/ Custodial Grandparent Families: Steps for Developing Responsive Health Care Systems


Grandparent-headed families represent an ever-increasing population in our culture, necessitating that health care practitioners become more aware of the special needs of both caregiving grandparents and their grandchildren. The authors discuss concerns of custodial grandparents, grandparented children, and steps for developing responsive health care systems.

Key Words: Custodial grandparent, health care systems, kinship care, grandparented children

    1. Barbara Grinwis, M.A. is Academic Career Specialist, Department of Physician Assistant, Ellsworth Hall, A307, Western Michigan University, Kalamazoo, MI, 49008. Electronic mail may be sent via the Internet to barbara.grinwis@wmich.edu.return to text

    2. Andrea B. Smith, MSW, Ph.D, is Associate Professor, Department of Teaching, Learning, and Leadership, Western Michigan University.return to text

    3. Linda L. Dannison, Ph.D., CFLE, CFCS is Professor and Chair, Department of Family and Consumer Sciences, Western Michigan University.return to text

    Grandparents raising grandchildren is not a new phenomenon. Elders have traditionally played important roles in family support and child rearing. The major differences are in the numbers—an over 60 percent increase during the 1990s—and in the social conditions causing the escalation of this family typology. High rates of adolescent pregnancies, drug and alcohol abuse, incarceration, physical and/or mental illness, unemployment, child abuse and neglect, desertion, divorce, and HIV/AIDS are all contributing social factors (Casper & Bryson, 1998). Nearly 5.5 million, or 7.7 percent of all American children, are currently being parented by their grandparents (U.S. Census Bureau, 1999). Grandparents raising grandchildren represent all socioeconomic levels and ethnic groups (Smith, Dannison, & Vacha-Haase, 1998; Smith & Dannison, 2003). Custodial grandparent families represent an ever increasing population in our culture, necessitating that health care practitioners become more aware of the special needs of both caregiving grandparents and grandchildren.

    Improving life skills in children being parented by grandparents is often challenging due to the grandparents' fears (Jones & Kennedy, 1996). Many grandparents raising grandchildren have few resources and limited choices related to childrearing practices, discipline strategies, nutrition, and basic health care. Managing grandchildren's multiple needs challenges many grandparents financially, physically, and emotionally; yet their fears of not meeting the perception of a particular standard of care makes them reluctant to acknowledge and discuss their shortcomings. Grandparents may believe that revealing behavioral or social problems endangers their custody status. Fear of losing their grandchild to the court system may lead grandparents to not disclose that they are fulfilling a caregiving role. This reticence poses particular problems for health care providers, who may not realize the extent of the grandparents' involvement or the challenges they face on a daily basis. Insuring the health and well being of both grandparents and grandchildren—populations which are often over looked within the health care arena—is an issue deserving greater attention.

    Concerns of Grandparents

    The relationship of grandparent to grandchild is second only to that of parent to child. When the parent-child relationship is nonexistent or jeopardizes the safety and well being of the child, the grandparent-grandchild relationship moves to the forefront. "Grandparents and grandchildren may face significant problems with respect to emotional adjustment and activities of daily living when these families are formed. The new family living arrangements are often borne of markedly stressful circumstances. Not surprisingly, then, the circumstances may disrupt the emotional equilibrium of both the grandparents and the grandchildren" (Edwards, 1998, p. 173).

    Assuming a parental role leads to changes in the grandparent's life that may be unanticipated and often unwanted. Many custodial grandparents do not fit the stereotypical notion of senior citizens actively enjoying retirement pursuits. For example, Minkler and Roe (1993) found that the age of custodial grandparents ranged from 41 to 71, with a median age of 53. Another study found that over half of custodial grandmothers were caring for two or more young children, and approximately half were grandmothers without partners (Creighton, 1991). Grandparents caring for grandchildren are more likely to be poor and are less likely to have graduated from high school or be employed (Casper & Bryson, 1998).

    Responsibilities associated with this new role may impact grandparents' leisure, friendships, health, work, finances, and retirement. Family stressors are prevalent. Custodial grandparents often find themselves caring for their own aging parents and struggling to maintain a relationship with their adult child while trying to care for one or more grandchildren (Smith et al., 1998). Many feel highly ambivalent about assuming a new relationship with their grandchild. "Often grandparents are gaining a grandchild but losing their own child. In addition, grandparents are facing double jeopardy as they question their own sense of inadequacy: What have they done wrong to have children who cannot care for their own children, and are they competent enough to deal with raising children again?" (Pinson-Millburn, Fabian, Schlossberg, & Pyle, 1996, p. 549). Grandparents may also grasp this relationship with their grandchildren as an opportunity to undo perceived parenting mistakes, either real or imagined. This situation may result in a grandchild who is over-indulged but more often leads grandparents to adopt a "woodshed mentality" which couples unrealistic behavioral expectations with frequent physical punishment (Smith & Dannison, 2002).

