Introduction

The 2006 census showed that almost 5 million Australians (approximately 24%) are 55 years of age or over.1 A significant proportion of them, and indeed of all over 40 year olds, are grandparents - but oddly enough, we do not know how many, how to define them, or how they define themselves. For example, is a person whose estranged children have had children whom they do not know about a grandparent? Is a person whose adult stepchildren have had children (or whose children have acquired stepchildren) whom they have never met a grandparent? Is a senior executive consumed by work, whose children happen to have reproduced, as thoroughly a grandparent as a never-employed coresident widow may be? We need to face the challenge that grandparenthood is more a psychological than a biological concept. This shift in perspective allows us to focus on the emotional relationships, which may change grandparents' lives and others' too. This conceptualisation also helps us see that grandparenthood is not a stable state, once entered into. Developmental changes over time in both the older and younger members of the grandparent-grandchild dyad mean the relationship is dynamic, evolving and responsive to circumstances. Grandparenthood offers risks as well as rewards, as does 'grandchildhood'.

A lot of writing about grandparents confines itself to the relationship between the grandparent and the grandchild. Caretaking roles have been the focus of much attention lately because the rising proportion of dual-income families, and the inaccessibility of high-quality child-care facilities, mean that grandparents often take on that task. However the grandparent also has other relationships and responsibilities, which may be longer-lasting and more central to identity than the grandparent role. There is potential for strain but also for personal growth and enrichment.

Szinovacz used 1992-94 data from the US National Survey of Families and Households (n = 10 008) to show that close to 95% of individuals with children aged 40+ years were grandparents.2 About one-third experienced this transition to grandparenthood either before 40 or after 65 years of age. The majority were married, about a third having at least one living parent of their own, and about a third employed full-time. Grandmothers typically survive well into the adulthood of at least their oldest grandchild, and about two-thirds of them, but few men, experience the birth of a great-grandchild. Recent UK data show that half of the grandparent population are aged under 65 and 26% living in low-income households.3

The conceptual framework of healthy ageing and lifespan development suggests many ways that older persons may achieve wisdom and integrity,4 age successfully,5 develop strategies to compensate for age-related deterioration,6 or continue to experience personal growth and well-being at older ages,7,8 without being defined by whether they and any children they had have had children. While it is normative to be a grandparent in later years, many older citizens will not be grandparents and others regard their grandparent role as very much secondary to other roles such as employee, confidant or partner to other adults, or caregiver for their own parent. Analyses of ageing rarely use grandparenthood as a defining category, and reports about grandparents rarely refer to the epidemiology and psychology of human ageing.

As Lumby commented recently in this Journal, grandparents who care for grandchildren can benefit their families and also their own sense of self-worth.9 We conducted a selective review of the medical and social sciences literature trying to learn more about grandparents' place in today's world of dual-income families and greater longevity, with a special focus on the conjunction of healthcare, workforce engagement and lifespan psychological development. Evidence that would be useful for both clinical and preventive health services is in many cases unavailable. In what follows we outline what is known and not known about grandparenting, a phenomenon that quickly shows itself to be more complex than popular stereotypes may suggest.

Grandparents as child-care providers

Grandparents have always had an important place within the family. However, this role has changed and become more diverse within the last few decades, because of both societal changes and familial changes. First, modern grandparents are facing greater caring responsibilities. The primary contributors for the increased need in child care provided by grandparents are the rise in both the number of single-parent families and maternal employment.10 Increased life expectancy along with falling fertility rates has resulted in longer, thinner 'beanpole' families, with four or even five generations.3 Thus there are more 'sandwich generation' grandparents, who find themselves caring for their own aged parents, while supporting their own children and caring for their grandchildren,3 although Szinovacz's findings suggest that the duration of a four-generation family is usually quite short.2

Not only have the expectations placed on grandparents changed, they are more likely to be facing them alone. For example in the UK, the proportion of single grandparents increased from 8% to 15% between 1998 and 2007, not including those widowed,11 while the Australian Bureau of Statistics has reported almost half of grandparent families (47%) were single grandparents without a partner.12 Divorce not only has psychological and economic repercussions on the individual experiencing it, but the ramifications can be felt over the life course of affected family members and throughout the network of family relationships.13

