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Grandmothers, Caregiving, Families and Transitions

Grandmothers, Caregiving, Families and Transitions. Carol Musil , PhD, RN, FAAN, FGSA Professor of Nursing Case Western Reserve University Cleveland, OH 44106 June 12 2012 Children’s Bureau HHS Grantee Annual Meeting

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Grandmothers, Caregiving, Families and Transitions

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  1. Grandmothers, Caregiving, Families and Transitions Carol Musil, PhD, RN, FAAN, FGSA Professor of Nursing Case Western Reserve University Cleveland, OH 44106 June 12 2012 Children’s Bureau HHS Grantee Annual Meeting Research support: American Nurses Foundation, NIH NIA R15AG15438, NINR RO1NR005067-10

  2. Grandmothers as Caregivers 1990’s Emergence of Grandmothers Raising Grandchildren • Parents unable or unwilling to care for children • Crack cocaine or other drugs • HIV/AIDS or other health problems • Incarceration or death of parents Little known about the phenomenon: Who was affected How the situation would unfold What these grandmothers and their families were like Early evidence suggested stress, depression and health problems Census 2000 4.1 million US homes (3.9%) include grandparents and grandchildren • 1.4 million US homes have no parent present; 91% of such homes have a grandmother • Drug, alcohol abuse, jail, mental or physical health problems • 3.7 million multigenerational homes • Teen pregnancy, unmarried mother, divorce, job loss, financial problems, “just live together”

  3. Studies to date1995 Health of Grandmothers • Pilot study: Grandmothers raising grandchildren v. grandmothers in multigenerational homes • Convenience sample metropolitan Cleveland OH N=90 • Grandmothers raising grandchildren (n=58) urban women of color • Grandmothers in multigenerational homes (n=32) • Mailed questionnaires: parenting stress, support, coping, depressive symptoms, anxiety

  4. 1996-7 Health of Grandmothers: A Follow-up(ANF Journal of Women and Aging 2000 ) • 10 month follow-up of the prior sample; added health practices • 74/90 (82%) completed questionnaires • All: increased parenting stress • Primary caregivers: ↑parenting stress and ↓ instrumental support • Continued ↑ depression and stress • Some grandmothers changed care giving status to grandchildren

  5. To Grandmother’s House We Go and Stay C. Cox Ed. Springer 2000 • Written comments by grandmothers: • Active coping: communications and discussions with other grandmothers; reading, seminars, workshops; involvement in local and state efforts for kin-caregivers • Work as coping resource • Finding reward … “joy of inner peace and genuine contentment” • Prayer/spirituality: 10% of sample

  6. 1998-2001 Health of Grandmothers: A comparison by caregiver status (R15 NIA AG15438) • Cross-sectional convenience sample N=283 • 86 primary, 85 multigenerational, 112 non-caregivers to grandchildren • Participants from 8 counties or w/in 50 miles of Cleveland OH • Mailed questionnaires • Are there differences between groups in stress, health, coping, support, depression, self-rated health • Do coping and support mediate or moderate the effects of stress on health? • What are the daily stresses, health problems and health actions of a sub-sample of grandmothers in each caregiver group?

  7. Quantitative findingsJournal of Aging and Health 2002 • Primary and multigenerational: more stress • Primary: lower self-rated health, more health problems and health visits • Multigenerational: more instrumental support • Coping affected both depression and self-rated health: active coping moderated the effects of stress on health • Subjective support: main effects on depression and self-assessed health, and mediated the relationship between stress and health

  8. Grandmother’s Diaries: A Glimpse of Daily LivesInternational Journal of Aging and Human Development To explore how the specific daily stresses of primary caregivers to grandchildren and grandmothers in multigenerational homes differ from those of grandmothers who are non-caregivers to grandchildren

  9. Method • Three week health diaries • 86% (243/283) interested in the diary • Systematic Random Sub-sample (n=64) • Primary (n=21) • Multigenerational (n=18) • Non-caregivers (n=25) • Diary participants • 73% white, 27% women of color • 39-85 years of age • Mean = 57 years

