consent for services? Have they been able to enroll the child in school?

44. Impacts to Pediatric Practice  Pediatricians need to be aware of the increased rate of poor health literacy in the older adult population.

45. Impacts to Pediatric Practice  Pediatric providers should also encourage Grandparent Caregivers to maintain their own health and healthcare.  If the pediatrician suspects the grandparent might have cognitive issues, they should encourage the grandparent to seek evaluation and contact a social worker and/or DHR, if indicated.

46. Conclusions  Grandparent Caregivers are increasing in frequency.  Being a grandparent caregiver has impacts on health and wellness of the grandparents, and children in the care of grandparents may have special health needs.  There are many social and legal ramifications of grandparent caregivers and medical providers should be aware of these challenges.

47. References  Children in Grandparent Care. The Urban Institute New Federalism National Survey of America’s Families. 2003. Pages 1-8  Jendrek, Margaret. Grandparents Who Parent Their Grandchildren: Circumstances and Decisions. The Gerontologist. 1994,Vol 34,No 2. Pages 206-216.  Hayslip, Bert et al. Custodial Grandparenting and the Impact of Grandchildren With Problems on Role Satisfaction and Role Meaning. Journal of Gerontology: Social Sciences. 1998, Vol 53B, No 3. Pages S164-S173.  Dell’Aringa, Stefanie. Aging Caregivers. AAP News. March 1997. Page 2.  Nugent, Tom. When Grandma and Grandpa are the caregivers: tips for Pediatricians. AAP News. Nov. 1999. Page 31  Hayslip, Bert and Patricia Kaminski. Grandparents Raising Their Grandchildren: A Review of the Literature and Suggestions for Practice. The Gerontologist. April 2005;45, 2. Pages 262- 269.  Grandparents Living with Grandchildren: 2000. Census 2000 Brief. Issued October 2003.  Grandfacts: A State Fact Sheet for Grandparents and Other Relatives Raising Children. AARP. Alabama, August 2007  Grandparents Raising Grandchildren: A Call to Action. Publication by the Administration for Children and Families, Region IV. Department of Health and Human Services  AAP Committee on Medical Liability and Risk Management, 2009-2010. Clinical Report- Consent by Proxy for Nonurgent Pediatric Care. Pediatrics. Vol 126, N. 5, November 2010.

48. References  Minkler, M, Driver, D, et al. Community Interventions To Support Grandparent Caregivers. The Gerontologist, 33( 6). 807-811.  Kelley, S., Whitley,D. Psychological Distress in Grandmother Kinship Care Providers: The Role of Resources, Social Support, and Physical Health. Child Abuse & Neglect. 24(3) 311-321.  Minkler, M., Fuller-Thomson, E. The Health of Grandparents Raising Grandchildren: Results of a National Study. American Journal of Public Health. 89(9) 1384-1388.  Minkler, M., Fuller-Thomson, E. Second Time Around Parenting: Factors Predictive of Grandparents Becoming Caregivers for their Grandchildren. Int’l J. Aging and Human Development. Vol 50(3) 185-200.  Gratton B. and C Haber. “Three phases in the history of American grandparents: authority, burden, companion.” Generations 20.1 (1996): 7-12.  Smith, D 1982 “Historical change in the household structure of the elderly in economically developed societies.” in Old Age in Preindustrial Society.  Livingston, G, Parker, K. Since the Start of the Great Recession, More Children Raised by Grandparents. Pew Research Center, September 2010.  Grandparents Raising Grandchildren in the District of Columbia: Focus Group Report. AARP 2006

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