Children and Youth Services Review 33 (2011) 21382145

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Children and Youth Services Review

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Behavior problems in children raised by grandmothers: The role of caregiver distress, family resources, and the home environment
Susan J. Kelley a,, Deborah M. Whitley b, Peter E. Campos c
a b c

Byrdine F. Lewis School of Nursing, Georgia State University, 140 Decatur Street, Atlanta, GA 30303, USA School of Social Work, Andrew Young School of Policy Studies, Georgia State University, 14 Marietta St., Atlanta, GA 30303, USA Project Healthy Grandparents, Georgia State University, 140 Decatur Street, Atlanta, GA 30303, USA

a r t i c l e

i n f o

a b s t r a c t
Over the past few decades there has been a dramatic increase in children being raised by grandparents due to a variety of factors including child maltreatment, parental abandonment, substance abuse, and incarceration. The purpose of this study is to examine the extent of behavior problems in children being raised by grandmothers and to determine factors in their current environment that are related to child behavior problems. The study draws on McCubbin's resiliency model of family stress, adjustment and adaptation. The sample comprised of 230 children ages 2 to 16 years who were being raised by grandmothers in parentabsent homes. The families were predominantly low income and African American. The grandmothers ranged in age from 37 to 80 years. Grandmothers responded to several self-report measures pertaining to child behavior problems, family resources, social support, and caregiver psychological distress. Trained research assistants completed a standardized observational measure of the home environment. Results indicated that 31.3% of child participants scored in the clinically elevated range for total behavior problems, with 21.3% and 32.6% scoring in the elevated range for internalizing and externalizing behaviors, respectively. Hierarchical regression analyses revealed that of the variables examined, increased psychological distress in grandmothers was most predictive of child behavior problems, followed by less supportive home environments and fewer family resources. Results of the present study underscore the need for interventions that focus on reducing child behavior problems, as well as enhancing the parenting skills of grandmothers raising grandchildren. Findings also support the need for strategies to reduce stress in grandmother caregivers and to improve access to resources needed to provide supportive home environments for their grandchildren. 2011 Elsevier Ltd. All rights reserved.

Article history: Received 26 April 2011 Received in revised form 23 June 2011 Accepted 24 June 2011 Available online 2 July 2011 Keywords: Children raised by grandparents Kinship care Child behavior problems

1. Introduction An increasing number of children are being raised by grandparents, yet limited information is available about their well-being. Between 1990 and 2000 there was a 30% increase in the number of grandparents providing primary care for their grandchildren (Hardy, 2005). This increase has been attributed primarily to rises in parental substance abuse, incarceration, and violence, as well as the trend to place children with relatives over non-relatives when removed by child protective services (CPS). According to the 2010 Current Population Survey, over 1.6 million children are being raised by grandparents in parent-absent households (U. S. Bureau of the Census, 2010). For the purposes of this paper, the term children raised by grandparents refers to children in the primary care of grandparents, whether through informal arrangements or through placement by the public child welfare system.
Corresponding author at: Georgia State University, P.O. Box 3995, Atlanta, GA 30302, USA. Tel.: +1 404 413 1101; fax: +1 404 413 1090. E-mail address: skelley@gsu.edu (S.J. Kelley). 0190-7409/$ see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2011.06.021

Being raised by grandparents can occur abruptly or after a long and difcult period with the biological parents. Oftentimes, there are multiple and interrelated reasons why children are raised by grandparents. The most commonly reported reasons are parental substance abuse, child maltreatment, abandonment, mental illness, incarceration, and homicide (Kelley, Whitley, Sipe, & Yorker, 2000; Smith, Palmieri, Hancock, & Richardson, 2008; Weber & Waldrop, 2000). Thus, many children raised by grandparents have experienced multiple adverse events that place them at increased risk for emotional and behavioral problems. Furthermore, when birth parents are no longer able to provide care, children can experience signicant disruptions in key attachment relationships which are critical to their later social and emotional development (Poehlmann, 2003). Despite a body of research indicating that children in the foster care system experience increased emotional and behavioral problems (Holtan, Ronning, Handegard, & Sourander, 2004; Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004; McMillen et al., 2005), studies focusing on children raised by grandparents are less available. Of the limited studies available, ndings suggest that these children also have increased behavior problems (Campbell, Hu, & Oberle, 2006; Edwards,