  10. Content Analysis • Transcribed verbatim and imported to NUD*IST 4 • Initial categories: Health, Stress & Symptoms • Collaborative, iterative process • Stressors were groupedinto categories. Child-rearing issues School routines Family tasks School progress Activities Grandchild’s health Effects on personal life Situational worries Other worries Stressful interactions: with grandchildren with others • The number of primary, multigenerational and non-caregiver grandmothers reporting each stressor was counted

  11. Grandchild health problems • “My grandchild’s emotional problems—bipolar and ADHD; problems with behavior at home and in school” • “My granddaughter’s speech and social” • “My daughter and grandson infected with AIDS” • “Granddaughter has a bleeding disorder…her mom and dad had another baby and she wants to be with them. They aren’t able to support her.”

  12. Grandmother’s HealthHealth and caregiving • “Since I’m not feeling well, how much longer will I be able or choose to take care of the girls…?” • “The greatest worry or concern is how long I will be able to care for (my granddaughter) and/or who will take care of her then?”

  13. Group Differences in stresses • School and daycare, healthcare, • Driving, brownie vests, school pictures, homework • Stressful interactions • With children, grandchildren • Situational worries: crossed all groups • Instability of children and grandchildren changing jobs, boyfriends, living arrangements • Drugs, Columbine • Other worries • Health (66%) • Finances

  14. Thoughts on grandmother stresses • Grandmothers focus on their connections with others • They may be reluctant to share concerns with family members, especially their own health concerns

  15. Parenting StressJournal of Mental Health and Aging 2002 • Matched (race, employment, marital status) sample of mothers ( J. Youngblut maternal employment sample) and grandmothers • Main and interaction effects of caretaker status, employment status, and race on parenting stress • Grandmothers raising grandchildren: more parenting stress and distress than mothers • Non-employed mothers had more negative perceptions of children and difficult interactions • White women and those with older children reported more stress and more difficult interactions

  16. Intergenerational Caregiving to Youth-at-risk (2001-2010 NINR RO1NR005067) • Studies show that grandmothers raising grandchildren may have worse physical and mental health than other grandmothers • Limited longitudinal data about the health effects of caregiving over time. • This study examined differences over two years in the physical and mental health of grandmothers as grouped by caregiving status to grandchildren.

  17. Resiliency Model of Family Stress • Resistance Resources • Instrumental Social Support • Subjective Social Support • Family Demands • Family life events • Intra-family strain • Individual & Family Health • Family Functioning • Depressive Symptoms • SF-36 Physical and Mental Health • Problem solving/coping • Resourcefulness • Demographics • Age • Race • Marital Status • Work

  18. Longitudinal Design • Random sample with supplemental convenience sampling of primary caregiver grandmothers • Grandmothers reported on their health and well-being in 3 mailed questionnaires one year apart • Grandmothers with caregiving status changes invited to qualitative interviews Sample • Grandmothers raising grandchildren (n=183) • Grandmothers in multigenerational homes (n=136) • Grandmothers not living with grandchildren (n=167) • Of the 486 participants, 440 continued in year 2 and 435 continued through year 3

  19. Measures Stress and Reward: Appraised Stress and Appraised Reward visual analog scales (Musil & Ahmad, 2002) Family Functioning: The General Family Functioning and Family Communication subscales from the Family Assessment Device (Epstein, Baldwin & Bishop, 1983) Life Events: Intra-Family Strain and Stressful Family Life Events (FILE) (McCubbin, et al, 2001) Support: Instrumental Social Support and Subjective Social Support from the Duke Social Support Index (Hughes, Blazer & Hybels, 1980) Resourcefulness: Rosenbaum’s Self Control Schedule (modified by Zauszniewski) Depression: 20 item CES-D (Radloff, 1977) SF-36 : Mental and Physical Health [General Health, Physical Health, Role Physical, Bodily Pain, Vitality, Social Functioning, Role Emotional, and General Mental Health] (Ware, 1993)