Health and welfare professionals are taking a new interest in 'grandparents' as caregivers for children. Labour market experts are also interested in this phenomenon as a contributor to national productivity. The extent of this assistance can range from occasional overnight visits to providing long-term, daily child care. The reasons for providing care may include wanting to assist the parents of the child financially, wanting to help because the parents of the child work full time, or not wanting the child to go to a day-care centre.14 Child care provided by relatives appears to be the most popular alternative when parental care is not available, because of circumstances such as parent participation in the workforce, and among family relatives, grandparents are the most popular.15 For example in Australia in 2002, of the 1.4 million 0- to 11-year-olds who had been in child care in the week before interview, less than half (43%) had been in formal care. Grandparents were by far the largest providers of informal child care, with 19% of children aged 0-11 years cared for by grandparents in the survey week. Grandparents provided 31% of the total hours of care provided in that week.16 Those numbers have remained steady, as the Childhood Education and Care Survey conducted by the Australian Bureau of Statistics in 2008 also found that grandparents were caring for 19% of the children aged 0-12 years who were usually in some type of child-care arrangement.17 The same study also reported that 52% of children younger than 2 years of age using any child care are cared for by a grandparent.17 Studies in the USA reported that between 40% and 50% of grandparents had provided some type of child-care assistance in the previous month.18,19 Bass and Caro's research, using national field poll data, found that 32% of individuals with grandchildren or great-grandchildren had provided care for at least 1 h during the previous week.20 European studies report similar figures. Attias-Donfut et al. found that 43% of grandparents having been involved in child care in the previous 12 months,21 while the 2004 Survey of Health, Ageing, and Retirement reported 58% of grandmothers and 49% of grandfathers provided some kind of care for a grandchild aged 15 or younger during a 12-month period.22

Concerns have arisen that child care may come at the cost of grandparents' well-being, and an important focus has been the impact of caring for grandchildren on grand parents' health. There is consensus in the literature that informal caregivers consistently report worse health and lower well-being than non-caregivers, although there is no clear evidence that caring causes poor health, rather than the equally plausible hypothesis that people in poorer health are the ones who leave paid employment earlier and thus are available to act as informal caregivers. Little is known about the differences in health effects of caring for children versus for one's own generation or one's parents' generation. However it seems that grandparents who care for grandchildren experience poorer health than those of similar age who do not.

What we do know about the healthcare needs of grandparents?

There are relatively few studies in the literature that have examined the health of grandparents who provide non-custodial child care, and information about health status is often reported incidentally.

Physical health

Caring for grandchildren can be a demanding task especially if it coincides with the onset of bodily aging, and if caring for grandchildren reduces time for self-care such as exercising and going to the doctor. A number of studies have reported that child care exerts a toll on a grandparent's physical health. Solomon and Marx showed that custodial grandparents experienced significantly greater declines in health.23 Minkler and Fuller-Thomson examined the physical health of grandparents providing varying amounts of child care using an activities of daily living scale, and reported that grandparents who were provided 30 h or more of child care per week had fewer limitations in activities of daily living than grandparents who were primary caregivers, but more than grandparents who provided between 1 and 30 h of child care per week.19 Musil and Ahmad found that primary caregivers reported more health problems and made more healthcare visits than did non-caregivers but did not differ from partial caregivers.24 Balukonis and colleagues reported that grandmothers who cared for but did not live with grandchildren had the highest body mass index, cholesterol and systolic blood pressure,25 while caring for non-ill grandchildren 9 h or more per week was associated with an increased risk of coronary heart disease.26

There is also a growing body of evidence suggesting that interactions between children and seniors contribute to the spread of influenza, and grandparental caregiving may facilitate the transmission of influenza virus from children. High levels of live-in grandparental caregivers were associated with consistently higher levels of pneumonia and influenza rates in low-income counties.27 Other research has found that vaccinating children against influenza provided an indirect protection of the elderly, as vaccination was associated with reduced influenza in the older population.28 Conversely, in a large sample of 12 872 grandparents, Hughes and colleagues found no evidence to suggest that caring for grandchildren has dramatic and widespread negative effects on grandparents' health and health behaviour, and reported it to be beneficial to grandmothers who babysit.29

Psychological health

While grandparents in the primary caregiver role have been identified as having poorer psychological health than their peers,30,31 the psychological effects of providing child care to grandchildren may not be limited to custodial grandparents. Several studies have reported that grandmothers who provide child care report more depressive symptoms than non-caregivers but fewer than custodial caregiver grandmothers.24,29,32 Minkler and Fuller-Thomson examined depressive symptoms in grandparents who provided a range of child-care services, and found that the reported depressive symptoms of grandparents who provided 30 or more hours of child care per week were comparable to those grandparents who were primary caregivers, but significantly higher than those of non-caregivers, and those who provided less than 30 hours of child care per week.19 Also, 20% of grandparents who provided 30 or more hours of child care per week had clinically relevant depression scores.

