Caregiver Strain in Families of Children with Serious Emotional Disturbance: Does Relationship to...

Caregiver Strain in Families of Childrenwith Serious Emotional Disturbance:

Does Relationship to ChildMake a Difference?

Craig Anne Heflinger, PhDKelly D. Taylor-Richardson, MSW

ABSTRACT. With the prevalence of kinship care increasing, it is criti-cal to understand the role of caregiver strain among this population. Thisstudy focused on the strain experienced by relative caregivers as com-pared to parents who were caring for children with serious emotionaldisturbance (SED). Descriptive and multiple regression analyses dem-onstrated that both caregiver groups reported similar amounts of ele-vated strain, with the exception that parent caregivers of children withSED reported more subjective internalized strain than did other relative

Craig Anne Heflinger is Associate Professor, Human and Organizational Develop-ment, Peabody College of Vanderbilt University, Nashville, TN.

Kelly D. Taylor-Richardson is currently a doctoral student in the Community Re-search and Action Program, Department of Human and Organizational Development,Peabody College of Vanderbilt University.

Address correspondence to: Craig Anne Heflinger, PhD, Peabody College ofVanderbilt University, Box #90, 230 Appleton Way, Nashville TN 37203.

The authors would also like to thank the caregivers who participated in this studyand shared their experiences with them.

Collection of the data used in this study was funded by the Substance Abuse andMental Health Services Administration (SAMHSA), Center for Substance Abuse Pre-vention (UR7 TI11304). Preparation of this article was supported by the SAMHSACenter for Substance Abuse Treatment (KD1 TI112328) and the National Institute forMental Health (T32 MH19544). Its contents are solely the responsibility of the authorsand do not necessarily represent the official views of the funding agencies.

Journal of Family Social Work, Vol. 8(1) 2004http://www.haworthpress.com/web/JFSW

caregivers. The child welfare system, providers of behavioral healthservices, and policy-makers need to pay closer attention to this special pop-ulation of caregivers and the children in their care. [Article copies availablefor a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mailaddress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Kinship care, caregiver strain, children with seriousemotional disturbance

BACKGROUND

The prevalence of kinship care has been increasing nationally. Approxi-mately 2.15 million children lived with relatives without a parent present in1994, slightly more than 3% of the child population (Harden, Clyman,Walker, & Rubinetti, 1997). In 1998, 5.4 million children lived in house-holds headed by a relative other than a parent (Children’s Defense Fund,2001). In 2000, 6.3% of all children were living with a grandparent(Bryson, as cited in Pruchno & McKenney, 2002). With the high levels ofchild abuse across the country and involvement of child protective ser-vices–879,000 children were found through investigation to have been vic-tims of abuse or neglect in 2000 according to the most recent NationalChild Abuse and Neglect System Data System (NCANDS) report (ACF,2002)–removing children from the abusing home has placed an increasingdemand on the foster care system. Of the over one half million children infoster care, one quarter were placed with a relative (Geen, 2003). The ma-jority of kinship caregivers are single females related to the biologicalmother of the child, including grandparents, aunts, or adult siblings(Bonecutter, 1999). Other studies have described the population of kinshipcaregivers similarly as older, minority, and female, with limited financialresources and mental and physical health problems of their own (Berrick,Barth, & Needell, 1994; Fuller-Thompson, Minkler, & Driver, 1997;Thornton, 1991; Kelley, Whitley, Sipe, & Yorker, 2000; Whitley, Kelley, &Sipe, 2001). There are many reasons offered for the rise in this phenomenonincluding the death of biological parents due to the AIDS epidemic, drug ad-diction, and incarceration (Burton, 1992; Dressel & Barnhill, 1994;Minkler & Roe, 1993). Mandates to place children in the least restrictivesetting have also increased the efforts of the child welfare system to seekout relatives for children needing foster care placement (Adoption andSafe Families Act of 1997).

28 JOURNAL OF FAMILY SOCIAL WORK

Due to the assumption by some child welfare caseworkers that rela-tive caregivers need less supervision and support than non-relative fos-ter parents and the assumption of the system that families have aresponsibility to their own, many relative caregivers receive irregular,limited services (Berrick, Barth, & Needell, 1994; Hornby, Zeller, &Karraker, 1996; Inglehart, 1994; Wilhelmus, 1998). In addition, al-though research has shown that children needing foster home placementmay have fewer adjustment problems when placed with relatives, manyof the financial and social supports available for non-relative caregiversare not available to relative caregivers, especially when the caregivingarrangement is not legally recognized by the child welfare system(Berrick, Barth, & Needell, 1994; Iglehart, 1994). Although in onestudy, grandparents stated that they would need “instrumental and emo-tional services” to continue caring for their grandchildren (Burton,1992), another study suggested that relative caregivers, particularly Af-rican American grandmothers, may not request social services (Gibson,2002).

