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

Since 2008, coinciding with the economic downturn and the continuing rise in housing costs, multigenerational household structures have experienced a resurgence in the United States [101]. A large national survey conducted in 2011 found that 51.4 million Americans live in multigenerational households (defined as three or more generations) [17]. The majority (65%) reported the living arrangement was the result of the economic climate; 40% indicated loss of employment, 20% stated it was due to the rising costs of health care, and 14% reported the foreclosure of their homes [17]. In 2016, there were 64 million multigenerational households [119]. In 2018, 7.8% of minor children in the United States lived with both a parent and a grandparent [120].

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

In 2014, Asian American (6%) and Native Hawaiian/Pacific Islander (9.9%) grandparents were the most likely to live with their grandchildren, although this is not necessarily a sign of custody or caregiving [98]. Custodial grandparents are racially/ethnically diverse, but they are disproportionately African American and Hispanic/Latino [25]. Among the population of custodial grandparents, 53.4% are White, 20.5% are Hispanic/Latino, and 19.2% are Black or African American [27].

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

The Substance Abuse and Mental Health Services Administration found that 11.9% of children younger than 18 years of age (or 8.3 million children) resided with at least one parent with a substance or alcohol abuse problem [28]. In a 2019 study, a common factor precipitating grandparents assuming parental responsibilities in Native American and White populations was parental drugs and alcohol abuse [165]. Of families in the child welfare system, an estimated 60% are affected by substance abuse [29]. The ongoing opioid crisis appears to have impacted the number of children moving to live with relatives, particularly grandparents [123]. Research indicates that states with higher proportions of custodial grandparents are also the states with the highest rates of opioid prescriptions [166]. Research indicates that children of parents who abuse drugs or alcohol are negatively affected in terms of their health and academics, have poorer parental attachment, and are at higher risk of physical abuse [30]. In these cases, grandparents may intervene of their own volition or as legally requested in order to care for affected children.

The terms "forgotten victims of crime" and "orphans of justice" have been used to describe children with incarcerated parents [34]. Approximately 2.7 million children have at least one incarcerated parent [125]. The average age of a child who has a parent incarcerated in federal prison is 10 years of age [167]. Almost 10% of African American children and 3.5% Hispanic children have a parent incarcerated [125]. Furthermore, about 10% of women who enter the prison system are pregnant [35]. It is estimated that more than 5 million children in the United States have experienced a parent incarcerated in jail or prison at some point during their childhood [126].

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

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

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

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

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

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

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

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

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

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

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

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

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

In one study, married grandparents in households in which the biologic parents of the grandchildren were not present (i.e., skipped generation households) were more likely to have increased participation rates in labor force compared to their counterparts who were living independently [64]. Grandmothers have the most substantial increase in labor participation rates in skipped generation households [64]. Unmarried grandfathers in skipped generation households were 29% less likely to be in the labor market. Single custodial grandparents may have to provide day-to-day child care for their grandchildren, making outside employment difficult. In a 2018 study, grandparents in skipped generation households reported being stretched financially and taking on work to supplement their finances, leaving them exhausted [134]. During the COVID-19 pandemic, custodial grandparents reported challenges in paying for food, utilities, rent, and medical bills. It is, therefore, not surprising that custodial grandparents who experienced job loss during the pandemic also experienced higher levels of parenting stress [183].

Unfortunately, custodial grandparents receive minimal financial support compared to foster families, with non-related foster care families receiving more services and financial stipends than families who provide care for their relatives [65]. In California, of the 281,067 grandparents who are responsible for grandchildren living with them, 15% live in poverty [66]. Of the 129,522 custodial grandparents in New York, 22% live in poverty [67]. More than 25% of grandparents raising grandchildren live in overcrowded conditions and almost 17% of them pay at least half of their income for rent [108]. It is estimated that 43% of grandchildren living with their grandparents receive food stamps to meet their basic needs.

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

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

Coping is defined as a set of directed behaviors employed to deal with stress and life challenges in order to reduce social, physical, and emotional distress [109]. Coping strategies can be generally classified as active or passive. Active coping involves relying on internal and external resources, while passive coping entails giving up control over the stressors and giving in to feelings of helplessness. A survey of 733 custodial grandmothers found that social support and active coping were correlated with less distress and less ineffective parental disciplining (defined by harsh and inconsistent disciplining) [110]. Passive coping, on the other hand, was related to more distress and more ineffective parental discipline.

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

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

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

Despite these feelings of loss, children tend to understand the importance of living with grandparents and how this allows for emotional stability and protection. Children often believe that their living situation is no different from children who live with biologic parents because they are being cared for and loved by their grandparents [65,152]. Some may be relieved to have "escaped" from the problems in their previous living situation. Studies indicate that children tend not to feel stigmatized or ostracized for having alternative living situations; feeling that they are well taken care of is more important than peer support [80]. Grandchildren are not naïve—they are aware of what is going on around them. They seem to be sensitive to the fact that their grandparents are older and express concern for their health and well-being [65]. Furthermore, children raised by other caregivers often express a desire for their voices to be heard in key decision-making areas such as schooling and living arrangements [112].

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

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

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

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

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

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

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

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