61584 • Grandparents Raising Grandchildren: Key Practice Issues

Table of Contents

61584 • Grandparents Raising Grandchildren: Key Practice Issues

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL OVERVIEW OF MULTIGENERATIONAL LIVING

3. AN OVERVIEW OF GRANDPARENT-HEADED HOUSEHOLDS

PREVALENCE

DEMOGRAPHIC PROFILE OF CUSTODIAL GRANDPARENTS

REASONS GRANDPARENTS MAY RAISE GRANDCHILDREN

4. CUSTODIAL GRANDPARENTS: AN INTERNATIONAL PERSPECTIVE

5. GRANDPARENTING: A CULTURAL CONTEXT

6. EFFECTS OF CUSTODIAL GRANDPARENTING

SOCIAL AND RELATIONAL ISSUES

HEALTH ISSUES

PSYCHOLOGICAL AND EMOTIONAL ISSUES

LEGAL ISSUES

ECONOMIC AND FINANCIAL ISSUES

OTHER ISSUES

7. RELIGION/SPIRITUALITY AND COPING

8. THE GRANDCHILDREN'S EXPERIENCES

9. ASSESSMENT GUIDELINES WHEN WORKING WITH CUSTODIAL GRANDPARENTS

10. INTERVENTIONS AND BEST PRACTICES

MACROSYSTEM

EXOSYSTEM

MICROSYSTEM

ONTOLOGIC LEVEL

11. INTERPROFESSIONAL COLLABORATION AND PRACTICE

12. CONCLUSION

13. RESOURCES

Works Cited

61584 • Grandparents Raising Grandchildren: Key Practice Issues

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

This course will examine the scope of custodial grandparenting in the United States. It will also give an overview of the demographics of these grandparents. The range of social, psychological, economic, family, mental health, and physical/health implications of being a custodial grandparent will be discussed. Given these clinical issues, clinicians will be alerted to appropriate services for grandparents parenting grandchildren. In order to serve custodial grandparents, practitioners should be fully informed about the life transitions, disruptions, and needs of grandparents and the dynamics of these skipped-generation family structures.

61584 • Grandparents Raising Grandchildren: Key Practice Issues

Education Category. Community Health

Release Date. 03/01/2026

Expiration Date. 02/28/2029

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3405 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

This course will examine the scope of custodial grandparenting in the United States. It will also give an overview of the demographics of these grandparents. The range of social, psychological, economic, family, mental health, and physical/health implications of being a custodial grandparent will be discussed. Given these clinical issues, clinicians will be alerted to appropriate services for grandparents parenting grandchildren. In order to serve custodial grandparents, practitioners should be fully informed about the life transitions, disruptions, and needs of grandparents and the dynamics of these skipped-generation family structures.

Audience

This intermediate course is designed for psychologists who work with grandparents who are raising their grandchildren.

Accreditations & Approvals

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0240. This course is considered self-study by the New York State Board for Psychology.

Designations of Credit

NetCE designates this continuing education activity for 5 credit(s).

Course Objective

When grandparents take on the main parenting responsibilities for their grandchildren, both must adjust socially, emotionally, and psychologically to these new roles. The purpose of this course is to provide psychologists with the skills necessary to assist grandparents who are raising their grandchildren.

Learning Objectives

Upon completion of this course, you should be able to:

1. Discuss the history of grandparents raising their grandchildren both in the United States and internationally.

2. Describe the prevalence and characteristics of custodial grandparents in the United States.

3. Evaluate the reasons grandparents are raising their grandchildren.

4. Analyze the role of culture and ethnicity in custodial grandparenting practices.

5. Describe the range of social, psychological, economic, relational, mental health, and physical/health implications of being a custodial grandparent.

6. Outline the use of religious/spiritual coping by custodial grandparents.

7. Evaluate grandchildren's experiences in skipped generation households.

8. Identify best practices for the assessment of families with custodial grandparents.

9. Discuss the types of interventions needed for custodial grandparents.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margaret Donohue, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In foster care, the concepts of kinship and intergenerational caregiving have become more commonplace, with blood relatives or kin being asked to step in to help raise children when biologic parents are unable to do so. Consequently, some family constellations are changing to include grandparents being primary caregivers to their grandchildren. Certainly, grandparents are not often pictured returning to the developmental stage of parenting; however, grandparents are increasingly finding themselves in this situation. Frequently, grandparents talk about the advantages of being able to spoil their grandchildren and having the luxury of leaving and going home. Being a custodial grandparent challenges this stereotypical model, and instead, grandparents have the responsibility of raising, disciplining, and ensuring that the basic needs of their grandchildren are met [1].

In the literature, the terms "custodial grandparents" and "informal kinship care" are used to distinguish these arrangements from formal foster care, which involves public child welfare agencies. Custodial grandparents are grandparents who serve as the primary caregivers for their grandchildren, assuming full daytoday responsibility. In some cases, they have legal authority, although not all do [28]. These caregiving arrangements are often set up through informal means, such as notarized statements or verbal understandings [67]. Although social service agencies and other institutions recognize these informal caregiving arrangements, custodial grandparents typically have access to only a limited range of services.

Reasons for grandparents assuming parenting responsibilities of their grandchildren are numerous, including parents' substance abuse, imprisonment, deployment, maltreatment, abandonment, divorce, health and mental health concerns, and death of a parental figure [2,22,36,98,119]. In a study of 90 grandmothers, the most common reasons given for assuming custody were a biologic parent's drug or alcohol addiction (28%), parental incarceration (15%), and biologic parents' financial instability (12%) [3]. Many grandparents are concerned that their grandchildren will enter the foster care system, if they do not step in, and placement of grandchildren with grandparents is viewed as a best practice in the foster care system, because the concepts of kinship care, family preservation, and maintaining family ties are highly valued. Worldwide, macrostructural contributors include migration, disease outbreaks such as the COVID-19 pandemic, and major adverse structural economic changes [97]. In 2020–2021, the United States reported one of the highest rates of children experiencing parental loss due to COVID-19 [24]. It is estimated that 140,000 children in the United States lost all parental figures due to the COVID pandemic [98].

Intergenerational households can have unique dynamics, and grandparents must reconcile the out-of-sequence life event of raising grandchildren [4,5]. Parenting and communication strategies that worked when grandparents were initially parenting may not necessarily work today. Others may feel uncomfortable addressing more pressing modern issues such as drugs, sexually transmitted infections, gangs, technology, and school violence [6]. Some grandparents may find raising grandchildren fulfilling in terms of providing a sense of direction in their lives and view it as an opportunity as a "second chance" in parenting [7]. However, research indicates custodial grandparents experience more depression, stress, and health-related problems compared to non-custodial grandparents [8,121].

This course will examine the scope of custodial grandparenting in the United States and provide an overview of the demographics of these grandparents. The range of social, psychological, economic, family, mental health, and physical health implications of being a custodial grandparent will be discussed. Given these clinical issues, clinicians will be alerted to appropriate services for grandparents parenting grandchildren. In order to serve custodial grandparents, practitioners should be fully informed about the life transitions, disruptions, and needs of grandparents, and the dynamics of these skipped-generation family structures [9].

2. HISTORICAL OVERVIEW OF MULTIGENERATIONAL LIVING

Children living with kin is not a new phenomenon; prior to the Industrial Revolution, multigenerational living was very common. In the 1850s, 66% of White adults 65 years of age and older lived with at least one adult child [120]. Many scholars contend that multigenerational living later declined because it was widely assumed that older adults resided with their adult children only out of necessity [120]. During that earlier period, it was also common for grandparents to take on parental responsibilities, as families frequently pooled resources to meet basic needs. There were no formal institutions (like child protective services) to help determine the care of children whose parents died; grandparents were typically the caregivers in such situations [10]. In rural areas, multigenerational living was common because government and charitable benefits for the elderly were not generally available [99]. If grandparents or other relatives could not take dependent children in, then the almshouses and workhouses would take these children to new homes and the children would learn a trade and work as servants or apprentices [11]. In the mid-1800s, multigenerational households began to show a decline. With the shift from an agriculture and farming economy to an industrial labor force in urban areas, many younger people started to leave these multigenerational households [12].

In the 1850s, the Children's Aid Society began sending orphaned children to homes in western states, and the New York Children's Aid Society began to place more children in private homes rather than institutions and asylums [11]. This concept of placing children into homes was increasingly accepted by reformers at the time [13]. With the creation of the Aid to Dependent Children section of the Social Security Act, "placing out" became a standard state response and foster care grew [11]. However, during the Great Depression, multigenerational households again became more popular as a necessity, with a significant number of grandparents also caring for their grandchildren [14]. After World War II, multigenerational living started to decline [23,101].