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2006, 2009; Ghuman, Weist, & Shafer, 1999). It is important to note that many of these studies are limited by relatively small sample sizes, use of retrospective chart reviews, or use of non-standardized measures. Researchers comparing children raised by grandparents to those raised by a single biologic parent, as well as to those raised by two biological parents, found that children in grandparent-headed homes were perceived to be academically less successful than children in two-parent families, but equally well behaved at school (Solomon & Marx, 1995). When children raised by grandparents were compared to children from single parent families, they were perceived to be better behaved and comparable on academic performance. Other researchers, however, found signicantly higher levels of behavioral and emotional problems with children in the care of grandparents in contrast to the general population (Smith & Palmieri, 2007). 1.1. Caregiver characteristics and home environment Previous studies have found that the family environments of children in foster care can inuence their current well-being. Foster children in better quality and more nurturing home environments manifest fewer behavioral problems than those in lower quality and less nurturing home environments (Dolan, Casanueva, Smith, & Bradley, 2009; Lindhiem & Dozier, 2007; Orme & Buehler, 2001). To date, there is very limited information available on the inuence of family characteristics when grandmothers are the primary care providers. This current study helps to ll this void by examining factors related to the caregiving environment, including caregiver attributes, and the well-being of children raised by grandmothers. Although grandparents raising grandchildren demonstrate remarkable commitment to their grandchildren, the considerable challenges they encounter may hinder their ability to provide a supportive home environment. These challenges often include inadequate nancial resources, the physical demands of parenting later in life, and increased psychological distress. A number of studies indicate that these caregivers tend to be economically disadvantaged, often living in poverty, with minority grandparents experiencing the greatest economic vulnerability (Hayslip & Kaminski, 2005; Minkler & Fuller-Thomson, 2005; Simmons & Dye, 2003). Because the majority of children raised by grandparents are there through informal arrangements, their access to essential resources may be diminished. In one study researchers found that grandmothers raising grandchildren under the auspices of the state foster care system had better access to essential resources than those raising grandchildren through informal arrangements (Goodman, Potts, & Pasztor, 2007). Compared to other substitute caregivers, grandmother caregivers tend to be older (Dolan et al., 2009), averaging around 57 years of age, but frequently reaching into their 60s and 70s (Kelley, Whitley, & Campos, 2010; Smith et al., 2008). A substantial body of literature indicates a propensity for signicant psychological distress among caregiving grandmothers (Fuller-Thomson & Minkler, 2000; Kelley et al., 2000; Scarcella, Ehrle, & Geen, 2003). For example, researchers using a nationally representative sample determined that grandmothers raising grandchildren were more likely to have signicantly higher levels of depressive symptomatology than non-caregiving grandmothers (Fuller-Thomson & Minkler, 2000). In another population-based study, researchers found that nearly one-third of grandchildren were raised by grandparents experiencing poor mental health (Scarcella et al., 2003). Risk factors for increased psychological distress in grandmother caregivers include lack of economic resources, physical health challenges, and, to a lesser extent, lack of social support (Kelley et al., 2000). Other factors that may contribute to their psychological distress include parenting children with emotional or developmental challenges, coping with the negative circumstances surrounding the grandchild's parents (e.g. substance abuse, incarceration, mental health issues), and managing health problems associated with aging.

Parenting later in life, when one would not normally expect to have full-time child care responsibilities, may add to their distress. In addition to grandchildren, these grandmothers may also be caring for ill spouses or aging parents. Considering these comparative disadvantages and challenges, research on the caregiving environment of children raised by grandparents is imperative. Studies are beginning to emerge that focus specically on the caregiver characteristics and home environment of caregiving grandmothers (Dolan et al., 2009; Smith et al., 2008). Using a nationally representative sample of children reported to CPS for maltreatment, researchers compared the parenting and home environments provided by grandmothers to non-relative foster caregivers (Dolan et al., 2009). Findings indicated that grandmother caregivers were older, less well educated, less likely to be married, and more likely to be low income than non-relative foster care providers. However, after controlling for the race, education, and poverty level of the caregivers, as well as the age of the children, grandmothers demonstrated signicantly better parenting than non-relative foster caregivers. The researchers concluded that the home environment provided by grandmothers was generally comparable to that provided by foster caregivers. To date, only one study has identied specic factors in the grandmother caregiving environment that inuence child outcomes (Smith et al., 2008). Employing a large national sample of grandmothers raising grandchildren, researchers found that the inuence of grandmothers' psychological distress on their grandchildren's adjustment was mediated by dysfunctional parenting, especially with regards to externalizing behavior problems (Smith et al., 2008). The effects of contextual factors, such as social support and family dysfunction, on grandchildren's adjustment were also indirect. The researchers concluded that caregiving grandmothers' distress levels do not bear an increased risk for grandchildren's psychological difculties independent of the family's psychosocial circumstances as a whole. In summary, the limited available literature indicates an elevated risk for behavioral problems among children raised by grandmothers. The increased levels of psychological distress found in grandmother caregivers raise questions regarding their ability to parent most effectively. Furthermore, the lack of resources experienced by many of these caregivers may negatively impact the caregiving environment and subsequently affect the emotional well-being of the grandchildren. 1.2. Theoretical framework The current study draws on the resiliency model of family stress, adjustment and adaptation (McCubbin, Thompson, & McCubbin, 1996) to conceptualize how the stressors placed on the family system might inuence the well-being of grandchildren raised by grandmothers. The resiliency model was developed to provide an understanding of how some families are able to cope, endure, and survive when faced with adversity (DeMarco, Ford-Gilboe, Friedmann, McCubbin, & McCubbin, 2000). The model considers the challenges to the family system imposed by family demands and how resources can affect individual or family adaptation and well-being (e.g. child behavior problems). According to this model, a failure to alleviate or resolve family demands through resources may increase the likelihood of negative outcomes, including compromised mental health. 1.3. Purpose and hypothesis The purpose of this study is to examine the extent of behavior problems in children raised by grandmothers and to describe the relationship among select background variables, as well as length of time in care, family resources, social support, the home environment, grandmother psychological distress and child behavior problems. Based on available literature and the theoretical framework, we hypothesized that less optimal family resources, social support, home