    Custodial grandparents find that they are often overlooked (Landry-Meyer, 1999), that they rarely seek out this new role (Smith et al., 1998), and that they become disconnected from their chronological age with changes in both their new social role and unexpected developmental tasks (Landry-Meyer, 1999). Many caregiving grandparents also have health concerns and needs unique to their stage in the life cycle. Major issues of emphasis include stress and depression; but parenting knowledge, competence, and financial well being must also be determined.

    Concerns of Grandchildren

    Children living in grandparent-maintained homes are different from those children living in parent-maintained households. Recent statistics indicate that nearly 4 million, or 5.5 percent of American children, live in grandparent-maintained households (Casper & Bryson, 1998). In Michigan, over 70,000 grandparents claimed primary responsibility for their grandchildren (Grand Rapids Press, 2002). Over half of grandparented children begin residing with grandparents before the age of six (U.S. Census Bureau, 1996). Children in the care of grandparents are often very needy due to a combination of congenital and environmental factors. They are more likely to have been exposed prenatally to drugs and/or alcohol, have experienced abuse and/or neglect, and have difficulties forming attachments (Minkler & Roe, 1993; Smith et al., 1998). While many act out inappropriately, others may cope by becoming either withdrawn, non-verbal, or "too good to be true."

    Grandparented children often deal with many troubling and confusing emotions. Grief is a commonly experienced emotion for grandchildren as they struggle to adjust to the dual losses in their lives. Children in the care of grandparents have not only lost a parent but also have suffered the loss of their "traditional" grandparent (Landry, 1999; Smith et al., 1998). Other commonly experienced feelings include fear, guilt, embarrassment and anger (Dannison & Smith, 2002; Smith & Dannison, 2002; Smith et al., 1998). Children in the care of grandparents also experience higher levels of behavioral and emotional problems than do children living with biological parents. Over 26 percent of children in grandparent-maintained households have clinically significant levels of emotional and behavioral problems, including learning disabilities, mental impairment, and school performance difficulties, compared to 10 percent of children in the general population (Dubowitz, Feibleman, Starr, & Sawyer; Sawyer & Dubowitz, 1994). Some grandchildren "defy authority and strain limit setting. They may also try to push grandparents away since they feel that others have abandoned them. Their inner feelings reflect a chaotic struggle over grief, guilt, anger, fear, embarrassment, or hopefulness for the parents' return" (Brown-Standridge & Floyd, 2000, p. 189).

    Professionals need to remember that these newly created families must have a strategy and plan for dealing with these past histories—and that the damage that may have been inflicted by parents—so that the newly emerging grandparent-grandchild relationship is not haunted and impeded by past incidences and relationships. Family practitioners also need to recognize and understand the life experiences that caused grandparented children to be placed in grandparents' care and the potential ramifications these factors may have on their developmental outcomes. Figure 1 illustrates some of the problems experienced by the birth parents, the behaviors/diseases which may be seen in children, and the consequential outcomes for these children if they are left untreated.

    Parental substance abuseFetal alcohol syndrome, ADD/ADHD, substance abuse & pregnancyPoor academic performance, grief & loss, embarrassment, anger, fear
    Child abuse/neglect, Teen unable to parentDepression, anxiety, post-traumatic stress, other psychiatric disorderInadequate coping skills, poor social supports, suicide, fear, anger, grief & loss
    Unemployment/divorceDepression, anxiety, post-traumatic stressInadequate coping skills, self-blame or guilt, embarrassment
    Death/AIDS/HIVDepression, anxiety, post-traumatic stressShame and isolation, anger, grief & loss, embarrassment, fear
    Imprisonment of parent(s)Emotional/behavioral problems, post-traumatic stressShame & isolation, anger, grief & loss, embarrassment, fear
    Figure 1. Note: Adapted from Pinson-Millburn et al., 1996; Smith et al, 1998