Historically, child welfare institutions have viewed kinship care as an informal and temporary arrangement in times of crisis [15]. In the 1990s, social service professionals began to focus their attention on children who were abused and/or neglected by their biologic parents (rather than orphaned), and for these children, grandparents became a preferred alternative to non-relative foster care [13]. This resulted in the coining of the term "kinship care," which is essentially defined as preferentially placing children with family, relatives, or any individual with close family ties. Kinship care includes both private kinship care (i.e., entered by private family arrangement) and kinship foster care (i.e., care provided for a child who is in the legal custody of the state child welfare agency) [13,26].

Although the adoption of this approach by social service providers is relatively recent, the concept of kinship care has been very common among ethnic/racial minority groups dating back hundreds of years. A good example of this is found in African American culture, which places an emphasis on self-help, family, and the church. African American children were excluded from orphanages, asylums, and other institutions in the early 1800s and had very few options unless they were sold into slavery [13]. Consequently, the care of dependent African American children was overseen by informal arrangements within their communities and the church [13]. Many African families were destroyed by slavery, and both biologic and fictive relatives assumed the responsibility of caring for and raising children who were separated from their parents [16]. Newly established family patterns emerged, with non-biologic relatives becoming part of kin and intergenerational and multigenerational living arrangements being very common to provide mutual support [16]. After the abolition of slavery and the reconstruction period, kinship family structures continued as African Americans migrated from the south to the north and west.

Since 2008, coinciding with the economic downturn and the continuing rise in housing costs, multigenerational household structures have experienced a resurgence in the United States [101]. A large national survey conducted in 2011 found that 51.4 million Americans live in multigenerational households (defined as three or more generations) [17]. The majority (65%) reported the living arrangement was the result of the economic climate; 40% indicated loss of employment, 20% stated it was due to the rising costs of health care, and 14% reported the foreclosure of their homes [17]. In 2023, 26% of U.S. households were multigenerational, and the primary driver was rising housing costs, as these households save an average of $27,000 per year. India is the country with the highest proportion of multigenerational households, but the precipitating factor in these cases is traditional family norms [125].

In a national survey by Pew Research, 13% of Americans cited the COVID-19 pandemic as the motivating factor for living in a multigenerational household [195]. Globally, the COVID-19 pandemic has led to more than 1.1 million children whose primary caregiver died, giving rise to more nontraditional households [159].

3. AN OVERVIEW OF GRANDPARENT-HEADED HOUSEHOLDS

Assuming custodial care of one's grandchildren involves taking on the responsibility for the children's physical, social, academic, and psychological welfare. This can result in a variety of family and legal configurations. There are formal custodial grandparenting arrangements, whereby the state intervenes to remove the children from the biologic parents and gives custody to able grandparent(s). If grandparents take legal custody of their grandchildren, a probate judge will review the case and grant custody and legal rights to the grandparents [32]. These families may be eligible for child-only Temporary Assistance to Needy Families (TANF) or a TANF family grant. Depending on the state of residence, the family may also be eligible for Kinship Navigator programs [32].

An informal or private arrangement can also occur, with the biologic parents and the grandparent(s) agreeing to a non-legal arrangement of the children residing with their grandparents because the parents cannot provide care [18]. If a child welfare agency helps to place a child with a relative but no court action is implemented to obtain legal custody of the child, this is referred to as voluntary kinship care [19]. Grandparents in this scenario may apply for TANF (child only) or the TANF family grant; however, there are no formal government services for the grandparents themselves [32].

One possible configuration of grandparents raising grandchildren involves the biologic parent(s) being absent from the household; the terms "skipped generation" and "grandfamily" have been used to describe a family structure in which the middle generation is absent [20,21]. Other terms used to discuss grandparent parenting families include "encore parenting," "grandparent-headed households," and "supergrands" (i.e., grandparents who have become surrogate parents to their grandchildren) [14,160].

Grandparents co-residing with their children and grandchildren are also common. Racial/ethnic minority families are more likely than White families to have this type of structure. African American and Hispanic/Latino families are more likely to incorporate grandparents into the household, and such grandparents are often also considered custodial grandparents because they coparent [6]. This trend is not surprising given the cultural and historical factors affecting these groups, such as African Americans' tradition of extended families assisting during economic crises and Hispanic/Latino's cultural emphasis of family (beyond the nuclear family) and incorporation of extended family and fictive kin into definitions of family [6]. The configuration of grandparents residing with their children and coparenting their grandchildren occurs frequently, but this course will focus on households in which the biologic parents are absent.

PREVALENCE

Prevalence figures are inconsistent due to varying uses of terminologies and definitions. Between 2006 and 2015, there was an 8.3% increase in custodial grandparents. In 2015, it was estimated that 5.9 million children younger than 18 years of age in the United States resided with a grandparent; 2.6 million grandparents are responsible for the basic needs of one or more grandchildren younger than 18 years of age [96,118]. Out of custodial grandparents, the majority are grandmothers [96]. In 2025, an estimated 2.4 million children in the United States are being raised in grandfamily households. Among grandparents who take on the primary caregiving role, nearly 35% share a home with the grandchildren they are helping to raise [128].

DEMOGRAPHIC PROFILE OF CUSTODIAL GRANDPARENTS

In the United States today, it is estimated that 2.55 million children in a household with a grandparent, and 2.3 million grandparents report being responsible for their grandchildren [162,163]. Although there are custodial grandparents of many ages, backgrounds, and socioeconomic situations, some similarities among the group are evident. Relatively speaking, grandparents who are raising grandchildren are young; 63% are younger than 60 years of age [164]. In 2023, the average and median age of custodial grandparents was 62 years of age [119]. Women are more often custodial grandparents than men, which is consistent with caregivers in general. Grandmothers and aunts are generally the relatives who assume the care of children when biologic parents are unable to [25]. However, 1.8 million grandparents who provide care to their grandchildren are married [96].

Overall, grandchildren who live with their grandparents are more likely to come from racial and ethnic minority families [161]. Custodial grandparents are racially/ethnically diverse, but they are disproportionately African American and Hispanic/Latino [25]. Among the population of custodial grandparents, 53.4% are White, 20.5% are Hispanic/Latino, and 19.2% are Black or African American [27].

The southern region in the United States has the greatest proportion of custodial grandparents (47.2%), and unfortunately, it is also the highest in terms of poverty rate for custodial grandparents [27]. In 2015, the median income for grandparent head of households (in homes with grandchildren) was $51,448; in cases in which the parent was not present, the median income was $37,580 [96]. Custodial grandparents are more likely to be living below the poverty line than parent-headed households and are more likely to receive public benefits [20]. It is estimated that 21% of grandparents raising grandchildren live in poverty [164]. As such, 1.6 million grandparents (58.7% of custodial grandparents) are working in order to provide for their grandchildren [122]. This rate is significantly greater than the overall labor participation rate for adults older than 60 years of age. Approximately 26% of these grandparents have some form of disability [196]. They are also most likely to have been responsible for their grandchildren for five or more years [196].

REASONS GRANDPARENTS MAY RAISE GRANDCHILDREN

There are a variety of pathways by which grandparents become caregivers to their grandchildren. Some of these factors can also influence parenting style and children's mental and emotional well-being. A typology of the motivations of grandparents assuming the role of rearing grandchildren has been established [124]. According to this typology, grandparents fall into one of three roles. The first classification is the child saver, and these grandparents intervene to "rescue" children when their parents fail or are not able to care for them. The second classification is the mother saver. Due to limited childcare options, grandparents may intervene on the behalf of adult children so that they can work. The third category is the family maximiser, whereby the grandparent is part of the extended family structure that works together to maximize the entire family's financial security by pooling resources. However, for the most part, being the primary carer for these grandparents was not a focus for future planning [67].

Parental Drug or Alcohol Abuse

According to the National Institute of Health, there were an estimated 19 million children younger than 18 years of age who reside with at least one parent or caregiver with a substance use disorder in 2023 [197]. The proportion of children entering outofhome care because of parental alcohol or other drug misuse has grown steadily over time, rising from 18.5% in 2000 to 39.1% in 2021 [198]. In a 2019 study, a common factor precipitating grandparents assuming parental responsibilities in Native American and White populations was parental drugs and alcohol abuse [165]. Of families in the child welfare system, an estimated 60% are affected by substance abuse [29]. The ongoing opioid crisis appears to have impacted the number of children moving to live with relatives, particularly grandparents [123]. Research indicates that states with higher proportions of custodial grandparents are also the states with the highest rates of opioid prescriptions [166]. Research indicates that children of parents who abuse drugs or alcohol are negatively affected in terms of their health and academics, have poorer parental attachment, and are at higher risk of physical abuse [30]. In these cases, grandparents may intervene of their own volition or as legally requested in order to care for affected children.