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environments, and grandmother psychological distress would predict increased behavior problems in children raised by grandmothers, after controlling for select background variables (grandmother age, level of education, number of grandchildren under care, length of time with grandmother, and grandchild age).

2.3. Measures 2.3.1. Child behavior checklist (CBCL) The CBCL is a widely used, empirically derived measure of children's behavior problems (Achenbach, 1991, 1992). While multiple versions are available based on the informant, we used the Parent Report Form. Achenbach created two versions based on age range. The CBCL-4-18 has 113 items pertaining to behavioral problems, while the CBCL-2-3 consists of 100 items. Respondents indicate on a 3-point Likert scale which problems their child displays. Items are scored according to internalizing, externalizing, and total behavior problems. T scores and clinical cut-off scores are determined from corresponding raw scores, based on the appropriate norm group for age. We used the standardized T scores as they provide an advantage over raw scores in that they are adjusted for child age and gender. The reliability and validity of the CBCL are well established (Achenbach, 1991). For the current sample, the reliability coefcients were .75 for internalizing behaviors, .83 for externalizing behaviors, and .88 for total behavior problems. Achenbach (1991) identied the cut point T 60 as providing efcient discrimination between children referred for mental health services and those who are not referred. Thus, T scores of 60, which is 1 standard deviation above the mean, serves as the clinical cutoff. 2.3.2. Home observation measurement of the environment (HOME) The HOME is a widely used screening inventory that was designed to assess the quality of the home environment in terms of the type and amount of support made available to the child that would foster emotional, social, and cognitive development (Caldwell & Bradley, 1984, 2003). Four versions (ranging from 45 to 60 items) have been created based on various age groups: the infant and toddler version (ages 0 to 2), the preschool version (ages 3 to 6), the elementary version (ages 6 to 10), and the early-adolescence version (ages 10 to 14). All four versions were used for this study. The assessment (approximately one hour) is administered through direct in-home observation of interactions between child and caregiver, as well as through a brief semi-structured interview between observer and caregiver. Specic psychometric data are available for each HOME version, including internal consistency scores, testretest correlations, and well established concurrent and predictive validity (Caldwell & Bradley, 1984, 2003). For the current sample, the reliability coefcients were .94 for infant toddler scores, .94 for early childhood scores, .88 for middle childhood scores, and .86 for adolescent scores. 2.3.3. Brief symptom inventory (BSI) The BSI is a 53-item, self-report symptom inventory designed to measure the psychological symptom patterns of psychiatric and medical patients as well as community nonpatient respondents (Derogatis, 1993). The instrument is a shorter version of the Symptom Checklist-90-R (Derogatis, 1983). Participants rate each item of the measurement on a 5-point scale of distress ranging from 0 (not at all) to 4 (extremely). The BSI has shown high levels of both internal consistency and testretest reliability and has well-established validity. The BSI is scored and evaluated in terms of three global indices of distress, including the Global Severity Index (GSI), a global measure of stress. By combining information about numbers of symptoms and intensity of distress, the GSI is considered the best summary score for psychological distress. Thus, the GSI was used to measure psychological distress in this study. For the current sample, the GSI reliability coefcient was .90. 2.3.4. Family resource scale (FRS) We chose the FRS (Dunst & Leet, 1987; Dunst, Trivette, & Deal, 1988) to measure caregivers' perceptions of adequacy of family resources. The FRS is a 31-item, self-report inventory derived from a conceptual framework that predicts an inadequacy of resources will

2. Methods 2.1. Participants Data on child behavior problems and the characteristics of the caregiving environment came from a larger study examining the efcacy of an intervention to improve the well-being of grandparentheaded families. Analyses for this study are based on data collected pre-intervention. Families were eligible for participation in this study if a grandmother was raising one or more grandchildren, ages 2 to 16 years, in a parent-absent household. Children under the age of two were excluded because of age related measurement issues. Because of the small number of grandfathers raising grandchildren, they were excluded from the present study. Participants were eligible for inclusion if they resided in one of two counties in a major metropolitan area in the Southeast. There were no inclusion criteria based on income level, race, or ethnicity. Grandmothers raising grandchildren through either the state foster care system or informal arrangements among family members were eligible for participation. On the basis of the inclusion and exclusion criteria described above, data on 511 children from 230 families were originally available for analysis. As some grandmothers had more than one grandchild in their care, the following procedure was used to obtain data on one grandchild for each grandparent with two or more children. This was to ensure that analyses would not include duplicated ratings from any grandparent measure used to predict child behavior scores. Ninety-two of the 230 families had only one grandchild; all of these grandchildren were retained. Among the 138 remaining families, one child was selected at random using their unique ID number to compare against a table of random numbers (Excel generated). In order to preserve the demographics of the original sample, grandchildren's age and gender were compared between the new random sample with the single children, and the original sample. If a signicant difference in age or distribution of gender was found, the randomization sequence was repeated and a new sample generated. After three iterations, no signicant differences were found in age or gender distribution, indicating that the new sample (N = 230) and the original sample (N = 511) of grandchildren were demographically similar. The nal sample for the present study comprised 230 children with a mean age of 8.2 years (SD = 3.6) and a range of 2 to 16 years. The majority of children were African American (97.8%); slightly over half (53.9%) were male.

