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REVIEW

CURRENT
OPINION Grandparents raising grandchildren: a primer
for pediatricians
William Ge a and Andrew Adesman b

Purpose of review
To provide clinicians with a review of key considerations relating to the physical and behavioral well-being
of children raised by their grandparents.
Recent findings
As the number of children being raised by their grandparents in the United States steadily increases, the
needs of these families require greater attention. These children and their custodial grandparents face unique
health, social, legal, and financial challenges. Children being raised by their grandparents are at higher risk
for developmental and behavioral problems because of prior or current adverse family environments.
Moreover, there is evidence that custodial grandparents may experience negative health, social, and
financial outcomes that may constrain their ability to provide the best care for their grandchildren.
Summary
Pediatricians should not only be aware of the medical and developmental status of children who are being
reared by their grandparents, but also assess the needs, abilities, and potential limitations of these
custodial grandparents. In addition to providing useful parenting advice and direct support to custodial
grandparents, pediatricians should refer these families as needed to local grandparenting groups, social
service agencies, experienced legal counsel, and relevant national organizations for support and
guidance.
Keywords
developmental and behavioral problems, fragile families, grandparents raising grandchildren, kinship care

INTRODUCTION
The number of American children living in a grand-
parent-headed household has risen significantly
over the past few decades. Between 1970 and
&&
one or more grandchildren [1,3 ]. Data from the
Fragile Families and Child Well-Being Study
(FFCWS) reveal that these grandfamilies are hetero-
geneous, with an average household size of nearly
&

1997, the number of American children living in five people [4 ]. Many children in grandfamilies live
a grandparent-headed household nearly doubled, with an aunt or uncle, cousins, siblings, or nonkin
&

growing from 2.2 million to 3.9 million in the short
span of 27 years [1,2]. By 2010, this population
nearly doubled again to 7.5 million American chil-
dren [1,2]. Although involvement of extended fam-
ily members in the care of children is a common
cultural practice, the contemporary expansion of
[4 ]. Over a third of grandfamilies include both a
grandmother and grandfather, nearly two-thirds
include only a grandmother, whereas very few
(1%) include a grandfather but no grandmother. A
majority of grandparents surveyed in the FFCWS
(86%) expected to live with their grandchildren
&

this unique family structure is largely precipitated
by adversity, not tradition. These children and their
grandparents face a unique set of health, social,
legal, and financial challenges that have yet to
receive adequate attention. The goal of this review
is to bring these challenges to the attention of
primary care providers and to suggest opportunities
for pediatricians to better meet the needs of these
children and their grandparents.
In these grandparent-headed households,
grandparents are responsible for the basic needs of
until they reached adulthood [4 ].
a
Yale University, New Haven, Connecticut and bDevelopmental and
Behavioral Pediatrics, Steven and Alexandra Cohen Children’s Medical
Center of New York, Lake Success, New York, USA
Correspondence to Andrew Adesman, MD, Developmental and Behav-
ioral Pediatrics, Steven and Alexandra Cohen Children’s Medical Center
of New York, 1983 Marcus Avenue, Suite 130, Lake Success, NY 11042,
USA. Tel: +1 516 802 6100; e-mail: aadesman@northwell.edu
Curr Opin Pediatr 2017, 29:000–000
DOI:10.1097/MOP.0000000000000501