Child Abuse/Maltreatment

In 2023, it is estimated that 7.4 of every 1,000 children in the United States are victims of abuse and/or neglect [31]. This is the unique rate, which means that each child is counted only once regardless the number of times a report may have been filed for abuse/neglect. In 2023, an estimated 546,159 children were victims of maltreatment [31]. Children who are abused or maltreated are more likely to have school difficulties, behavioral problems, social problems, and mental health issues than children who do not experience maltreatment [33].

Parental Incarceration

The terms "forgotten victims of crime" and "orphans of justice" have been used to describe children with incarcerated parents [34]. Approximately 1 out of 14 children experience a parent who is or was incarcerated [199]. The average age of a child who has a parent incarcerated in federal prison is 10 years of age [167]. Parental incarceration was highest among Black, Hispanic, and Native American families [199]. Furthermore, about 10% of women who enter the prison system are pregnant [35]. It is estimated that more than 5 million children in the United States have experienced a parent incarcerated in jail or prison at some point during their childhood [126].

HIV/AIDS

Children who have experienced the trauma of living and coping with a parent with acquired immune deficiency syndrome (AIDS) or the death of a parent from AIDS often end up being raised by a grandparent [25]. Worldwide, an estimated 8.2 million children have been orphaned by AIDS, and in the United States, 80,000 children fall into this category [127]. This phenomenon occurs overwhelmingly in sub-Saharan Africa. In 2010, 6% of all African children younger than 15 years of age were orphaned as a result of AIDS [37].

Parental Deployment

Parental separation due to military deployment is another reason grandparents may take custody of children [168]. Since 2001, 2 million children have experienced parental deployment [129]. If a single parent or both parents are deployed, grandparents have not only the task of raising their grandchildren but also continually confronting the potential loss of their own child [38]. Children of deployed servicemen and women are more likely to struggle with anxiety and aggression than the general child population.

Parental Mental Health Problems

More than 5 million children in the United States have a parent with a serious mental illness [39]. A 2021 systematic review found the rate of parental mental illness ranged from 16% to 79%. Mothers were slightly more likely to experience mental illness than fathers [169]. The most common condition is major depression, which affects 7.1% of the U.S. adult population [40]. Symptoms such as hallucinations, delusions, low energy, fatigue, mood swings, and difficulties with day-to-day functioning all impact a parent's ability to raise a child.

Divorce

Divorce rates in the United States have essentially stabilized since 1990, with a rate of 2.3 per 1,000 population in 2020 (45% of the marriage rate) [100]. In 2025, estimates suggested that roughly 39% to 42% of first marriages in the United States end in divorce [200]. It has long been established that family environment impacts children's mental health and psychological well-being, and divorce and marital strife are no exception. When children are exposed to chronic conflict, they experience stress, insecurity, shame, and self-blame [41]. When parents get divorced, many children exhibit academic, social, and behavioral difficulties during both the divorce process and the phase of adjusting to a new family environment. In some cases, removing the child to a more stable environment (e.g., a grandparent's home) can be beneficial.

4. CUSTODIAL GRANDPARENTS: AN INTERNATIONAL PERSPECTIVE

Custodial grandparenting is not a unique phenomenon to the United States. Although it is a worldwide phenomenon, the terminology varies. In Asia, the term "surrogate mothers" is used; in South Africa, the preferred term is "carer grandparents," while in Uganda, the term is "grandparent-caregivers" [28]. It is estimated that as many as 163 million children worldwide are being raised by grandparents or other relatives [130]. In the United States, grandparents assuming parenting responsibility is largely the result of parental substance abuse; however, in Africa, it is due primarily to parental deaths, and in Korea, to divorce [201,202].

In a survey study, 81% of custodial grandparents in New Zealand were older than 50 years of age [42]. The top reasons cited for becoming a custodial caregiver were child neglect and parental drug abuse. In Australia, there were 31,100 grandparents raising grandchildren, which represented 1% of families with minor children [43]. A European study found that multigenerational households were more common in Eastern Europe (29.7%) than Western Europe (5.5%) [131]. In some Asian cultures, approximately half of older individuals live with their grandchildren [170]. In these cases, internal and external migration of parents for employment is a major reason grandparents play such a dominant role in the lives of grandchildren [171].

In Asian countries, informal grandparent caregivers are quite common. In China, for example, grandparents have typically been good sources of child care for working parents, and grandparents will often travel to the grandchild if they are not residing with the family [44,132]. In China, with the economic reforms that began in the 1970s, there has been an increase of rural-to-urban migration, whereby young parents move to cities to find employment, leaving their children behind with grandparents [133,172]. With the one child policy, the typical urban household arrangement was "4-2-1" (four grandparents, two parents, and one child), although this is becoming less common due to difficulty obtaining housing for a larger family [44]. In these cases, grandparents are not formally custodial per se, but they are often viewed as domestic helpers, and there is some evidence that they experience similar stress as custodial grandparents [44]. In other parts of Asia, such as Thailand, the Philippines, and Taiwan, 40% of persons 50 years of age and older live in a household with a grandchild younger than 18 years of age; more than 50% of these individuals live with a grandchild younger than 10 years of age and provide child care [45]. In Thailand, there is a high internal rural-to-urban migration rate as well [134].

In Africa, families are affected by a phenomenon called "skip generation," whereby the middle generation migrates from rural to urban areas seeking employment. Children are left with grandparents so the parents can financially support their families [45]. In sub-Saharan Africa, the AIDS epidemic, poverty, relentless wars, and disease outbreaks (e.g., malaria, Ebola) make orphans relatively common, with these children being cared for by grandparents and other family members [44,97]. So, even internationally, grandparents have increasingly had to assume the role of primary caregivers for young children with minimal to no assistance.

5. GRANDPARENTING: A CULTURAL CONTEXT

Regardless of the cultural context, grandparents are generally viewed as providing emotional and concrete support to their grandchildren. Concrete support may be monetary in nature or it may be in the form of providing child care or household help. The amount of support is contingent upon proximity to the grandchildren, relationship with their children, and health [46]. However, the level of expected grandparent involvement is influenced by cultural beliefs and traditions.

Culture, race, and ethnicity all affect a family's views regarding the roles of grandparents. White European/American norms are centered around individualism, and therefore, the definitions of family tend to be limited to the nuclear family. However, collectivism, or an emphasis on community and the group, is the dominant orientation among many non-White families, with social behaviors focused on promoting the welfare of the group [47]. In collectivistic cultures, family roles may be different than those in individualist cultures. For example, Hispanic/Latino cultural values of familismo result in the family's interests being emphasized over the individual's [135]. In Asian families, individual needs are relegated to the needs of the collective unit. Furthermore, filial piety is highly valued, meaning children are expected to repay their parents for the sacrifices they have made.

In African American families, grandparents tend to be viewed as the guardian of the generations [136]. African American families have a long history of grandparent-headed households because private children's agencies often denied services to African American children; therefore, African American families historically had to rely on grandparents and other relatives [173,203]. Stereotypes regarding strong Black matriarchs lends to the expectation that African American grandmothers will intervene in times of need [173]. In Native American families, the family is the foundation of social relationships and elders are highly respected for their wisdom and life experiences [137]. In these cultural contexts, grandparents are viewed as the families' roots—necessary teachers of cultural traditions to younger generations. In interviews with 28 Native American grandparents, they reported taking on "ceremonial" and "cultural conservator" roles in addition to their emotional roles for their biologic and fictive grandchildren [48]. Native American grandparents served as models of appropriate ceremonial behaviors and took on the responsibility for exposing their grandchildren to tribal ways of life in order to reinforce and perpetuate the Native American culture and tradition. This belief that grandparents have "enculturative responsibilities" is echoed in other studies with Native American grandparents [46,165]. These grandparents report using storytelling as a way of teaching younger family members. They also saw themselves as family facilitators, ensuring that the family is brought together. Similarly, in African American culture, grandparents have long played a key role in families. Historically, they uphold and transmit values and traditions and serve as the support for their families during times of hardship and stress [102,137]. In a 2018 qualitative study, Native American grandparents raising grandchildren in Alaska described being family providers, teachers for socializing prosocial behaviors, and transmitters of important cultural values and traditions to grandchildren [138].