2.2. Procedures A variety of community agencies, including health care clinics, child care centers, public schools, churches, and child welfare agencies, referred participants to the study. As part of the research protocol approved by the university's institutional review board, all grandparent participants signed letters of informed consent. Children aged 11 to 16 years provided written assent and those aged 6 to 10 years gave verbal assent. Prior to implementation of an intervention, trained graduate student research assistants collected data in participants' homes. Data were obtained during both structured interviews and observations, as well as through administration of standardized measures. Because of the overall low educational attainment of the sample, research assistants read questionnaires to participants. Participants were compensated $40 for data collection.

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negatively affect personal well-being and parental commitment. Items refer to specic resources and are rated on a 5-point Likert scale. Total scores are obtained by adding the score for each item, with higher scores indicating more resources. The measure has good internal consistency (.92) and testretest reliability (.52). For the current sample, the reliability coefcient was .88. 2.3.5. Family support scale (FSS) The FSS (Dunst & Trivette, 1989) measures the helpfulness of various sources of support to families raising children. The FSS includes 18 items that are rated on a 5-point scale from 1 (not at all helpful) to 5 (extremely helpful). Total scores are obtained by adding the score for each item, with higher scores indicating a perception of increased social support. The measure has strong validity and reliability. For the current sample, the reliability coefcient was .70. 2.4. Analyses Prior to analysis, we examined the variables through various SPSS programs for assumptions of multivariate analysis. Initial examination of the data revealed no violations of multiple regression assumptions among the variables (normal distribution, multicollinearity, homoscedasticity). Descriptive statistics were used to summarize demographic and background data, as well as to determine proportions of participants with clinically elevated behavior problem scores. Correlations were used to determine relationships among continuous independent and dependent variables. Hierarchical regression was employed to determine if family resources, family support, home environment, and grandmother psychological distress improved prediction of child behavior scores beyond that attributed to differences in grandmother age and level of education, number of children in her care, and length of time caring for grandchild. Regression analysis was conducted using the enter method in SPSS for the dependent variables of externalizing and internalizing child behavior problems. 3. Results As a group, the grandmother caregivers (N = 230) had low educational attainment, with approximately half (49%) having less than a high school education. While the majority were grandmothers (96%), some were great-grandmothers (4%). For the purposes of this paper, the great-grandmothers are referred to as grandmothers. Thirty percent of participants were currently employed; slightly over half (51.7%) were unemployed for various reasons, and 18.3% were retired. The mean age of the grandmother caregivers was 56.1 years (SD = 8.7) (range = 37 to 80 years), with almost a third (32.6%) over the age of 60. The marital status of the grandmothers was as follows: divorced/ separated, 41.3%; widowed, 24.3%; married, 19.2%; and single, 15.2%. On average, the grandmothers were raising 2.7 children (SD = 1.6) (range = 1 to 8). The vast majority (98.7%) of grandmothers were African American. Participants reported the following as the main reasons for assuming full-time care of their grandchildren: child abuse or neglect, 78.7%; parental alcohol or drug abuse, 67%; child abandonment, 37%; child removed by CPS, 18%; one or both parents deceased, 17%; one or both parents incarcerated, 16%; and parent with HIV disease, 3%. It is important to note that many of these factors are interrelated and, thus, exceed 100% when added together. With regard to the type of past child maltreatment, neglect was the most common form (76.5%), followed by emotional abuse, 34%; physical abuse, 15%; and sexual abuse, 3%. Despite the nding that most children had experienced one or more forms of maltreatment, only a small proportion (6.8%) of children were in state foster care; the remainder (93.2%) were in informal kinship arrangements. Descriptive statistics for all independent and dependent variables, as well as skewness values are found in Table 1.