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Office pediatrics
KEY POINTS
 The number of children being raised by their
grandparents in the United States has increased
significantly.
 These children and their custodial grandparents face
unique health, social, legal, and financial challenges
that have yet to receive adequate attention from local
and national communities and governments, including
the pediatrics community.
 Children being raised by their grandparents are at
higher risk for developmental/behavioral problems and
academic difficulties because of prior or current
adverse family environments.
 There is evidence that custodial grandparents may
experience negative health, social, and financial
outcomes that may constrain their ability to provide the
best care for their grandchildren.
 Pediatricians must not only be aware of the child’s
medical and developmental status, but also be sensitive
to the needs, abilities, and potential limitations of the
custodial grandparents.
 In addition to providing direct support to custodial
grandparents, pediatricians should refer these families
as needed to local grandparenting groups, social
service agencies, experienced legal counsel, and
relevant national organizations for support and
guidance.
The parents of these children are absent from
their lives for a wide variety of reasons. Substance
abuse, parental incarceration, intimate partner vio-
lence, parental mental illness, and child abuse and
neglect all contribute to the contemporary rise in
grandparent caregiving [5]. In this context, grand-
parents who are raising their grandchildren are
often faced with the dual burden of coping with
the issues their adult children may be facing, such as
substance abuse, psychiatric issues, or incarceration,
and the trauma that their grandchildren may experi-
ence resulting from unstable relationships with
their parents.
Prior research examining the well-being of chil-
dren raised by grandparents has generally compared
them with the population of US children in general,
reporting a higher incidence of emotional and
behavioral problems and less academic engagement
in school [6,7]. Given the emotional difficulties and
trauma these children often face, this may not be an
appropriate comparison. Indeed, although Solomon
and Marx (1995) [8] found that children from grand-
parent-headed households were less likely than
those in traditional two parent households to excel
academically, they were equally likely as children in
2 www.co-pediatrics.com
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single-parent households to do so. Moreover, chil-
dren in both grandparent-headed households and
traditional two-parent households were less likely
than those in single-parent households to experi-
ence behavioral problems at school [8]. However,
although children who are raised by their grand-
parents generally achieve a higher level of well-
being than those raised by single-parents or placed
in traditional foster care [9], grandparents who
assume the primary caregiving role for a grandchild
generally report greater emotional and financial
stress, poorer physical and mental health, and
higher incidences of depression, diabetes, hyperten-
sion, and insomnia compared with their noncare-
giving peers [10,11]. The challenges facing these
children and the grandparents who are raising
them, as well as potential areas in which pedia-
tricians can help, are the foci of this review.
RISK FACTORS: THE WELL-BEING OF
CHILDREN RAISED BY THEIR
GRANDPARENTS
As noted, the recent rise in the number of grand-
families in the United States has been precipitated
by a rise in substance abuse, parental incarceration,
intimate partner violence, and child abuse and
neglect. In a study examining 230 predominantly
African American children between 2 and 16 years of
age raised in low income, parent-absent homes by
their grandmothers, 79% of grandmothers reported
child abuse or neglect by the parents as the primary
reason for assuming full-time care of their grand-
children, followed by parental drug or alcohol abuse
(67%), child abandonment (37%), child removal by
Child Protective Services (18%), death of one or
both parents (17%), and/or incarceration of one
or both parents (16%) [12]. This same study found
that children raised by their grandparents are more
likely to have behavioral problems compared with
US children generally and that behavioral problems
were exacerbated in homes with fewer family resour-
ces, less social support, less supportive environ-
ments, and grandmother caregivers with higher
levels of psychological distress. These findings are
corroborated by a multitude of other studies of
behavioral conditions of children in grandparent,
kinship, and foster care [8,9,13].
A second mechanism by which children raised
by their grandparents may be subject to elevated risk
of emotional and behavioral problems concerns the
life course mismatch of grandparenting. Negative
health outcomes associated with grandparenting are
extraordinarily well documented. Custodial grand-
parents are more likely to experience poorer
physical and mental health compared with their
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peers [11,14,15]. Given the various adverse causes
that precipitate most grandfamily arrangements,
this is perhaps not surprising. In addition to navi-
gating the oft-unplanned parenting role for a second
time, grandparents raising grandchildren must
simultaneously deal with the concurrent trauma
of their relationships with their adult children
&&
[3 ,16]. One study showed that nearly two-thirds
of custodial grandparents expressed disappoint-
ment in their adult children, and nearly one-third
resented them [13], though feelings of being bur-
dened were less common in settings where there
were healthier relationships between the custodial
grandparent and their adult children [14]. This ‘dual
burden’ of managing both child and grandchild-
related trauma, combined with exacerbated physical
and mental health conditions, often create difficult
circumstances for grandparents to parent well and
for grandchildren to flourish.
Despite these barriers, children can certainly
blossom when they are raised by a grandparent,
although studies examining their well-being and
academic performance compared with that of other
children in comparable economic and kinship care
situations are relatively few. Solomon and Marx [8]
found that although children in two-parent house-
holds were most likely to excel academically, chil-
dren raised by their grandparents were as likely as
those from single-parent households to succeed in
school [14]. Moreover, examinations of the grand-
parent–grandchild relationship have revealed that
most grandparents raising grandchildren feel a close
emotional bond with their grandchild, and vice
versa [17], and 90% of custodial grandparents report
that they would take responsibility for their grand-
children if they had to make that choice again [18].
The bottom line is this: for children who do not have
a strong and supportive family environment, or
whose parents are absent because of abandonment
or incarceration, grandparents can provide a strong
foundation of love, care, and safety. A large body of
evidence details the advantages of kinship care com-
pared with nonkinship foster care, where a majority
of these children would otherwise be placed. How-
ever, these grandparents cannot optimally care for
their grandchildren without greater structural and
social support.
CONSEQUENCES OF GRANDPARENTING
FOR GRANDPARENTS
Studies suggest that custodial grandparents experi-
ence increased risk of negative health, social, and
financial outcomes that limit their ability to provide
the best care for their grandchildren. Kinship care
arrangements with grandparents, while preferable
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Grandparents raising grandchildren Ge and Adesman