  20. Family Inventory of Life Events Subscales • Intra-family strain (11 items α =.78; α =.72 McCubbin) • increase in conflict among children • increased disagreement about a family member’s friend(s) or activities • a family member appeared to depend on alcohol or drugs • Financial strains (2 items α =.53. α =.60 McCubbin) • increased strain on family money for medical and dental • increasing debts due to overuse of credit cards • Work-family transitions (6 items α =.58 ; α =.55 McCubbin) • a member lost or quit a job • family moved to a new home • Illness and family care strains (4 items α =.56; α =.56 McCubbin) • child became seriously ill or injured • increased difficulty managing a chronically ill or disabled member • Family legal violations (4 items α =.46 (α =.62 McCubbin). • incidents of physical abuse or aggression • a member went to jail or juvenile detention

  21. Resourcefulness: Rosenbaum’s Self control Schedule Modified 25 items (Zauszniewski 2006) e • Self-efficacy and self-control • I can’t avoid thinking about mistakes I made in the past • I often find it difficult to overcome my feelings of nervousness and tension without outside help • Although it makes me feel bad; I cannot avoid thinking about all kinds of possible catastrophes • When I am feeling depressed, I try to think of pleasant events • When in a low mood, I try to act cheerful so that my mood will change • When an unpleasant thought is bothering me, I try to think about something pleasant

  22. Family Assessment Device: General Family Functioning(Epstein, Baldwin, & Bishop, 1983) • 12 items, lower score better functioning • “In times of crisis we can turn to each other for support,” • “Individuals are accepted for what they are” • “We are able to make decisions about how to solve problems

  23. Cross-sectional Questions:Depressive symptomsGrandmother caregiving, family stress and strain and depressive symptoms. Western Journal of Nursing Research, 31(3), 389-408. • Are there differences in specific family life stresses by caregiving status to grandchildren • GM raising grandchildren • GM in multigenerational homes • GM non-caregivers to grandchildren? • Do grandmother resourcefulness and social support reduce the effects of family life stress and caregiving to grandchildren on depressive symptoms?

  24. Questions and Methods • We hypothesized that grandmother’s depressive symptoms would be affected by: • Contextual factors: age, grandmother’s race, marital status, work status • Caregiving status • Family stressful life events • Grandmother resourcefulness • Subjective and Instrumental social support • We used ANOVA and Hierarchical Multiple Regression

  25. ANOVA: Life Events

  26. ANOVA: Study Variables

  27. Among all grandmothers: What affects depressive symptoms • Intra-family strain: strong association w/symptoms for all groups • Employed and older grandmothers: fewer symptoms • Multigenerational homes: fewer symptoms • Life events: overshadowed by strain, but legal issues had a significant effect • Subjective support and resourcefulness: reduced effects of strain on symptoms

  28. Grandmothers’ and Family Functioning: Perceptions of FamilyJournals of Gerontology Social Sciences 2006 • See their role as • an extension of the parent role • more significant than other non-family adult roles • view families as including adult children, their spouses and grandchildren • feel responsible for grandchildren’s successes and failures, as they do their own children • Desire to (and many do) have good relationships with adult children

  29. Predictors of Family Functioning • Perception of better family functioning • Greater Resourcefulness • Role reward • Subjective and instrumental support • Perception of worse family functioning • Intra-family strain • Family life stresses

  30. The element of time Musil, C., Warner, C., Standing, T., Wykle, M., Zauszniewski, J., & Bohne, A. (2004). Grandmothers, caregiving to grandchildren and families: changes over one year. The Gerontologist, 44, 280 • Grandmothers concerns and worries over 12 months time

  31. Grandchildren and their parents • “Children’s parent. Father in jail. We filed for custody” (12 months later) • “.......We received legal custody of grandchild. Father in jail, due out in September. Visitation will be different for him. Don’t know how that will be resolved.” • “My grandson‘s mom (my daughter) wants to come in and out of his life and now is getting married to an abusive man and they are on drugs” • “..…my daughter is trying to get custody back from me after I had him his whole life…” (12 months later)

  32. Family conflicts:Jealousy • “…conflict between myself, daughter and my grandchildren which I am raising, and my youngest son and family. A lot of jealousies on his part.” • “My youngest daughter is jealous of my granddaughter I am raising.”