Table 1 Descriptive statistics on independent and dependent variables. Mean Total behavior problemsa Internalizing behavior problemsa Externalizing behavior problemsa Child age Grandmother age Number children in household Length of time with grandparent (months) Psychological distressa HOME totalb FRS totalb FSS totalb HS graduate 51% b HS graduate 49% 53.31 50.41 53.69 8.21 56.07 2.73 62.01 55.96 42.10 99.42 24.67 SD 12.02 11.94 11.48 3.59 8.75 1.64 47.24 10.60 8.68 18.21 11.06 Median 54 51 53 8 55 2 53 57 43 99 23 Skewness 0.147 0.293 0.307 0.003 0.381 0.905 0.644 0.147 0.073 0.075 0.067

HOME, Home Observation Measurement of the Environment; FRS, Family Resource Scale; FSS, Family Support Scale. HS, High school. a Low score optimal. b High score optimal.

3.1. Child behavior problems The rst objective was to determine the proportion of children with total, internalizing, and externalizing behavior problem scores in the clinically elevated range (see Table 2). Results indicate that 31.3% of participants scored in the clinically elevated range for total problems, with 21.3% and 32.6% scoring in the clinically elevated range for internalizing and externalizing problems, respectively. 3.2. Bivariate analyses Correlations for the continuous variables of child's age, number of grandchildren in care, grandmother's age, length of time living with grandmother, family support total score, family resource total score, home environment total score, grandmother psychological distress, and total, externalizing and internalizing child behavior scores appear in Table 3. Using Cohen's (1977) recommendations, correlations in this study are termed weak (R = .1.3), moderate (R = .3.5), or strong (R .5). Participants reporting more family resources and less psychological distress tended to report fewer internalizing and externalizing behavior problems. These relationships were moderate in strength. It can also be noted that grandmothers with fewer grandchildren in their care tended to report more internalizing behavior problems, although this relationship was weak. A moderate relationship was found among family resources and family social support. Grandmothers with more children, as well as those with younger children, tended to report fewer resources, although these relationships were weak. Those with less supportive home environments tended to have more grandchildren in the home and reported more internalizing and externalizing behavior problems, as well as fewer resources, less social support, and increased psychological distress. These relationships were also weak. 3.3. Multivariate analyses The second objective was to describe the relationship among select background variables, family resources, social support, the home environment, grandmother psychological distress and behavior problems in children raised by grandmothers. We conducted two separate multiple regressions using standardized scores for internalizing and
Table 2 Child behavior checklist clinical scores. Total Nonclinical (T 59) Clinically elevated (T 60) 68.7% 31.3 Internalizing 78.7% 21.3 Externalizing 67.4% 32.6

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Table 3 Correlations of independent and dependent variables. 1 1. Total problems 2. Externalizing 3. Internalizing 4. Child age 5. No. children in care 6. Grandparent age 7. Family support 8. Family resources 9. Psychological distress 10. HOME environment 11. Length of time in care HOME, .90 .87 .05 .15 .11 .07 .26 .51 .21 .06 2 .69 .06 .03 .10 .01 .23 .47 .19 .09 3 4 5 6 7 8 9 10 11

.03 .18 .09 .09 .25 .48 .17 .02 .01 .22 .03 .13 .01 .12 .48 .06 .06 .16 .01 .21 .05

.11 .15 .19 .03 .22

.47 .19 .16 .07

.45 .17 .03

.17 .04

.03

Home Observation Measurement of the Environment. p b .05. p b .01. p b .001.

externalizing behavior problems as the respective dependent variables. Potential predictors consisted of nine independent variables: child's age, grandmother's age, level of education (high school graduate vs. nongraduate), number of children in grandmother's care, length of time with grandmother (months), grandmother psychological distress as measured by the GSI score, home environment as measured by total score on the HOME inventory, family resources as measured by the total FRS score, and family social support as measured by the total FSS score. Independent variables were entered into hierarchical regression models for each analysis. Because of the likelihood that certain extraneous variables (grandmother age and level of education, number of grandchildren in her care, and length of time caring for grandchild), would inuence the dependent variable, they were entered rst as a block to control their effect in Step 1 for each regression analysis. Family resources, family social support, and home environment scores were entered simultaneously in Step 2 for two reasons. First, family resources, family social support, and the home environment can be viewed as closely related in terms of supporting the child's well-being. Second, the theoretical model does not indicate whether family resources, family social support, or home environment is more likely to moderate child behavior problems. Grandmother psychological distress was entered in Step 3. 3.3.1. Internalizing behaviors Hierarchical multiple regression was rst conducted with internalizing behavior scores as the dependent variable. Table 4 contains

the unstandardized regression coefcients (B) and intercept, the standardized coefcients (), and the semipartial correlations (sr 2) for each step, and the multiple correlation coefcient (R), the squared multiple correlation coefcient (R 2), and the adjusted squared multiple correlation (adjusted R 2) after entry of all nine independent variables. R was signicantly different from zero at the end of each step. After Step 3, with all nine independent variables in the equation, R = .55, F (9, 220) = 10.33, and p = b.001. After Step 1, with number of grandchildren in care, grandmother age, education level (b HS graduate), grandchild age, and length of time with grandmother in the equation, R 2 = .05, F (5, 224) = 2.15, and p b .05. After Step 2, with family social support, family resources, and home environment scores added, R 2 = .16, F (8, 221) = 5.29, and p b .001. After Step 3, with psychological distress in the equation, R 2 = .30, F (9, 220) = 10.33, and p b .001. 3.3.2. Externalizing behaviors Next, hierarchical multiple regression was conducted with externalizing behaviors as the dependent variable. Table 5 contains the unstandardized regression coefcients (B) and intercept, the standardized coefcients (), and the semipartial correlations (sr 2) for each step, and the multiple correlation coefcient (R), the squared multiple correlation coefcient (R 2), and the adjusted squared multiple correlation (adjusted R 2) after entry of all nine independent variables. R was signicantly different from zero at the end of the second and third steps. After Step 3, with all nine independent variables in the equation, R = .51, F (9, 220) = 8.45, and p = b.001.