There is reason to believe that relative caregivers experience strain incaring for the children placed with them, especially those with specialneeds (Kolomer, McCallion, & Janicki, 2002). Caregiver strain is de-fined as the demands, responsibilities, difficulties, and negative psychicconsequences of caring for relatives with special needs (Brannan,Heflinger, & Bickman, 1997). Often referred to as “burden of care,”caregiver strain has been studied in relation to care provided to relativeswith Alzheimer’s, dementia, chronic health problems, developmentaldisabilities, and mental illness. Research regarding caregiver strain hasidentified several areas of strain including, but not limited to, financialstrain, conflict between family members, effect on family life, effect onphysical and mental health of the caregivers, and limitations on time,personal freedom, and privacy (Braithewaite, 1992; Burton, 1992;Fuller-Thompson, Minkler, & Driver, 1997; Platt, 1985; Schene, 1990;Strawbridge, Wallhagen, Shema, & Kaplan, 1997). The field broadlyacknowledges both the objective and subjective dimensions of care-giver strain (Hoenig & Hamilton, 1967; Montgomery, Gonyea, &Hooyman, 1985; Platt, 1985). Objective strain refers to onerous observ-able events and occurrences experienced by the family and caregiver asa result of the relative’s problems, such as financial strain, disrupted re-lationships, interruptions at work, reduced personal time and social con-tact, among others. Subjective strain captures caregiver’s feelings aboutcaring for relatives, such as anxiety and worry, or anger and resentment.

Craig Anne Heflinger and Kelly D. Taylor-Richardson 29

It is well-established that families caring for relatives with physical,emotional, behavioral, or mental disorders experience considerablestrain associated with their caregiving responsibility (e.g., Biegel,Milligan, Putnam, & Song, 1994; Hoenig & Hamilton, 1967; Marsh,1992; McDonald, Poertner, & Pierpont, 1999). There is a growing liter-ature on caregiver strain experienced by parents of children with seriousemotional disturbance (Angold et al., 1998; Brannan & Heflinger, 2001;Brannan, Heflinger, & Bickman, 1997; Farmer, Burns, Angold, &Costello, 1997; Kuhlthau et al., 2001). To date, however, little research hasbeen done that focused specifically on the needs of those providing kin-ship care, and none has examined caregiver strain among relative care-givers of children with serious emotional disorders (SED).

This study addresses that gap in our knowledge of this phenomenonamong this growing population. The purpose of this study was to pro-vide information on caregiver strain among family members other thanparents who were providing care for children with SED. The primaryresearch questions were: (1) What is the extent of caregiver strain re-ported by kinship caregivers of children with SED? (2) Do kinship care-givers experience higher levels of caregiver strain than parents caringfor children with SED?

METHODS

Sample

We conducted secondary analysis on existing interview data withfamily caregivers of children with serious emotional disturbance inMississippi and Tennessee. All children were Medicaid beneficiariesand these families participated in the Impact of Medicaid Managed CareStudy (IMMC), for which a stratified random sample of Medicaid chil-dren and adolescents in two states was recruited and interviewed to ex-amine the impact of a shift to Medicaid managed care on services toyouth with emotional and behavioral problems (for more details onIMMC, see Heflinger et al., 2000). The sample included children in onestate who were enrolled through managed care Medicaid, and childrenin another state with traditional fee-for-service Medicaid. Because thisstudy is interested in caregiver strain generally and not in site differ-ences, caregivers from the two states were combined.

Recruitment for the study proceeded in three steps. First, the projectidentified 310,366 youths in Tennessee and 132,733 in Mississippi who

were enrolled in Medicaid at some point between July 1, 1995 and June30, 1996 and who would be between the ages of 4 and 17 at the time ofinterviews. A stratified random sample of approximately 5,000 childrenper state was selected for recruitment. Next, a two-stage recruitmentprocess was used because of confidentiality concerns expressed by thestate Medicaid bureaus. In the first stage, parents/guardians of the chil-dren were contacted by mail originating from a state agency on its letter-head until 1,000 respondents consented to participate (500 in each state)through return of a post card or a call to a toll-free number. Based onprior research with Medicaid populations that were recruited throughmail only, a 20% response rate was expected (Rohland & Rohrer, 1996;Rubin et al., 1996) and was achieved. In the second stage, interviewersobtained written consent to participate during an in-person visit. No onewho consented to be interviewed refused to be interviewed, but somewere excluded because they no longer had Medicaid eligibility or be-cause we had met our quota of interviews. The result was a net yield of473 Tennessee interviews and 490 Mississippi interviews. This studywas approved by the Vanderbilt University Institutional Review Board.