This theme of grandparents viewing their role as cultural teacher was found in other cultures as well [49]. In a study with Vietnamese grandparents, participants saw themselves as "living ancestors" and "family historians," the only connection or link to the family's past and cultural traditions. Again, storytelling was a key activity, and grandparents reported using every opportunity to recount family stories and Vietnamese customs and traditions. In addition, the Vietnamese grandparents believed they should be models of family unity. With extended family members scattered around the world, grandparents wanted to demonstrate to their grandchildren that the family was still united. Chinese families view grandparents as generational intermediaries, the persons responsible for passing down wisdom. Dependency, obligation, and reciprocity underscore the central values of traditional Chinese households [174]. This is also the case in Filipino culture. Grandparent caregiving has a longstanding cultural expectation. Informed by the cultural principles of pakikipagkapwa (a sense of shared humanity) and utang na loob (reciprocal indebtedness), intergenerational care is understood as a moral commitment in Filipino families [204].

In Sudanese families, grandparents (particularly grandmothers) tend to take on a protective role of the entire extended family [50]. They provide instruction and mentoring of correct behavior and morals; teach and perpetuate cultural practices; and assume concrete child-care roles, such as helping to discipline, assuming household tasks, and providing emotional security. In the United States, African American grandmothers also play a pivotal role in protecting the extended family and often act as surrogate parents [9].

The theme of symbolic kin-keeping appears to surface frequently in studies of grandparent roles in culturally diverse families. Symbolic kin-keeping refers to more than just activities to help maintain family ties and relationships; rather, it extends to promoting and preserving cultural and ethnic ties [51]. Symbolic kin-keeping is predominant in immigrant and ethnic/racial minority families, in which activities such as sharing family stories, passing on family recipes, and celebrating religious and cultural values are highly promoted [51].

6. EFFECTS OF CUSTODIAL GRANDPARENTING

Many custodial grandparents view their new role as a chance to rectify mistakes they felt they made as parents [38]. In a study of custodial grandmothers, some said they enjoyed parenting the second time around because they felt they had more experience, had learned from past parenting mistakes, and could now offer wisdom. In many respects, this created a sense of freedom, relaxation, and confidence [1]. They felt it was a joy and a blessing to be helping to raise a second generation [205]. Other grandmothers felt they had more time and attention to give to their grandchildren compared to when raising their own children, as they were often working and taking care of their families [1]. Many custodial grandparents feel that the time they have with their grandchildren is a blessing and has renewed their sense of purpose in life [20,172]. Furthermore, they felt it was part of their duty to help preserve the family unit. Custodial grandparents find joy in parenting their grandchildren and feeling useful in a time of need for their children [139,140].

Unfortunately, the reality of being a custodial grandparent is not always positive. Some have used the theoretical perspective of time-disordered roles to explain the negative social, psychological, and health effects experienced by custodial grandparents [52]. This theory posits that when individuals' roles and social domains are not aligned, they are more likely to experience stress [53]. Grandparents generally do not expect to be raising young children, and as a result of dramatic changes in expectations and the lack of congruence between this role and what is socially expected of them and their peers, stressful dissonance develops. The strain may further stem from grandparents not having the skills to take on these new roles and/or their support network being unable to provide help [52].

The effects of this stress are evident in many aspects of custodial grandparents' lives. It is important to remember that the repercussions vary depending on the type of care grandparents provide, cultural expectations, and preconceived notions of life roles. Caregiving intensity is an important variable to take into account. The effects on health and mental health have a U-shaped pattern, meaning that low-to-moderate grandparent caregiving has beneficial outcomes, while high or intense levels of caregiving have more negative or adverse consequences [206]. Furthermore, grandparents who provide care to, but do not live with, grandchildren will have a different experience than grandparents who have sole legal and physical custody of their grandchildren. Financial situations and existing social support networks will also influence custodial grandparenting experiences.

SOCIAL AND RELATIONAL ISSUES

Custodial grandparents often find that their social network is impacted by assuming the role of a custodial grandparent. A phenomenological study with eight grandparents found that grandparents raising their grandchildren reported feelings of loss related to several arenas—loss of free time, loss of money, and loss of freedom [175]. No longer can they go out with their friends; arrangements for babysitters or child care are necessary [141]. Their peers are usually not involved in extensive child care, so custodial grandparents tend to see their friends less frequently and feel they have less in common with them [52,54]. In addition, they may also have difficulty relating to the young parents of their grandchildren's friends [55]. In school activities, for example, they are often the oldest guardians present [20]. Consequently, custodial grandparents may feel more isolated.

Marital relationships can also be negatively impacted [20]. Grandparents who have legal custody of their grandchildren are four times more likely to report an increase in marital dissatisfaction compared to grandparents who provide some child care but are not necessarily living with their grandchildren [52].

In many cases, grandparents' relationships with their own children are fraught with stress and conflict after assuming primary child-care responsibilities. The factors that initiate loss of custody (e.g., substance abuse, child abuse/neglect, general irresponsibility) are often a source of this conflict, with grandparents struggling with their parenting relationship with a potentially unstable adult [56]. Biologic parents may show up without any warning, negatively affecting routines that grandparents have established, or they may provide conflicting disciplining messages [56]. In one study, grandparents raising their grandchildren reported often feeling they had to "deprogram" their grandchildren after they spent time with the biologic parents [20]. Some younger grandchildren may experience role confusion (e.g., calling grandparents mom or dad), which can cause tension with biological parents [134]. A participant in one qualitative study expressed the realization and sorrow that her adult child would never be capable of parenting [176]. The realization was heartbreaking for the grandparent but having to explain to the grandchild was even more distressing.

Custodial grandparents may have to deal with grandchildren's emotional, academic, and behavioral problems stemming from the unstable home life [20,55]. This can be taxing for them physically and emotionally, but it can also affect their relationships with their grandchildren. Custodial grandparents report needing help in a variety of arenas; however, people often assume that because of their age and experience of having raised children, the process is easier [20]. However, disciplinary and child-rearing practices grandparents used to raise their own children may no longer work with their grandchildren [141; 142; 207]. Overall, custodial grandparents find that they put their own selves on hold in order to meet their grandchildren's needs [139].

Concrete needs such as housing may also be problematic. Because they did not anticipate having living with grandchildren, custodial grandparents' residences may not be large enough or may lack the required number of bedrooms. Regulations may prohibit children from joining grandparents in senior housing [143]. Many custodial grandparents express frustration that there are few services available to custodial grandparents [143].

Future planning taking into consideration grandchild custody is also a concern. In a mixed-methods study with 110 custodial grandparents, few had a future care plan regarding who will assume the parenting of the grandchildren [140]. Alternative care involving other family members is often infeasible.

HEALTH ISSUES

Raising children can be physically taxing at any age, but grandparents may be affected more due to their age and difficult circumstances [208]. Custodial grandparents report that they do not have the same level of energy they had when they were parenting their own children. Instead of actively participating in activities with their grandchildren, they find themselves sitting and telling their grandchildren to play alone or with each other. Depression and poor physical and mental quality of life are more common in custodial grandparents than in non-custodial grandparents [144]. In a large-scale national study, custodial grandparents reported more limitations in six areas compared to noncustodial grandparents, including mobility inside the house, completing daily household tasks, climbing stairs, walking street blocks, working outside the home for pay, and performing heavy tasks [57]. Researchers were unable to conclude whether custodial grandparents' greater functional limitations were directly due to higher levels of stress or whether custodial grandparents were more likely to be confronted with their physical limitations due to their caregiving roles [57,205].

Custodial grandparents tend to rate their health worse than other grandparents [5]. However, in one study, biomarkers (e.g., cholesterol levels) were compared between custodial grandparents and non-custodial grandparents [177]. Custodial grandparents did not necessarily have worse biomarkers, but they did self-report as less healthy than their counterparts. Custodial grandparents tend to rate their energy levels lower and their stress levels higher than their non-custodial grandparent counterparts [177]. Their sleep quality and duration also declines due to disruptions [208]. There is some evidence that grandmothers (not necessarily custodial) who care for healthy grandchildren for nine hours or more on a weekly basis are significantly more likely to have coronary heart disease [58]. In a large-scale study comparing health outcomes in single parents and single grandparents, the grandparents were found to have more health problems [103]. In a 2022 systematic review, custodial grandparents fared worse in terms of stress, depression, and self-rated health compared with grandparents living in a three-generation household or grandparents babysat grandchildren occasionally [178]. For grandparents in three-generation households, the results are mixed.