Table 4 Regression ndings: internalizing behaviors. Variables entered Education Child age Number children in care Grandmother age Length of time in care Family support scale Family resource scale HOME environment Psychological distress ANOVA tests at each step R at each step R2 (adjusted R2) at each step Intercept Step 1 B () .283 (.012) .099 (.030) 1.367 (.188) .152 (.111) .011 (.043) Step 2 B () .231 .355 1.836 .081 .001 .048 .185 .297 (.094) (.107) (.252) (.060) (.004) (.045) (.283) (.216) Step 3 B () 2.352 .261 1.528 .013 .005 .046 .065 .227 .479 (.099) (.078) (.210) (.009) (.021) (.042) (.099) (.165) (.426) R square change (see note) Step 1: .046

Step 2: .115

Step 3: .136

F (5, 224) = 2.152 .214 .046 (.025) 60.732

F (8, 221) = 5.290 .401 .161 (.130) 83.413

F (9, 220) = 10.332 .545 .297 (.268) 36.582

Note: Initial R2 at step 1 is given, followed by subsequent incremental R2 changes at steps 2 and 3. p b .05. p b .001.

S.J. Kelley et al. / Children and Youth Services Review 33 (2011) 21382145 Table 5 Regression ndings: externalizing behaviors. Variables entered Education Child age Number children in care Grandmother age Length of time in care Family support scale Family resource scale HOME environment Psychological distress ANOVA tests at each step R at each step R2 (adjusted R2) at each step Intercept Step 1 B () 1.353 .123 .398 .193 .025 (.059) (.038) (.057) (.147) (.103) Step 2 B () .125 .374 .805 .114 .013 .136 .177 .267 (.005) (.117) (.115) (.087) (.054) (.131) (.281) (.202) Step 3 B () .239 .285 .516 .026 .007 .134 .064 .201 .450 (.010) (.089) (.074) (.019) (.030) (.129) (.101) (.152) (.416)

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R square change (see note) Step 1: .031

Step 2: .096

Step 3: .130

F (5, 224) = 1.419 .175 .031 (.009) 65.073

F (8, 221) = 4.006 .356 .127 (.095) 83.686

F (9, 220) = 8.457 .507 .257 (.227) 39.679

Note: Initial R2 at step 1 is given, followed by subsequent incremental R2 changes at steps 2 and 3. p b .05. p b .001.

After Step 1 with number of grandchildren in care, grandmother age, education level, number of grandchildren in care, grandchild age, and length of time with grandmother in the equation, R2 = .03, F (5, 224) = 1.42, and p b .05. After Step 2 with family social support, family resources, and home environment scores added, R2 = .13, F (8, 221) = 4.01, and p b .001. After Step 3 with psychological distress in the equation, R2 = .26, F (9, 220)= 8.45, and p b .001. For both regression analyses, psychological distress was the most predictive variable, suggesting that higher psychological distress in grandmothers raising grandchildren is associated with higher internalizing and externalizing child behavior problems. The next most predictive variable was home environment. Children with less supportive home environments displayed increased behavior problems, both internalizing and externalizing. Fewer family resources, to a lesser extent, were predictive of increased behavior problems in both models. 4. Discussion The nding that almost one-third of children in the present study had clinically elevated behavior problem scores is not unexpected considering the vast majority had experienced multiple adverse events prior to living with grandmothers, such as child maltreatment, abandonment, or the incarceration of one or both parents. Furthermore, children raised by grandmothers typically experience a disruption in attachment relationships with their birth parents, placing them at increased risk for emotional distress. The clinically elevated child behavior problems found in this study fall within the range of those found in numerous studies of children in state foster care, whether residing with relative or non-relative caregivers (Dubowitz et al., 1994; James, Landsverk, & Slymen, 2004; Leslie et al., 2004, 2005; Lindhiem & Dozier, 2007). These behavior problems raise concerns for grandmother caregivers as they undoubtedly contribute to the myriad of challenges already faced by grandmothers who are trying to provide a safe and stable environment. Coping with these child behaviors can contribute to, or exacerbate, the elevated psychological distress levels found in grandparents raising grandchildren (Fuller-Thomson & Minkler, 2000; Kelley et al., 2000; Minkler & Fuller-Thomson, 2001; Ross & Aday, 2006; Scarcella et al., 2003). If grandmother caregivers reach a point in which they are unable to effectively cope with problematic behaviors, their grandchildren may be at risk for placement in the state foster care system, a residential setting, or even in the juvenile justice system. Research has shown that disruptions in foster care placements lead to further emotional trauma, thereby worsening behavior problems (Leathers, 2006; Newton, Litrownik, & Landsverk, 2000). It is imperative, therefore, that children