  33. Family conflictSpouse and family • “Husband’s depression and alcoholism” ………“My husband and I are no longer dealing with each other. He treats the children poorly. He’s given to depression….”(12 months later) • “The constant bickering between spouse and grandson. I feel at times my spouse is immature and only wants to prove a point.”

  34. Grandchildren and parents… custody issues • “If the children are going back to their mother or going for adoption. They have been here almost two years.” • …..“The children we are about to adopt…if we are going to let them keep their last name and ours, or they just get our last name.” (12 months)

  35. Childrearing Concerns • “Trying to keep our granddaughter on the right track after being diagnosed with alcohol and drug syndrome.” • “Being able to teach granddaughter to control her anger and to not be so mean to people, to be beautiful on the outside as well as on the inside…” (12 months later)

  36. Grandmother participation patterns over 24 months • Grandmother participants Time 1 n= 485, Time 2 n =440 and Time 3 n= 435 • Grandmothers participated T1-T3 n=419 • Grandmothers in same group Times 1 & 3: n=350 • Grandmothers raising grandchildren: primary n= 146 • Grandmothers in multigenerational homes n=62 • Grandmothers in separate residence n= 142 • Grandmothers with changes in caregiving status during the course of the study: n=100

  37. Analyses • Repeated Measures ANOVA and Proc Mixed to examine changes over time and differences between caregiver groups

  38. Group and Time (24 months) Effects • Group effects • Primary caregivers: most stress, intra-family strain, depressive symptoms and perceived problems in family functioning; the worst physical health and the least reward and subjective support. • Grandmothers in multigenerational homes: the most instrumental support. • Time Effects • Worsening self-rated and overall physical health • Increased stress over the three time points. • Subjective support: lower at Time 1 • Instrumental support : highest at T1

  39. Intra-family StrainT1-T3

  40. General Family FunctioningT1-T3

  41. CES-D Depressive symptomsT1-T3

  42. Caregiving status changes 117 changes reported by 100 grandmothers • Primary to multigenerational (n=10) • Primary to non-caregiver (n=16) • Multigenerational to primary (n=9) • Multigenerational to non-caregiver (n=56) • Non-caregiver to primary (n=10) • Non-caregiver to multigenerational (n=16)

  43. Reasons for caregiving transitions • Associated primarily with adult child problems • Moves into and out of caregiver groups reflected the resolution of existing problems or the development of new problems. • Mental health • Substance problems • Financial /Housing issues • Marital / relationship issues • Military deployment

  44. Problems in family functioning over two years:Multigenerational grandmothers at T1

  45. Problems in family functioning over two years:Noncaregiver grandmothers at T1

  46. Changes in mental health over two years:Multigenerational grandmothers at T1

  47. Evaluating the effects of Switching Caregiver Groups .. Transitions in responsibility: -2 to 2 -2: Primary to Non-caregiver -1: Multigenerational to Non-caregiver or Primary to Multigenerational   0: No change;   1: Non-caregiver to Multigenerational or Multigenerational to Primary   2: Non-caregiver to Primary

  48. Transitions in caregiving status MusilCM, Gordon NL, Warner CB, Zauszniewski JA, Standing T, Wykle. (2011). Grandmothers and Caregiving to Grandchildren: Continuity and Change over 24 Months.TheGerontologist,51(1):86-100. • Switching to higher levels of caregiving: • Worsening physical health • Increased stress, intra-family strain and perceived problems in family functioning. • A (non-significant) trend toward worsening of self-rated health with increases in caregiving responsibility.

  49. Grandmothers’ Changes in Caregiving Status: Qualitative • Purposive Sampling • Telephone interviews with 21 grandmothers who changed their caregiving status • Hermeneutic Phenomenology • -to examine the meanings that changes in caregiving status have for grandmothers • Grandtour question: • -“Tell me the story of the changes in your family during the past year?” • Verbatim transcriptions of audio-taped interviews • Thematic Analysis:-Giorgi method

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