Of course, this is often related to age. Single grandparents were less likely to report having exercised in the last month but were more likely to have access to health services. In a separate study of African American custodial grandparents, sleep disorders were common, with most linking the lack of sleep or poor sleep quality on the stresses of parenting their grandchildren [104]. In another study, solo custodial grandparents had higher incidences of chronic health conditions and poorer physical functioning than coupled grandparents [145].

Health-related quality of life decreases depending upon level of education, their grandchild(ren)'s health, and number of grandchildren in custody [5]. While custodial grandparents may rate their health as good or fair, they are more concerned about their overall health [55]. Despite their concerns, they may sacrifice self-care if it is perceived to get in the way of caring for their grandchildren. One study showed that younger grandmothers had higher levels of health and mental health problems compared to older grandmothers, and it is suggested that custodial grandparents who find themselves confronted with early out-of-role transitions have more difficulty adjusting to these unexpected roles [3].

PSYCHOLOGICAL AND EMOTIONAL ISSUES

A diverse range of emotions and psychological issues surface for grandparents who assume the care of their grandchildren. Some custodial grandparents may report feeling trapped and feeling guilty for having this response. On the one hand, they want to help their children/grandchildren, but at the same time, they did not expect to be raising young children during this stage of their lives [56]. Feelings of anger and resentment may also arise—anger toward their adult child and the situation they are in [55]. Guilt may emerge if they feel they failed as parents [56].

The types of stressors custodial grandparents face generally fall into three categories [55]:

- Caregiver-related stressors: Concerns about parenting, finances, and managing multiple responsibilities to grandchildren, the biologic parents, and one's own health and well-being

- Grandchild(ren)-related stressors: Worries about the child's academic, behavioral, and/or disciplinary problems, present and future well-being, relationship with the biologic parent, and conflict between the child and other family members

- Family-related stressors: Concerns about long-term caregiving, relationships with spouse/other family members, and lack of help from family members

Various coping strategies are used to deal with these stressors, including positive reappraisal and escape avoidance strategies [59]. Some grandparents try to reframe the situation or difficulties in a positive manner, viewing the role change as an opportunity to grow as a person. Others avoid directly coping by hoping a miracle will happen or that the difficulties will disappear. A study of Ugandan grandparents raising their grandchildren due to the death of a biologic parent found that action-based coping strategies were common, as were spirituality and inner resiliency [60]. Age may also play a role, as research indicates that social support mediates the relationship between depression and quality of life among grandparents older than 55 years of age, but not for younger groups [105].

Grief is also often part of the custodial grandparenting situation. Some grandparents are grieving the loss of an adult child; others are experiencing the loss of their child to prison or drugs [61]. Some experience shame having to admit that their adult child is not responsible in providing care [179]. Indirect losses, including loss of free time, freedom, and the expected role of being a traditional grandparent, may also cause grief [61]. Because family members and friends do not necessarily understand the stressors and types of loss custodial grandparents are experiencing, individuals often must deal with disenfranchised grief, or grief unacknowledged by society and one's social support system [61].

In one international study, grandparents in skipped generation households reported being less happy compared with those living in multigenerational households or simply with their spouse [133]. Custodial grandparents experience stress, anxiety, and depression in the clinical range, with levels correlated with the severity of the grandchildren's emotional and behavioral problems [43,106]. In a quantitative study with 76 custodial grandparents, higher rates of parenting stress positively correlated with lower levels of life satisfaction and worse mental health [180]. Consistent with other studies, those who had more informal social support and service utilization rates fared better. However, older custodial grandparents are less likely to report psychological distress, possibly due to differences in responses to challenges and life perspective [106]. In a study of Native American custodial grandparents, they also experienced clinical depressive symptoms and high levels of parenting stress. When asked about their symptoms, they mentioned that providing care to their grandchildren at a stage when they least expected it was difficult, particularly in light of the minimal support provided [62]. In terms of impact on level and severity of depression, the stress of having a grandchild move in and assuming care is comparable to the stress of being a victim of a crime, having a spouse diagnosed with an illness, having a serious injury, or being hospitalized [63]. Financial burden, intergenerational conflict, and legal concerns are also common stressors [141]. Despite high levels of stress, custodial grandparents tend to experience satisfaction with their lives as long as they have social support and sufficient coping skills [146]. This finding is consistent with a 2021 quantitative study with 94 caregiving grandparents [181]. In this study, grandparents who perceived having social support and the choice to parent were more likely to report greater life satisfaction. Another study found that grandparents' health predicted overall life satisfaction regardless of the circumstances [209].

LEGAL ISSUES

Grandparent-grandchild caregiving arrangements can range from entirely informal situations (in which no legal paperwork establishes the caregiver's authority) to fully formalized options (such as adoption) [210]. Minor, or probate, guardianship falls in the middle of this continuum. This type of guardianship grants relatives many parental powers, including enrolling the child in school and consenting to medical treatment, while also obligating them to provide the child with housing and daily care. After a guardian is officially appointed, these rights and duties typically remain in place unless a court later changes or ends the guardianship order [210]. Courts in 46 states, as well as in the District of Columbia, possess statutory authority to establish minor guardianships [211].

If they are appointed legal guardians but the parental rights are not terminated, then the parents are still legally responsible for the child. This can cause role confusion for both the grandparents and grandchildren [20]. Grandparents who have an informal arrangement can also experience confusion as to how they parent, and disciplining may be compromised if the biologic parent gives mixed messages to the child. They may also have limited access to services, such as housing, food, childcare, and grandchildren's medical and educational records, because the eligibility for which is often dependent on a legal relationship with the grandchildren [107,136,147]. Despite the drawbacks of these less formal situations, grandparents may be reluctant to seek legal custody because they are not familiar with the legal system, are mistrustful of the legal system, or are fearful of negatively affecting their relationship with their children [20,107]. Obtaining legal assistance can be costly and time-consuming, though it may be necessary in order to obtain custody of grandchildren [182]. However, the legal process of obtaining minor guardianship or full custody is complex [205,211].

Many grandparents have not made formal, legal custodial arrangements for their grandchildren in the event that they are no longer able to care for them. Seeking legal services to discuss and arrange formal arrangements is often impeded by lack of financial resources [148; 205].

ECONOMIC AND FINANCIAL ISSUES

While raising grandchildren full-time, grandparents may find that they are unable to work or they may have to return to work after retirement in order to provide for a larger family. This is particularly true if biologic parents are not contributing financially to the household. Custodial grandparents who are unable to work may have difficulty applying for TANF [107]. The TANF family grant offers financial support based on the income of the entire family, but it also has a work requirement for the grandparent [107].

In one study, married grandparents in households in which the biologic parents of the grandchildren were not present (i.e., skipped generation households) were more likely to have increased participation rates in labor force compared to their counterparts who were living independently [64]. Grandmothers have the most substantial increase in labor participation rates in skipped generation households [64]. Unmarried grandfathers in skipped generation households were 29% less likely to be in the labor market. Single custodial grandparents may have to provide day-to-day child care for their grandchildren, making outside employment difficult. In a 2018 study, grandparents in skipped generation households reported being stretched financially and taking on work to supplement their finances, leaving them exhausted [134]. Research indicates that African American families engaged in informal kinship care tend to demonstrate financial challenges in the following domains [212]:

- Greater difficulty meeting routine household costs

- Less likely to have an income surplus

- Less likely to possess savings for unexpected emergencies

During the COVID-19 pandemic, custodial grandparents reported challenges in paying for food, utilities, rent, and medical bills. It is, therefore, not surprising that custodial grandparents who experienced job loss during the pandemic also experienced higher levels of parenting stress [183].

Unfortunately, custodial grandparents receive minimal financial support compared to foster families, with non-related foster care families receiving more services and financial stipends than families who provide care for their relatives [65]. In California, of the 281,067 grandparents who are responsible for grandchildren living with them, 15% live in poverty [66]. Among children being raised by their grandparents, 13% live deep poverty (i.e., household income below half of the federal poverty line); this level of economic hardship affects only 8% of children in parentled households without grandparents [119]. More than 25% of grandparents raising grandchildren live in overcrowded conditions and almost 17% of them pay at least half of their income for rent [108]. It is estimated that 43% of grandchildren living with their grandparents receive food stamps to meet their basic needs. Ultimately, financial hardship and stress contribute to overall caregiver stress, which can then affect the grandchildren's overall health, behavior, and academic performance [212].