in the care of grandmothers receive mental health services, when warranted. Additionally, the grandmothers may benet from assistance in developing effective strategies for coping with problematic child behaviors. Children of grandmother caregivers who had increased psychological distress, fewer family resources, less social support, and less supportive home environments had increased behavior problems, both internalizing and externalizing. These ndings are consistent with previous research on the effects of foster family characteristics and the home environment on children's behavioral functioning (Lindhiem & Dozier, 2007). The results also support a major premise of McCubbin's family resiliency model, which served as the theoretical basis of the current study, in that inadequate resources were found to be associated was less favorable outcomes. The association found between child outcomes and custodial grandmothers' psychological distress, as well as other contextual factors in the present study, supports the ndings of other researchers (Smith et al., 2008). The present study expands on prior research (Dolan et al., 2009) by examining the role of the home environment on behavior outcomes in children raised by grandmothers primarily through informal arrangements among family members. It remains unknown whether the elevated behavior problems reported in this study are the result of conditions precipitating placement with grandparents (e.g. child maltreatment, parental incarceration), disruption in attachment relationships with birth parents, or circumstances in the current caregiving environment. A direct causal relationship between grandparent caregiving and grandchild behaviors should, therefore, not be assumed. The ndings do, however, suggest that factors related to the caregiving environment (e.g. lack of resources) and attributes related to grandparent caregivers (e.g. psychological distress) are closely related to the child's well-being, with caregiver psychological distress having the strongest association. From the bivariate analyses, the nding that less supportive home environments are associated with increased behavior problems is consistent with other study ndings of children in foster care (see review by Orme & Buehler, 2001), as well as in the general population (Bradley & Corwyn, 2007; Votruba-Drzal, 2006). At a time in their lives when income is typically limited, grandparents often do not have the economic resources necessary to adequately provide for grandchildren. Many grandparents are subsisting on working poor wages or xed incomes from retirement or social security benets. When public assistance is available through programs such as Temporary Assistance to Needy Families (TANF) or kinship care stipends, it is often inadequate to properly house, clothe, and feed children. The increased health problems experienced by grandmothers raising