Another psychological cost associated with caring for one's grandchildren is stress, which can arise from financial, marital, physical and activity difficulties associated with providing child care. Non-caregivers have reported fewer financial strains than primary and partial caregivers.32 Younger near-parental role grandparents have reported different stressors, such as 'having to care for the grandchildren' and 'discipline of grandchildren', where as those older than 70 years more often cite 'financial concerns', 'difficulties in school' and 'grandchildren in trouble' as a stressor.33 Poor physical function has also been associated with greater risk of psychological distress among elderly Latinos, especially those who have child-care responsibility.34 Non-caregivers have reported less stress than primary or partial caregivers; there were no differences between primary and partial caregivers on the stress measure.24

Some grandparents have reported caring for their grandchildren as enriching and adding to their quality of life. Those who do may view themselves as establishing and guiding the next generation, achieving what Erikson et al. described as 'grand-generativity'.4 Qualitative studies have reported that caring for a grandchild allowed grandparents to change their previous child-rearing strategies, to become more tolerant, gentler and amenable to requests.35,36 Interaction with a grandchild may also help a grandparent remain active and stimulated, as caring for the grandchild provided an opportunity to open up new social horizons. Balukonis and colleagues reported that grandmothers who provided child care had better quality of life scores than did the non-caretaking grandmothers, and non-grandmothers had the lowest quality of life scores of all.25 Bowers and Myers examined life satisfaction in grandmothers who provided different amounts of child care, with full-time caregiving grandmothers reporting significantly lower life satisfaction than part-time and non-caregiving grandmothers.37

Drew and Silverstein reported that grandparents who lost contact with their grandchildren experienced a steeper increase in depressive symptoms as they aged compared with other grandparents.38 Depressive symptoms of grandparents who lost contact because of a sudden event increased up to 3 years following the loss but returned to equilibrium thereafter. In addition to suffering with the loss of a loved one, such grandparents also suffer with the loss of the grandparent role.

Financial needs

As the population ages the decreasing ratio of workers to retirees and other pensioners poses threats to the sustainability of health and welfare services. Employers are being encouraged to reduce barriers to the continued employment of older workers, to reduce this decrease in the workforce. There are also individual benefits, both psychological and financial, of employment. How then does taking on child-care responsibilities affect older people's capacity to maintain their workforce participation? Is there for example a critical number of hours per week beyond which caring for grandchildren prohibits keeping a job? Considerations of the 'family-friendly' work place may often be as relevant to older workers as to younger ones.

Technological challenges

Communication with grandchildren is highly valued by grandparents. With new forms of technology such as mobile phones, SMS, email and webchat so readily adopted by younger generations, grandparents could be left behind. Dench and Ogg reported that communication between generations has traditionally happened via direct contact or landline telephone, and that grandmothers appeared to see and speak on the phone with grandchildren more than grandfathers.39 Cherlin and Furstenberg found that grandparents do not compensate for infrequent meetings by phoning. If grandparents meet often with their grandchildren, they also phone them more frequently.40

Even though newer technologies provide convenient means for grandparents to maintain relationships with their grandchildren, the take-up of these new methods of communication seems to be occurring only in a minority of grandparents. Quadrello and colleagues reported that face-to-face contact remained the most frequent method of contact with their grandchildren, followed closely by landline telephone; there was moderate use of mobile phones, and many used letters/cards occasionally; a minority used SMS and emails.41 Even grandparents separated from their children by large geographic distances are more likely to use the telephone than email.42

Diversity in grandparents

Gender differences

Several studies have reported that grandmothers are more satisfied in the grandparent role than grandfathers.43,44 For many women of previous generations in particular, the grandmother role has been an extension of their familiar maternal role. This is not the case for grandfathers, the current generation of whom are likely to have had little contact with young children during their working lives. It remains to be seen if, in the future, the current-generation X and Y with their purportedly more democratic views of gender-stereotyped behaviours will show the same sex-typed skills and interests. More recent studies however have reported no gender differences in grandparent satisfaction and qualitative studies have also suggested that greater grandparent satisfaction appears to be related to the degree of negotiation that occurs about the boundaries and responsibilities associated with that role.35 45 46 47 48