OTHER ISSUES

Racism

Because a high proportion of custodial grandparents are racial/ethnic minorities, it is crucial to acknowledge the intersection of racism and poverty and how this affects the lives of some custodial grandparents. The group most affected by this issue is African Americans, who are 1.8 times more likely than White Americans to assume custody of grandchildren and provide child care [64]. Racism can exacerbate problems that many African Americans and other racial minorities confront, including poor living conditions, substance abuse, and crime in the communities. Attempting to access services and resources can be disempowering, as service delivery models are often not flexible to the unique needs of economically disadvantaged families [212]. One study found that custodial grandparents who perceived racial discrimination were more likely to experience depressive symptoms and were less likely to access available services [184]. As such, the harm reduction model has been developed to help improve the efficacy of working with racial minority groups [68]. Harm reduction practitioners reject universal interventions and attempt to make interventions culturally relevant and sensitive. They also strive to understand how oppression and marginalization in a client's historical legacy can affect experiences. Advocacy is a large part of this approach, and minimizing barriers to help-seeking and service use is vital [68].

Elder Abuse

There is some evidence of custodial grandparents being abused by their grandchildren, although the prevalence of this problem is not known; it is difficult to obtain statistical information on this problem in general given the invisible nature of elder abuse and the shame and stigma attached to it. Some grandparents in multigenerational households experience injuries when attempting to intervene in cases of violence or abuse. Others may be abused by their own children or grandchildren [149]. In addition, the context of custodial grandparents' lives plays a role in making the problem more difficult to detect. Custodial grandparents tend to be more isolated from their peers and frequently do not have the support networks that other families may have. As discussed, this stems in part from being outside the normal developmental life cycle [69].

In a study focused on custodial grandfathers, disrespectful and demeaning words and behaviors were often attributed to the contemporary times and societal norms, and participants considered these behaviors an expected part of their caregiving experience, not necessarily abuse [70]. In another study of child welfare workers and custodial grandparents, the two groups differed in their views about what constituted psychological and verbal abuse [71]. Grandparents felt disrespectful behaviors could be abusive and should be addressed early as they could lead to more harmful behaviors. Child welfare workers felt that cursing or talking back to grandparents was not necessarily abuse but irritating behaviors that are part of normal adolescent development [71]. Overall, both groups agreed that more supportive services are needed, particularly better collaboration between child protective and welfare services and adult protective services [71]. In many cases, some simply minimize the abuse or put up with it, rationalizing it as part of their caregiving duty [213].

Three theoretical perspectives have been posed to explain the phenomenon of grandchildren abusing custodial grandparents. The first is the neurophysiologic perspective, which posits that children raised in traumatic environments (e.g., with parents who are abusive) are in a constant and perpetual "fight-or-flight" mode. This state of anxiety becomes so ingrained within them that even when they are in a "safe" environment, they expect threats and harm, and this increases the risk of aggressive behaviors and acting out [69]. The second perspective is attachment theory. According to this theory, children whose child-parent attachment bonds have been disrupted are more likely to exhibit aggression, disruptive behaviors, impulsivity, and lack of control [69]. The third theoretical explanation involves family systems theory, which focuses on the dynamics and interactions of the grandparent-grandchild relationship as well as the intergenerational transmission of violence. This perspective also argues that violence is intergenerational and that aggressive behaviors are learned. Grandchildren may project the anger they feel regarding their biologic parents and their fear of intimacy onto their grandparents. Grandparents' attempts to discipline and cope with bad behaviors may cause distress, triggering a "fight-or-flight" response. This could then result in aggressive behaviors and perpetuation of a cycle of violence [69]. Children observe their parents dealing with conflict using aggression and learn to use this method themselves [72].

Elder abuse is considered an invisible problem, and when the grandchildren are the perpetrators, it may be minimized or dismissed. Some victims simply do not know where to get help or have easy access to formal services [213].

7. RELIGION/SPIRITUALITY AND COPING

Coping is defined as a set of directed behaviors employed to deal with stress and life challenges in order to reduce social, physical, and emotional distress [109]. Coping strategies can be generally classified as active or passive. Active coping involves relying on internal and external resources, while passive coping entails giving up control over the stressors and giving in to feelings of helplessness. Research with custodial grandmothers found that social support and active/adaptive coping were correlated with less distress and less ineffective parental disciplining (defined by harsh and inconsistent disciplining) [110; 214]. Passive coping, on the other hand, was related to more distress and more ineffective parental discipline. For example, custodial grandparents who face elevated stress stemming from financial pressures, role-related demands, and grandchildren's behavioral challenges and who relied more heavily on avoidant coping strategies reported the poorest overall quality of life [215].

It is important for practitioners to remember that religion and spirituality are at the core of many individuals' coping strategies and personal and family lives and has a long historical tradition in the survival of racial/ethnic minority communities. Spirituality has been defined as beliefs and practices that develop based on personal values and ideas regarding the meaning and purpose of life [73]. It refers to the belief that there is a power outside of one's existence or a life force that transcends understanding [74]. On the other hand, religion has been defined as "an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (e.g., God, higher power, ultimate truth/reality) and to foster an understanding of one's relation and responsibility to others in living together in a community" [75]. Religiosity has been categorized as either non-organizational, which consists of prayer and importance of religious beliefs, or organizational, which consists of attendance at services and other activities [76]. There is a correlation between religiosity/spirituality and willingness to ask for help caring for grandchildren [139]. In general, churches and other places of worship are a source of help with child care, food, holiday gifts, and other concrete goods [142].

When individuals experience health or mental health problems, spirituality or religiosity may be used as a form of coping. Pargament identified three ways that religion might aid individuals in coping [77]. First, religion can influence the perspective an individual assumes toward the stressor; the source of stress may be viewed as part of a divine plan. Second, religion can shape the coping process; that is, religion or spirituality can be employed as an inner resource to overcome the challenges associated with life challenges. Finally, the coping process may strengthen an individual's spiritual or religious orientation. Three different types of religious coping have been identified [77]:

- Self-directed coping: No reliance on God or higher power(s) to solve problems. ("It's my problem to solve, not God's.")

- Collaborative religious coping: Utilization of strategies within oneself and God or higher power(s). ("God helps those who help themselves.")

- Deferred religious coping: Passive attitude toward problems; waiting for God or higher power(s) to intervene. ("It's in God's hands.")

Custodial grandparents frequently identify their faith, determination, and a sense of connectedness to a higher spirit as their main coping mechanisms. Some indicate that their faith allows them to maintain a positive attitude despite challenges and is a source of emotional healing [78]. Custodial grandparents have stated that they use church attendance and prayer to stay healthy and rely on their faith as a major source of support [5,79]. A survey study of 241 custodial grandparents found that well-being was correlated with support, which was specifically defined as having social assets (e.g., support network, religiosity/spirituality) [111]. All eight custodial grandparent participants in a 2021 qualitative study identified their faith in God as their mechanism for strength and coping [175]. In a study with 26 rural custodial grandparents, the researchers found that the participants' religion and spirituality were an integral mechanism for coping. Prayers helped with emotional regulation; support from their faith communities was essential for both emotional and concrete assistance, and their faith gave them meaning for the often hard work of caregiving [216]. Faith-based communities can provide emotional support as well as concrete assistance [186]. Grandparents with a positive view toward life also experienced greater mental health well-being. Practitioners should be sensitive to clients' religious and spiritual worldviews and allow interventions to incorporate meditation and prayer. It is important to acknowledge that faith and spirituality are important resources for many people.

8. THE GRANDCHILDREN'S EXPERIENCES

Kinship care offers children more stability than being removed and placed in a foster home with strangers. However, there is no doubt that it can be a stressful situation for grandchildren. The experiences of children whose biologic parents are no longer living with them and who are now living with kin (e.g., a grandparent) can vary and are the primary concern when determining the optimal living situation.

One of the main concerns is the child's relationship with his or her biologic parents, particularly the mother [55]. In focus group studies of children living with kin, findings regarding children's adjustment are mixed. Some children report feeling happy about moving in with their family caregiver; in some cases, the children have already been spending a significant amount of time with the caregiver. However, others are sad, frustrated, and angry, harboring anger and confusion about their parents' inability to care for them [150]. Many children still longed to be reunited with their parents in the future [80]. Parents who frequently do not come through on promises of visiting or calling were a source of disappointment, shame, loss, and anger [81]. Unresolved grief at having lost a permanent relationship with one of their biologic parents is a recurrent theme [65]. This can also result in internalizing (e.g., withdrawal, somatization, depression) and externalizing symptoms (e.g., aggression) [151]. Children who come to grandparents who have pre-existing mental health issues and financial difficulties are more likely to experience depressive symptoms, anxiety, and stress [187].

