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

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

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.

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

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

Residency of Older Adults

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

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

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

Percentage of Children Cared for by Grandparent Caregivers

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.

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

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.

Etiology of Grandparent Caregivers

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

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 , the first year of the “Great Recession”.  The increase was greatest among Caucasians.

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

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:

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.

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

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.

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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?

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.

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.

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.

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.

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.

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.

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?

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

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.

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.

References  Children in Grandparent Care. The Urban Institute New Federalism National Survey of America’s Families Pages 1-8  Jendrek, Margaret. Grandparents Who Parent Their Grandchildren: Circumstances and Decisions. The Gerontologist. 1994,Vol 34,No 2. Pages  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 Page 2.  Nugent, Tom. When Grandma and Grandpa are the caregivers: tips for Pediatricians. AAP News. Nov 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  Grandparents Living with Grandchildren: Census 2000 Brief. Issued October  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, Clinical Report- Consent by Proxy for Nonurgent Pediatric Care. Pediatrics. Vol 126, N. 5, November 2010.

References  Minkler, M, Driver, D, et al. Community Interventions To Support Grandparent Caregivers. The Gerontologist, 33( 6)  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)  Minkler, M., Fuller-Thomson, E. The Health of Grandparents Raising Grandchildren: Results of a National Study. American Journal of Public Health. 89(9)  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)  Gratton B. and C Haber. “Three phases in the history of American grandparents: authority, burden, companion.” Generations 20.1 (1996):  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  Grandparents Raising Grandchildren in the District of Columbia: Focus Group Report. AARP 2006

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