More conclusive evidence exists of a gender difference in frequency of contacts. Several studies have shown that significantly more grandmothers than grandfathers saw their grandchildren at least once a week or were in touch with at least one of their grandchildren more often,47,49,50 even when lineage is controlled for.13 Grandmothers are also more likely to have participated in activities with their grandchildren than were grandfathers.50,51 However, while the frequency of contact may decline irrespective of gender when the grandchild becomes an adolescent, there is evidence that the existing emotional connection remains.52

There are also reports of gender differences in the care of grandchildren. Several large studies from the USA and Europe have reported that grandmothers provide more care for their grandchildren than grandfathers do. Guzman found that more grandmothers (54%) provided child care for their grandchildren than grandfathers (38%),18 while Hank and Buber reported that 58% of grandmothers and 49% of grandfathers provided some kind of care for a grandchild aged 15 or younger.22 Results from the British Social Attitudes Survey found that working-age, working-class grandmothers on low incomes were more likely to be providing child care than any other groups.3 Grandmothers also provide more hours of child care than grandfathers do. Parents reported that young children who were cared for by grandparents received an average of 23 h of care a week from grandmothers, compared with 16 h from grandfathers.18 Traditional gender divisions in the type of child care that grandparents provide also seem to exist.36,53 Grandmothers report that they are more engaged in the welfare of the child, and take on a more caregiving role. In addition to playing with their grandchild and taking them on excursions, grandmothers report they are more likely to feed, change clothing/nappies and clean their grandchild. Grandfathers, on the other hand, appear to involved with the entertainment of the child, playing with them, taking them for walks and showing them how to make things.

Age differences

There have been a number of studies examining the associations between age and grandparenting. Neugarten and Weinstein reported that younger grandparents were more likely to have distance or fun-seeking relationships with their grandchildren, while older grandparents were more likely to have a stricter relationship.54 Thomas found that younger grandparents expressed greater responsibility for disciplining, caretaking and offering child-rearing advice. The diversity of roles has been found to be an issue for grandparents, but especially for younger grandmothers.43 Somary and Stricker reported that grandparents who were less than 55 years of age reported high scores for caretaking responsibility.44 Burton and Bengtson noted that women who became grandmothers at a young age were dissatisfied because their grandmotherhood role conflicted with their other social roles.55

Age differences have also been reported in grandparent provision of child care. Hank and Buber found that grandfathers were more likely to provide care if between ages 60 and 69, and grandmothers were less likely to if they are 70 years of age or older.22 Baydar and Brooks-Gunn reported that there was a non-linear relationship between age of a grandmother and caring for grandchildren. Other characteristics being equal, grandmothers younger than 67 had increasing odds of giving care as they got older and these odds peaked around age 67. Grandmothers older than 67 had decreasing odds of providing child care as they got older.56

Attachment differences

Numerous studies on contemporary grandparents and grandchildren show that they interact with each other often and tend to be emotionally close and have mutually satisfying relationships. Spitze and Ward in general found that grandmothers tend to be more nurturing than grandfathers, which seems to be a component of building emotionally close relationships.57 Qualitative studies have also reported similar findings. In Gattai and Musatti's study of Italian grandmothers, all of the participants explicitly acknowledged the feeling of affection linking them to their grandchildren. They expressed this as a bond of attachment, or as strong physical involvement/physical expressions. Many grandmothers admitted that this new feeling was even stronger than that felt for their own children.36 Connor also noted that attachment between grandparents and their grandchildren can be affected by a diverse range of factors, including the grandparents' own lifestyle, in terms of employment, available social supports and socioeconomic stability, and the involvement of grandparents before children entering their care.58 More frequent contact, greater grandparent involvement and better parent-grandparent relationships predicted adolescents' reports of higher levels of emotional closeness to their closest grandparent.59

Residential grandparents and grandparents who are primary caregivers, not surprisingly, also form strong attachments with their grandchildren. Grandchildren who physically resided in their grandparents' home for a period of time were found to have significantly higher intergenerational relationship satisfaction. In addition, these grandchildren also showed more positive perceptions of their grandparent as a nurturer and as a mentor, as well as being an influential factor in their lives.52 However, when that attachment is lacking, children whose custodial grandparents are less responsive to them at home are more likely to exhibit externalising behaviour problems.60 61