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S.J. Kelley et al. / Children and Youth Services Review 33 (2011) 21382145 Caldwell, B. M., & Bradley, R. H. (2003). Home observation for measurement of the environment: Administration manual. Little Rock, AR: University of Arkansas. Campbell, L. R., Hu, J., & Oberle, S. (2006). Factors associated with future offending: Comparing youth in grandparent-headed homes with those in parent-headed homes. Archives of Psychiatric Nursing, 20, 258267. Chamberlain, P., Price, J. M., Reid, J. B., Landsverk, J., Fisher, P. A., & Stoolmiller, M. (2006). Who disrupts from placement in foster and kinship care? Child Abuse & Neglect, 30, 409424. Cohen, J. (1977). Statistical power analysis for the behavioral sciences. New York: Academic Press. DeMarco, R., Ford-Gilboe, M., Friedmann, M. L., McCubbin, H. I., & McCubbin, M. (2000). Stress, coping, and family health. In V. H. Rice (Ed.), Handbook of stress, coping and health: Implications for nursing research, theory, and practice (pp. 295332). Thousand Oaks, CA: Sage. Derogatis, L. R. (1983). SCL-90 administration, scoring, and procedures manual-II. MD: Clinical Psychometric Research. Derogatis, L. R. (1993). Brief symptom inventory manual. Towson, MD: Clinical Psychometric Research. Dolan, M. M., Casanueva, C., Smith, K. R., & Bradley, R. H. (2009). Parenting and the home environment provided by grandmothers of children in the child welfare system. Children and Youth Services Review, 31, 784796. Dubowitz, H., Feigelman, S., Harrington, D., Starr, R., Zuvarin, S., & Sawyer, R. (1994). Children in kinship care: How do they fare? Children and Youth Services Review, 16, 85106. Dunst, C. J., & Leet, H. E. (1987). Measuring the adequacy of resources in households with young children. Child: Care, Health and Development, 13, 111125. Dunst, C. J., & Trivette, C. M. (1989). Toward experimental evaluation of the family, infant, and pre-school program. In H. Weiss, & F. Jacobs (Eds.), Evaluating family programs (pp. 315346). New York: Aldine Publishing. Dunst, C. J., Trivette, C. M., & Deal, A. G. (1988). Enabling and empowering families: Principles and guidelines for practice. Cambridge, MA: Brookline Books. Edwards, O. W. (2006). Teachers' perceptions of the emotional and behavioral functioning of children raised by grandparents. Psychology in the Schools, 43, 565572. Edwards, O. W. (2009). Empirical investigation of the psychosocial functioning of children raised by grandparents. Journal of Applied School Psychology, 25, 128145. Fuller-Thomson, E., & Minkler, M. (2000). The mental and physical health of grandmothers who are raising their grandchildren. Journal of Mental Health and Aging, 6, 311323. Ghuman, H. S., Weist, M. D., & Shafer, M. E. (1999). Demographic and clinical characteristics of emotionally disturbed children being raised by grandparents. Psychiatric Services, 50, 14961498. Goodman, C. C., Potts, M. K., & Pasztor, E. M. (2007). Caregiving grandmothers with vs. without child welfare system involvement: Effects of expressed need, formal services, and informal social support on caregiver burden. Children and Youth Services Review, 29, 428441. Hardy, D. R. (2005). The booming dynamics of aging: From awareness to action. Report of the 2005 White House Conference on Aging Retrieved June 21, 2011, from. http:// www.genpolicy.com/articles/whcoa_report_2005.pdf Hayslip, B., & Kaminski, P. L. (2005). Grandparents raising their grandchildren: A review of the literature and suggestions for practice. The Gerontologist, 45, 262269. Holtan, A., Ronning, J. A., Handegard, B. H., & Sourander, A. (2004). A comparison of mental health problems in kinship and non-kinship foster care. European Child & Adolescent Psychiatry, 14, 200207. James, S., Landsverk, J., & Slymen, D. J. (2004). Placement movement in out-of-home care: Patterns and predictors. Children and Youth Services Review, 26, 185206. Kelley, S. J., Whitley, D. M., & Campos, P. E. (2010). Grandmothers raising grandchildren: Results of an intervention to improve health outcomes. Journal of Nursing Scholarship, 42, 379386. Kelley, S. J., Whitley, D. M., Sipe, T. A., & Yorker, B. C. (2000). Psychological distress in grandmother kinship care providers: The role of resources, social support and physical health. Child Abuse & Neglect, 24, 311321. Leathers, S. J. (2006). Placement disruption and negative placement outcomes among adolescents in long-term foster care: The role of behavior problems. Child Abuse & Neglect, 30, 307324. Leslie, L. K., Gordon, J. N., Meneken, L., Premji, K., Michelmore, K., & Ganger, W. (2005). The physical, developmental, and mental health needs of young children in child welfare by initial placement type. Journal of Developmental and Behavioral Pediatrics, 26, 177185. Leslie, L. K., Hurlburt, M. S., Landsverk, J., Barth, R., & Slymen, D. J. (2004). 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grandchildren may further drain limited economic resources (Kelley et al., 2010; Whitley, Kelley, & Sipe, 2001). In this study, grandmothers with fewer children in their care tended to report more internalizing behavior problems. One possible reason is that grandmothers with fewer children under their care may be in a better position to notice the more subtle signs of internalizing behaviors such as withdrawal, anxiety and depression. Another plausible explanation is that children with siblings may transition more successfully from a negative caregiving environment to living with grandmothers than children with no siblings. In other words, siblings may buffer some of the stress associated with difcult family situations. 4.1. Methodological limitations Several limitations may qualify the current ndings. First, the sample is limited primarily to African American children whose grandmothers had predominantly low educational attainment and were residing in an urban setting in the Southeast. Second, the grandchildren were primarily in the care of grandmothers through informal arrangements. Third, with the exception of the home environment assessment, caregiver reports served as the primary measurements of both caregiving environment and child outcomes, raising concerns about shared method variance. Interpretation of these ndings must consider the potential of the caregivers' own levels of psychological distress to inuence their assessments of the grandchildren's distress levels. 4.2. Implications for research, policy, and practice In order to identify critical intervention points, longitudinal research is needed to investigate the emotional well-being of children raised by grandmothers and their adjustment over time. Additional studies with participants who are more diverse with regard to race and ethnicity, socioeconomic status, geographical settings, and types of placements (state foster care vs. informal arrangements) will further our understanding of the inuence of caregiving characteristics and home environment on child outcomes. Study ndings have several implications for policy and practice. Interventions that focus on reducing child behavior problems, as well as enhancing the parenting skills of grandmothers raising grandchildren are warranted. Investigators have identied an increasing number of evidence-based interventions that improve outcomes for children with behavioral problems and facilitate caregivers' ability to cope (i.e., McMahon & Forehand, 2003; Timmer, Urquiza, Zebell, & McGrath, 2005). Very few, however, have focused on children in foster care, whether through formal or informal arrangements (Chamberlain et al., 2006). Children with behavioral problems require specialized support services and resources that may not be easily accessible to grandmothers because of limited nancial resources or lack of knowledge about the types of services required. The association found between the amount of support in the home environment and child outcomes speaks to the need for practice strategies and public policy that address the community-based needs of grandmothers raising grandchildren, especially as it relates to economic resources for raising children in a supportive environment. References
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