    Steps for Developing Responsive Family Practices

    Family practicioners can do many things to promote health and wellness in nontraditional family units. Instrumental services, including increased worker contracts, positive parenting classes, therapeutic child care, respite care, and specialized services such as transportation tokens or vouchers are needed by many custodial grandparents (Brooks & Barht, 1998). Providing a safe, nurturing, and healthy environment for both grandparents and grandchildren optimizes the children's development and positively influences their chances for success, both individually and as a family unit (Smith et al., 1998). Steps that practioners can take to positively support custodial grandparent family members include:

    1.Identify grandparents who have taken on this parenting role. Specifically define what role the grandparent is playing in the caregiving as well as the role, if any, that the biological parent(s) fulfills. Don't assume that because the grandparent always brings the child to the office that she is doing the working mother a favor. Learn who is responsible for the child. Identify the legal relationships.

    2.Attend to needs specific to the grandparent. Depression is common among custodial grandparents (Smith & Dannison, 2001). Custodial grandparents are unique among their peers and as a result often feel isolated and lonely, which increases their psycho-social problems. Screening by standardized assessment may be beneficial, but health care providers also need to attend to changes in mental status, cognition, and physical ability.

    3.Educate the custodial grandparent on realistic performance expectations and normal parenting skills. Grandparents' lack of access to support and educational resources may lead them to maintain unrealistic demands for developmental skills beyond the abilities of the child. They may view corporal punishment as an appropriate standard and end up alienating the children they are attempting to nurture. Grandparents also may be excessively permissive out of a sense of guilt or misguided compassion. Either approach will be detrimental to grandchildren who are in need of guidance and security.

    4.Suggest involvement in available parenting or social support programs. These services can help all members of custodial grandparent families overcome the difficulties they may experience within the school, court, or social service systems. Other benefits are the potential availability of respite and opportunities to interact with others who are experiencing similar circumstances.

    5.Assist grandparents in advocating for services to meet the special needs of their grandchildren. Many custodial grandchildren have specific physical, cognitive, or social needs that must be identified and treated. Provide grandparents with specific information about their grandchild's condition and instructions about how best to obtain services. Making this task as easy as possible—by providing grandparents with phone numbers, contact names, and established appointment times—will help grandparents take the first steps toward obtaining necessary services and/or treatment.

    6.Demonstrate concern regarding financial stability. Anxiety about money creates a great deal of stress for many grandparents. Determine ways that medical costs can be decreased. Are the prescribed medications (for either grandparents or grandchildren) not being purchased because they are unaffordable? Consider providing them with samples of medication to alleviate some of the financial stress. At the same time, determine if there are adequate financial resources to provide for basic needs including food, heat, and necessary clothing. Are grandchildren eligible for state provided programs, including Medicaid, MiChild, WIC, school lunch programs, or other existing services?

    7.Provide nutrition education and develop exercise and personal wellness goals for both grandparents and grandchildren. Reliance on outdated parenting practices may predispose grandparents to offer empty calorie foods, use food as a reward, and depend on the television as a babysitter. A dietary consultant may influence positive changes in the home. A simple, attainable exercise program can not only improve personal well being but can also be used by both grandparent and grandchild for stress relief and a time of positive interaction.

    8.Discuss immunization schedules, counseling, and well-child visits, which are proactive tenets of medicine. Provide a resource list of area agencies that offer free immunizations and well-child check-ups and organizations that offer counseling services at a reduced or sliding fee scale.

    9.Take time to discuss the importance of established routines for meals, sleep, and schoolwork. Emphasize the necessity of boundaries and consistency for all children, but especially for children coming from chaotic past environments. Assist grandparents in developing a schedule for each day and also for each week. Planning fun times together on a regular basis (e.g., Tuesday is Pancake dinner night; Friday afternoons is when we go to the library) will enable grandchildren to establish a sense of family history and traditions that will enhance this new family relationship. Encourage consistency within the daily schedule.

    Affirm grandparents' commitment to raise their grandchild. The task they are undertaking is daunting and they will receive little recognition or feedback for their efforts. Offer the support necessary to insure their success and to enhance developmental outcomes for the children in their care.


    Numbers of grandparent-headed families continue to rise. Social, emotional, cognitive, and physical needs of grandparents and grandchildren often require specialized attention and services within the medical arena. The health care practitioner occupies a unique position to assist grandparents at teachable moments. Providing education, support, information, and linkages to existing services are essential components in maintaining the health and well being of all grandparent-headed family members.


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    Michigan Family Review, 9, 1, 37-44, 2004 © Michigan Council on Family Relations