to nonkinship foster care, are accompanied by less
financial and structural support from social service
agencies [19]. This reduced support is concerning, as
grandparents who care for their grandchildren are
typically more financially vulnerable than families
who participate in foster care. For instance, in 2012,
25% of children being raised by their grandparents
were living in poverty, compared with 20% of chil-
dren being raised by their parents [20]. As grand-
parents who raise their grandchildren are generally
quite young (approximately 40% are below the age
of 55 and approximately 75% below the typical
retirement age of 65), many custodial grandparents
also give up working outside the home to raise a
grandchild, resulting in lost wages and the other
financial benefits of employment [21,22].
Grandparents raising grandchildren are often at
a stage of life with emerging health problems that
may be exacerbated by their parenting roles and
responsibilities. Compared with noncustodial
grandparents, those raising their grandchildren
experience poorer physical and mental health
[22]. Custodial grandparents are at greater risk for
illnesses such as diabetes, hypertension, insomnia,
and depression [23] and report more difficulty per-
forming daily tasks than their same-aged peers [15].
In addition, social isolation is often identified as a
significant problem for custodial grandparents.
Many grandparents report that loneliness and feel-
ing different or invisible are significant barriers to
achieving a greater degree of mental well-being [24].
Research suggests that these feelings of isolation
stem from the belief that neither their same-age
peers nor the younger parents of their grandchild’s
classmates can understand or relate to them [22].
Grandparents are a vulnerable population in
terms of their financial well-being and health status,
and custodial grandparents are only more so.
Ideally, they should receive the support of their local
and national communities and governments to be
able to raise their grandchildren in the best way
they can. Moreover, the fragmented nature of most
grandfamilies, with traumatic incidents often stress-
ing the relationships between grandparent, adult
child, and grandchild, makes social and legal
support critical for maintaining the stability and
viability of nurturing grandfamilies.
Many custodial grandparents lack a legal
relationship with the grandchild they are caring
for, and thus may encounter significant barriers to
seeking school or health services on behalf of their
&&
grandchildren [25 ]. Without a legal relationship
between the grandparent and grandchild (and in
some cases even with a legally established relation-
ship), the child’s parents may still be able to reclaim
the child. Custody battles involving grandfamilies –
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though not commonplace – can take a large toll on
the stability of the grandchild’s family life and his or
her mental and emotional well-being. More broadly
speaking, legal barriers to caregiving can limit the
abilities of well meaning and often much-needed
grandparents to give their grandchildren the edu-
cation, healthcare, and agency that they deserve.
IMPLICATIONS FOR PEDIATRIC PRACTICE
Despite the barriers that grandparents and children
in grandfamilies often face, there is tremendous
opportunity for providing grandfamilies with struc-
tural support that will facilitate strong and nurtur-
ing family environments. Pediatricians play an
important role, although the primary care that they
provide must take into consideration not only the
health and development of the child, but also the
well-being of the custodial grandparents (Table 1).
Specifically, children in grandfamilies should be
closely surveyed for signs of behavioral, emotional,
or developmental disorders that may arise from
early childhood trauma or unstable family environ-
ments. They should be assessed for developmental
risk factors, such as prenatal exposure to alcohol,
cocaine, or other substances of abuse or drug para-
phernalia, especially if the child’s parents are known
to be heavy alcohol or drug users. Early identifi-
cation and referral of children in need of develop-
mental services will have considerable payoffs for
the child’s future mental and emotional well-being
and academic achievement.
Table 1. Clinical considerations for pediatric surveillance
when young children are being raised by their
grandparents
Child:
Assess for signs of abuse/neglect (especially initially)
Provide close developmental surveillance
Custodial grandparent:
Assess and monitor mental health of custodial grandparents
(e.g., stress, anxiety, depression)
Assess and monitor physical well-being of custodial
grandparents
Clarify involvement of biological parent (s) and determine if this
poses a risk to the child
Provide anticipatory guidance that considers the age,
experience, and supports of the custodial grandparents
Clarify and counsel regarding the legal status of the child and
the benefits of this being defined
Assess and counsel custodial grandparents’ regarding social
service supports and financial resources
Refer to local grandparenting support groups and on-line
resources
4 www.co-pediatrics.com
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In addition to assessing the child in terms of
specific risk factors and functioning, pediatricians
also need to assess the health and parenting ability
of grandparents. Custodial grandparenting is a con-
siderable risk factor for poor physical and mental
health. Social isolation from friends, family, and the
parents of their grandchild’s classmates is a real issue
repeatedly vocalized by grandparents raising their
grandchildren. The physical or mental health issues
of custodial grandparents can have a significant
negative impact on the well-being of the grandchil-
dren they are raising. Consequently, grandparents
should be encouraged to have regular physical
examinations with a primary care provider to not
only monitor their own health, but also ensure that
they can continue providing effective care for
their grandchildren.
In terms of parent education and anticipatory
guidance, pediatricians must be mindful of the
many outdated parenting practices to which custo-
dial grandparents may still subscribe (Table 2).
Table 2. Out-dated parenting beliefs to which custodial
grandparents may still subscribe
It is okay to put a baby to sleep on his abdomen or on
his side
Ice baths can be used to bring down a high fever in young
children
If a child hits his or her head, a parent needs to keep the child
awake
Teething is sometimes a cause for a high fever in an infant
If a child has a seizure, place a soft object (such as a wallet)
into the child’s mouth to prevent choking or biting the tongue
Babies who spend time in walkers will walk independently at a
somewhat earlier age
Sunscreen should not be used on infants younger than 6 months
Babies who are learning to walk benefit from the ankle support
provided by high-top shoes
Treat a burn with an application of ice
Vitamin C supplements help ward off colds
A child who has diarrhea should not be given dairy products
until the diarrhea resolves
Butter is a good first-aid remedy for a minor burn
Aspirin can be used to treat a fever in school-age children
Wounds will heal quicker if exposed to fresh air at night
Reading in the dark can cause later vision or eye problems
Eating chocolate causes acne in adolescents
Drinking milk causes increased production of phlegm or mucus
and should be avoided during a cold
To prevent earwax build-up, parents should carefully clean the
ear canals with a cotton swab after a bath, when the wax is
softest
Children should not go swimming until 30 min after they eat
Adapted with permission [26,27].
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Grandparents raising grandchildren Ge and Adesman