Ethnicity differences

Families of minority ethnic background have been described as more likely to have grandparents with significant caretaking responsibilities for their grandchildren for a number of reasons, including their household arrangements, societal/environmental factors, and cultural beliefs and practices.62 Research on ethnicity and grandparenting showed important differences with regards to expectations concerning the grandparenting role. African-American grandmothers attach key values to the grandparent role and experience greater social identity, expansion of self, altruism and power as a result,63 and grandparents often support young parents and influence their daughters in three-generation families.64 Hispanic grandparents often expect to be involved in raising their grandchildren and have greater expectations for intergenerational assistance than African-American or Caucasian grandparents.65,66 Hispanic grandparents also expect to provide for their grandchildren in times of crisis, mothers and grandmothers collaborate extensively with child care, and family members share expenses.67,68 Asian-American grandparents are more likely to live with their grandchildren and adult children than by themselves or with their spouses.2,69 Tam and Detzner found the typical form of assistance offered to families by Asian grandparents was child care.70 Grandmothers were a source of child care when both parents were working and acted as substitute parents. Grandmothers especially travelled to help out in times of need. Child-rearing knowledge is highly valued, and grandparents were reported to be helpful in the development of ethnic identity. Caucasian grandmothers have been reported as being more burdened by the primary caregiver role than African-American grandmothers,71 and it is speculated that Caucasian grandparents emphasise parental independence and maintain a companionable or remote style of grandparenting.51,72 In terms of activities, Caucasian grandparents are more likely to be involved in recreational and companionable activities, whereas African-American grandparents tend to share religious activities with their grandchildren.51

Evidence gaps in the healthcare and other needs of grandparents

As we have seen there is no particular reason to offer different healthcare services to people who happen to be grandparents, although services such as information, computer literacy, transport and peer support may always be welcome as they are with any segment of the population. From a preventive mental health perspective it is appropriate to maximise opportunities that grandparenthood may bring for chances to learn and to gain a sense of worthwhile contribution to family and society. The nurturance and guidance that grandparents provide for their grandchildren may also be valued by their adult children. Especially when parents are inexperienced and struggling to define their parenting values, cope with unfamiliar baby demands and achieve a balance between home-life and employment, grandparents may be tempted to offer unsolicited advice or to take control in ways that reduce the parents' self-confidence rather than foster it. Empathetic support is likely to be appreciated but if the grandparent-parent attachment is to be maintained and even strengthened, parental decisions and policies need to be treated with respect. This may apply particularly in times of rapid social change or where there are large cultural or socioeconomic differences between the generations.

What do grandparents themselves express need for? At the website for Family Relationship Services Australia (accessed 21 May 2010) advice is offered to those who feel upset about entering this new phase of life, feel concerns about their children's readiness to have children, are unwilling to provide emotional, practical or financial support, or worry about conflict over religion and cultural observance. Conflict, whether with the disturbed, parent-absent grandchild, or with the parent over child-rearing practices in three-generation households, has indeed been linked to poorer health of grandmothers.73

Future research needs

As theory is relatively underdeveloped and most reports are descriptive only, it may be premature to call for a systematic literature review with meta-analyses of findings.

Here we summarise some of the unanswered questions that could beneficially be addressed by large-scale surveys with representative samples and standardised measures of individual and family psychological well-being, followed up by qualitative methods to pursue issues in depth.

We agree with Szinovacz's conclusion that researchers must pay more attention to the dynamic rather than static nature of the grandparent-grandchild interaction.2 How does it change as each party grows older, and as others (parents, siblings, partners) enter and leave the family? How is it affected by the relations between maternal and paternal relatives, and among the adult children of the grandparent? She also called for more attention to the effects of divorce and the phenomena around stepgrandchildhood.

Are there specific training or support needs for the important emotional work of grandparenthood? For example, how might these needs differ from those of other informal caregivers? It seems likely that such needs will be as diverse as the grandparents themselves and their family structures and expectations are. What are the most effective and cost-effective resources to meet these needs? How may grandparenthood contribute to individual psychological development and well-being?

A comprehensive view of the health-promoting society means a lot more evidence needs to be collected about grandparenthood in all its complexity.

References