Despite these feelings of loss, children tend to understand the importance of living with grandparents and how this allows for emotional stability and protection. Children often believe that their living situation is no different from children who live with biologic parents because they are being cared for and loved by their grandparents [65,152]. Some may be relieved to have "escaped" from the problems in their previous living situation. Studies indicate that children tend not to feel stigmatized or ostracized for having alternative living situations; feeling that they are well taken care of is more important than peer support [80]. Overall, stronger grandparent-grandchild bonds correspond with reduced likelihood of emotional difficulties, behavioral issues, and peer-related challenges. This pattern is consistent with attachment theory, which posits that warm, secure relationships foster a child's sense of safety and stability [209]. Grandchildren are not naïve—they are aware of what is going on around them. They seem to be sensitive to the fact that their grandparents are older and express concern for their health and well-being [65]. Furthermore, children raised by other caregivers often express a desire for their voices to be heard in key decision-making areas such as schooling and living arrangements [112].

9. ASSESSMENT GUIDELINES WHEN WORKING WITH CUSTODIAL GRANDPARENTS

Six areas have been identified as crucial for practitioners to assess when working with custodial grandparent families [95]:

- The child, parent, and grandparent relationships and interactions and how these affect the child's views about the relationships

- The child's understanding of the situation and why he/she will be living with the grandparents, taking into account the child's age and developmental capacities

- Each family members' feelings about the parental separation and explore denial of negative feelings or even glorification of positive feelings toward parents, if present

- The family's current situation in terms of risks and resources and family members' perceived needs

- What grandparents have told the child about the parental separation

- How grandparents view the situation (e.g., whether they focus on the stressors and potential challenges or the potential rewards of caregiving)

When conducting an assessment, it is important to obtain as many perspectives as possible, including the child, parent(s), grandparent(s), and other family members [95]. It may also be helpful to use genograms and ecomaps. Genograms that provide a visual representation of a family tree with dates and relationships can give practitioners a sense of who in the family system is available to provide support to the custodial grandparent [217]. Ecomaps can give a snapshot of the environmental resources available to custodial grandparents, such as social services, human service organizations, health care, schools, and churches [217].

10. INTERVENTIONS AND BEST PRACTICES

Various interventions and best practices for assisting custodial grandparents have been established based on the premises of ecologic theory. Ecologic theory is a conceptual framework employed to examine a social problem within a multi-level context: the individual, family, neighborhood and community, and sociopolitical and sociocultural structures [82]. This allows for multi-level interventions targeted at various systems levels, which is important. It is impossible to discuss improving academic, emotional, and/or behavioral outcomes for the grandchildren without including interventions for grandparents and the family system.

MACROSYSTEM

The macrosystem level includes the broad social and cultural values that affect the individual. Custodial grandparents who have informal arrangements to care for their grandchildren often have a more challenging time accessing health and social services and financial assistance compared to those with formal kinship care agreements [83]. Because they lack the legal authority to assume care for their grandchildren, they often do not qualify for TANF, Medicaid, or other financial or concrete services [83,136]. Despite the fact the informal kinship care outnumbers formal kinship care by a ratio of 6 to 1, less governmental support is available to informal caregivers [84]. Today, states are required to make the same payments to kin caregivers of children as foster parents, but only if kin caregivers meet foster care licensing standards [85,188]. Some have argued that there appears to be a societal view that family members should step in to provide care to children without the need of any additional assistance [83]. The National Family Caregiver Support Program was established in 2000 to help states provide assistance to family caregivers, including grandparents [113]. Assistance can range from offering financial and legal counseling to support services. The Supporting Grandparents Raising Grandchildren Act was passed in 2018 to specifically address the needs of grandparents, particularly within the context of the opioid crisis. As part of this initiative, a federal taskforce will work on identifying outreach, mental health and supportive services, information, and resources to support this population [153,154,176]. The Guardianship Assistance Program (GAP) is a federal program with the goal of strengthening permanency for children in foster care. As of 2021, 40 states and the District of Columbia have been approved to operate GAP, through which licensed foster parents who become permanent guardians are eligible for monthly assistance [188].

Professionals can connect kinship caregivers with resources such as Volunteer Income Tax Assistance (VITA) sites and nocost online taxfiling services to assist grandparents in claiming benefits (e.g., earned income tax credit, child tax credit). Children in the care of relatives may meet the eligibility criteria to be claimed for these tax credits [212].

Grandparents frequently assume the care of grandchildren due to circumstances beyond their control, and it is often not possible to prepare in advance for this situation. In addition to the challenges of raising their grandchildren, these individuals must navigate social service, medical, and legal systems, which can be complex and bureaucratic [4,86]. This can cause stress for custodial grandparents [114]. Legal services can be difficult and expensive to access, with free or subsidized legal aid services only available for very low income families and with long waits [114]. While there is legislation in the United States for a national kinship navigator system with the sole purpose of assisting custodial grandparents in accessing services, it has yet to be fully implemented [56]. One of the major roles of social workers, counselors, and mental health practitioners is being an advocate for custodial grandparents. Grandparents are often not familiar with public assistance and their eligibility [87]. In addition to material resources, grandparents may also require case management, psychoeducation, and psychological, mental health, and health services; spiritual resources may also be helpful [86]. Mental health professionals are in the position to serve as liaisons to the various agencies involved. It is also important to remember that many individuals, particularly those who are disenfranchised, may be more wary and mistrustful of governmental institutions, including the child welfare system. When family arrangements fall outside the conventional norms of the nuclear family system, child welfare workers may be implicitly biased to label such non-traditional family arrangements as dysfunction or unfit [210]. It is important to call out these biases and advocate for these families.

EXOSYSTEM

The influence of formal and informal social structures (e.g., work, peer groups, support groups, friendships, schools, communities, neighborhoods) on larger social problems and individual behaviors is referred to as the exosystem level. In some cases, grandchildren will have academic problems or will move to a new area, requiring adjustment to a new school environment. The custodial grandparents must then navigate the school system, meet with teachers, and provide assistance with homework. This can be difficult, especially as school officials and teachers often do not understand the context of skipped generation family structures and the needs of the grandchild and grandparents [56]. Many teachers focus on the traditional family structure and are not familiar with the unique academic, behavioral, and emotional issues that custodial grandchildren bring to the classroom [155]. If possible, school forms that typically ask questions about family members and guardians should include grandparents, as this will help teachers and administrators identify custodial grandparent households [156]. The same holds true for health records, which should include grandfamilies as a family structure so grandparents do not have to continually explain the circumstances [218]. Education should be provided to teachers, school personnel, and guidance counselors about the unique needs of these family structures and how they can help grandparents navigate the school system. Other recommendations include implementing Grandparent Teacher Associations and open houses to foster open dialogue and partnerships and to reduce marginalization experienced by custodial grandparents [156,157]. This provides custodial grandparents the opportunity to meet teachers and be involved in decision making regarding their grandchildren's academics.

Custodial grandparents who are still working will need to resolve the issue of child care. Workplace policies for child care and parental leave should also apply to custodial grandparents. Workplaces should review their human resource policies to address the fact that some of their employees may be custodial grandparents and adjust the policies as necessary to meet their needs [88].

Child care, transportation services, and medical and legal services are ongoing concerns. Like younger parents, custodial grandparents require respite from parenting, but accessing babysitting or child care can be difficult [88,189]. Community support groups can assist grandparents to cope with their new roles and the conflicting emotions they may have toward their adult children. Because they often feel isolated, custodial grandparents benefit from spending time with peers who have been in similar roles. Grandparents may also need information about how to obtain supportive and financial resources [4,189]. Linguistic and culturally appropriate resources for these services include senior citizen centers, community centers, churches, health clinics, and other community agencies [9,153,189]. The main obstacle to the use of services by custodial grandparents is lack of knowledge; education regarding available services and how to access them is paramount [89,113]. In addition to accessing information, custodial grandparents often need help with navigating social service agencies, trauma-informed care, legal assistance, financial help, respite care, and Child Protective Services [18,189,219]. Unfortunately, many caregivers encounter barriers that can feel overwhelming, stemming from stigma, discrimination, limited familiarity with complex institutional systems, and restricted access to services—particularly when their caregiving role is informal [219].