Table 3. Organizations which provide resources for grandparents raising grandchildren

Organization Description Website

American Association of Provides searchable database of grandparents support http://www.aarp.org/relationships/

Retired Persons
Grandfamilies Guide
Generations United: National
Center on Grandfamilies
The Brookdale Foundation
Group: Relatives as Parents
Program
The Grandfamilies’ State Law
and Policy Resource Center
Advocates for Families First
groups, state-by-state GrandFacts fact sheets, and advice friends-family/info-08–2011/
on all aspects of grandparenting grandfamilies-guide-support.html
National organization and leading advocate of children http://gu.org/ourwork/
and caregivers in intergenerational families, including grandfamilies.aspx
grandfamilies
Support program initiated in 1996 that facilitates training http://www.brookdalefoundation.
and networking and provides technical assistance and net/RAPP/rapp.html
information primarily to relative caregivers caring for
children outside of the foster care system
Legal resource for grandfamilies that includes summaries, www.grandfamilies.org
comparisons, relevant stories, and a searchable database
of laws affecting grandfamilies for all 50 states and the
District of Columbia
Collaborative providing technical and educational www.advocatesforfamiliesfirst.org
assistance to support and advocacy organizations for
foster, adoptive, and kinship families across the country

Adapted with permission [13,24].

Although some of these beliefs may be innocent and their needs can be better met by the pediatric com-
benign (e.g., eating chocolate causes acne in teens), munity are needed.
other outdated beliefs may have profound con-
sequences (e.g., ice baths are a good way to bring Acknowledgements
down a very high fever, infants should be put to None.
sleep on their side or abdomen). Pediatricians can
also provide custodial grandparents with support Financial support and sponsorship
resources in their immediate community and online None.
to help them raise their grandchildren (Table 3).
Other organizations that provide resources specifi- Conflicts of interest
cally for grandparents raising grandchildren include
There are no conflicts of interest.
the Brookdale Foundation (Relatives as Parents Pro-
gram), the American Association of Retired Persons,
and Generations United. These organizations can REFERENCES AND RECOMMENDED
guide grandparents on where to find local support READING
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been highlighted as:
tices, and assist them with navigating strained fam- & of special interest
ily dynamics and establishing a strong relationship && of outstanding interest

with their grandchildren.
CONCLUSION
The number of families in which children are raised
by their grandparents has grown rapidly since the
1970s and may well increase further in the foresee-
able future. In 2010, these children numbered 7.5
million, highlighting the importance of ensuring
the well-being of this large and vulnerable popu-
lation. Although the barriers facing grandfamilies
cross health, social, legal, and financial boundaries,
the opportunities for pediatricians to support these
children and their caregiving grandparents are tre-
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