MICROSYSTEM

The microsystem level involves issues related to the family unit or the immediate environment of the child. This includes the physical characteristics of the immediate family, interactions within the family system, and the child's perception of the familial environment. As discussed, many custodial grandparents are concerned about discipline and parenting skills and style. Although they have parented before, the challenges and influences for children today are likely vastly different. For example, video games, the Internet, and social media were probably not major considerations when grandparents were first parenting [90,219]. Even school work can be different and challenging.

Parenting grandchildren is often complicated by the dynamics unique to children's sense of loss and grief of the absence of their biologic parent either through death, incarceration, substance abuse, neglect, or some other painful circumstance, all of which require more emotional resources from the grandparents [4,115]. Therefore, human service agencies can offer family-strengthening skills and parenting classes targeted to custodial grandparents with educational sessions on topics like intergenerational living, generational patterns impacting parenting and communication, disciplining tactics, communication strategies, renegotiating roles, and boundary and limit setting [173]. Social issues like school violence, bullying, drugs, and sexuality may be unfamiliar to custodial grandparents and should be addressed [4,91].

Furthermore, grandparents may benefit from education on problem solving, communication strategies, and handling conflicts with their grandchildren's biologic parents, especially if they do not have legal guardianship of the grandchildren [116]. Targeting interventions to grandparents does not necessarily mean that parents cannot or should not be involved. Ideally, interventions should be offered to both the grandparents and parents so the children are getting consistent messages. Interventions should harness grandparents' existing strengths and empower them [153].

ONTOLOGIC LEVEL

The ontologic level refers to factors inherent to the individual, such as developmental history, skill level, behavior patterns, and personality structure. Some children come to their grandparents with negative and unstable relationships with their parents, and this may affect their relationships with their grandparents, peers, and teachers. These children may require social skills education covering cooperation, intimacy, and competition to help them establish friendships and interact with adult authority figures [90].

Some grandchildren may have difficulty forming strong relationships with their grandparents for a variety of reasons [92]. First, the initial quality of care by their biologic parents will influence their ability to form a relationship with their grandparents. The child's age, developmental stage, and previous attachment experience will also impact the quality of their relationships with their custodial grandparents. Previous experience and exposure to their grandparents is a factor in bonding as well. For example, if a grandparent has intervened on multiple occasions, the child will likely trust the grandparent to protect them. Finally, grandparents' own circumstances and lifestyles will affect how grandchildren will respond. A financially stable household and a strong support network will make it easier for the grandchildren to adjust [92].

In light of the situations that lead to children living with their grandparents, it is understandable that many have significant emotional and psychological issues (e.g., depression, oppositional-defiant disorder), behavioral problems (e.g., poor concentration, hyperactivity, tantrums), and academic struggles (e.g., truancy, poor grades, chronic absences). In one study, children who lived with grandparents exhibited higher levels of emotional and behavioral problems compared to children who lived with their biologic parent(s) [93]. School personnel may benefit from training regarding the psychological and sociologic consequences of underlying trauma experienced by children living with grandparents [157]. As a result of these academic, psychological, and behavioral issues, children residing with their grandparents are also more vulnerable to using substances [220]. Individual or group counseling is beneficial for these children as is social skills, communication, and problem-solving training.

Some children come to grandparents with special needs, such as autism spectrum disorder, serious emotional disturbances, or intellectual and cognitive disabilities [94]. Undoubtedly, these children will require a tremendous amount of educational, psychological, and behavioral services and interventions, and grandparents may not have a complete understanding of their needs. Counseling is recommended for grandparents to help them cope with the emotional toll, and supportive and case management services are necessary to assist grandparents to access services that are not very well coordinated [94]. Peer support groups for custodial grandparents can also reduce the sense of isolation. Mutual assistance, sharing of resources and information, and supportive listening make members feel less alone and introduce new perspectives. Support groups can bring in guest speakers (e.g., lawyers, social workers, teachers, physicians) to provide concrete information [158].

Custodial grandparents also often need assistance interpreting, sorting, and evaluating the information they receive. How information is processed depends on timing, and it may be necessary to give information multiple times before it is incorporated [115].

Teaching resourcefulness skills and parenting skills are also crucial [117,157]. Resourcefulness skills encompass behavioral and cognitive strategies, including self-help and help-seeking skills. In a study with 102 custodial grandmothers, resourcefulness training helped reduce the women's stress and depression and improve quality of life [117]. Empowerment-focused interventions that strengthen grandparents' selfefficacy, enhance their problemsolving and goalsetting skills, and provide opportunities to share experiences with peers can lead to improved relationship quality with their grandchildren [221]. Holistic interventions targeted to both custodial grandparents and grandchildren and engaging in diverse stakeholders (e.g., school personnel, social service caseworkers, lawyers, physicians, psychiatrists) will be most effective [185].

11. INTERPROFESSIONAL COLLABORATION AND PRACTICE

Interprofessional collaboration and practice (ICP) has been identified as effective in meeting the complex and multifaceted needs of custodial grandparents and their grandchildren. ICP is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for clients/patients and their families to improve health, mental health, social, and/or family outcomes [190]. Services are delivered by a host of providers, including school personnel; social workers, nurses, and other health practitioners; child welfare workers; mental health professionals; legal professionals; religious and spiritual stakeholders; community agencies; and cultural experts [191]. These services might include case management, educational services, psychosocial support, and psychological, emotional, and health services [191].

With ICP, instead of providers working in silos, they work collaboratively so services are delivered in a holistic manner. This type of collaboration can be viewed as a continuum of shared knowledge, skills, and expertise whereby providers are involved in shared decision-making on meeting the needs of the clients and their families [193]. Each discipline will offer their unique lens in viewing situations and by collaborating, providers have the opportunity to merge their expertise [194]. For example, in one study, grandparents reported being fearful that their grandchildren may be taken away because of their lack of knowledge of the child welfare system and their legal rights [192]. This is compounded when professionals are insensitive to this form of nontraditional family system, resulting is stigmatization. However, this is effectively mitigated by ICP, which allows sharing of knowledge across disciplines to address needs in a systematic and coordinated manner.

12. CONCLUSION

Grandparents are frequently willing to assume guardianship of their grandchildren to avoid them being removed from their family and placed with strangers. Despite this, grandparents do not plan for raising children and all its associated tasks and challenges at this stage in their lives. The stresses of assuming a parenting role, including fatigue, concerns about new technology and social issues, financial strains, and loss of expected life stage, can have negative effects on custodial grandparents' lives. However, many grandparents view this time as an opportunity to spend time with their grandchildren, to grow from their past parental experiences and the wisdom they have acquired, and to restore meaning to their lives.

Overall, the social service, child welfare, education, medical, and legal systems are fragmented when it comes to providing services to grandparents in such situations. Many custodial grandparents need help but are unaware of the services available, if they are eligible, and how to access them. Behavioral health professionals and other practitioners can play a vital role in assisting custodial grandparents to navigate these complex systems.

13. RESOURCES

American Bar Association Center on Children and the Law

Can provide legal advice on custodial grandparents and other legal issues related to children.

https://www.americanbar.org/groups/public_interest/child_law

Child Welfare Information Gateway

Provides access to print and electronic publications, websites, databases, and online learning tools for improving child welfare practice, including a page devoted to grandparents raising grandchildren.

https://www.childwelfare.gov

Child Welfare League of America

A powerful coalition of hundreds of private and public agencies serving vulnerable children and families.

https://www.cwla.org

Children's Defense Fund

A nonprofit child advocacy organization that works to ensure a level playing field for all children.

https://www.childrensdefense.org

Center for Law and Social Policy (CLASP)

An organization that develops and advocates for federal, state, and local policies to strengthen families and create pathways to education and work.

https://www.clasp.org

U.S. Department of Health and Human Services

Administration for Children and Families

Responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities.

https://www.acf.hhs.gov

Eldercare Locator

A public service of the U.S. Administration on Aging that connects elders to services.

(800) 677-1116

https://eldercare.acl.gov

Generations United

A national membership organization focused solely on improving the lives of children, youth, and older people through intergenerational strategies, programs, and public policies.

https://www.gu.org

Grandfamilies State Law and Policy Resource Center

A national legal resource in support of grandfamilies both within and outside the child welfare system.

http://www.grandfamilies.org

National Caregiver Support Program (NFCSP)

Offers a range of services to support family caregivers.

https://acl.gov/programs/support-caregivers/national-family-caregiver-support-program

National Center on Grandparents Raising Grandchildren

Seeks to inform professionals, decision makers, and the public on the unique needs, challenges, and strengths facing many custodial grandparent families.

https://wmich.edu/grandparenting

Grandparents Raising Children Support Group

https://www.dailystrength.org/group/grandparents-raising-children

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