Children were determined to have serious emotional disturbance(SED) based on their past use of mental health services, per the IMMCprocedures (Cook et al., in press). Based on Medicaid claims and/orcaregiver report, children were identified as SED if they had receivedany of the following services for a mental health disorder (other than ad-justment or developmental diagnoses): inpatient hospitalization, resi-dential treatment, case management, partial hospitalization, or 10 ormore outpatient visits within one month. Caregivers were included ifthey had completed the Caregiver Strain Questionnaire (described be-low) as part of their interview. Persons other than the parents or otherrelatives caring for the child (e.g., professional caretakers in residentialtreatment) were excluded from the sample. For this study, our sampleconsisted of 648 family caregivers of children with SED (children ages4-17 years), of which 539 were parents and 109 were other relatives.The other relatives who were providing kinship care were primarilygrandparents but included aunts and uncles, and older siblings.

Instruments

Measures of child, caregiver, and household characteristics were in-cluded in this study.

Child characteristics. Child emotional and behavioral problems haveconsistently been found to be a primary predictor of caregiver strain

(Angold et al., 1998; Brannan, Heflinger, & Bickman, 1997; Yatchmenoffet al., 1998). In this study, child’s mental health symptomatology was mea-sured with the Child Behavior Checklist (CBCL; Achenbach, 1991). TheCBCL is a symptom checklist completed by caregivers listing 113symptoms rated on a 3-point scale ranging from 1 (i.e., not true) to 3(i.e., very true or often true). The internalizing and externalizing scalescores were used for this study. The CBCL has been widely used inchild and adolescent behavioral health research (e.g., Bickman et al.,1995) and has demonstrated good validity and reliability with multiplesamples (Achenbach, 1991). The CBCL T-scores (i.e., standardized forage and gender) scores were used for descriptive purposes, but rawscores were used for the regression analyses, per the author’s recom-mendations (Achenbach, 1991) when child age and gender are used ascontrols.

Youth psychosocial functioning was measured with the caregiver re-port version of the Columbia Impairment Scale (CIS; Bird et al., 1993).The CIS includes 13 items assessing psychosocial functioning at home,school or job, and peers rated from 0 (i.e., no problem) to 4 (i.e., a verybig problem). The reliability and validity of the CIS has been supportedin previous research (Bird et al., 1993).

Child age and gender were included as control variables. Measures ofemotional and behavioral problems have been shown to differ by ageand gender (e.g., the CBCL, Achenbach, 1991). Race was also includedas a covariate, since race has been found to influence caregiver strain inseveral studies in both adult (Cook et al., 1994; Guarnaccia, Parra,Deschamps, Milstein, & Argiles, 1992; Horwitz & Reinhardt, 1995;Stueve, Vine, & Streuning, 1997) and child (Kang, Brannan, &Heflinger, 2003) samples.

Caregiver characteristics. Caregiver strain is the focus of this studyand was measured by the Caregiver Strain Questionnaire (CGSQ;Brannan, Heflinger, & Bickman, 1997), a 21-item self-report instru-ment that asks specifically about the impact of caring for children withemotional and behavioral problems in the past 6 months. Items wererated on a five-point Likert scale with 1 equivalent to “not at all” and 5equivalent to “very much” in reference to the amount of burden felt bythe caregiver in relationship to the child. The questionnaire consists ofsubscales tapping three dimensions of caregiver strain: objective strain(negative, observable occurrences resulting from caring for the child),subjective-internalizing strain (feelings internalized by the caregiver re-garding caring for the child such as sadness, fatigue, and worry), andsubjective-externalizing strain (negative feelings about the child’s

problems such as anger, resentment and embarrassment). The CGSQ’ssubscales and total scale have demonstrated adequate validity and inter-nal consistency.

A measure of caregiver mental health status was included as acovariate since studies have documented high level of emotional dis-tress among grandparent caregivers (Kelly, Whitley, Sipe, & Yorker,2000) and the need to differentiate between caregiver distress and strainhas been emphasized (Brannan & Heflinger, 2001). Caregiver mentalhealth status was measured using the SF-12 Health Survey (Ware,Kosinski, & Keller, 1996), a 12-item instrument for self-report of healthstatus condensed from the Medical Outcomes Study SF-36 Health Sur-vey (Hays & Sherborne, 1993). The measure includes a physical com-ponent summary (PCS) and a mental component summary (MCS), butonly the MCS was used for this study. For the SF-12, scale scores havebeen calculated on a 0-100 scale, with higher scores indicating betterhealth status and functioning. Adequate reliability and validity of theshorter SF-12 have been demonstrated, as has its ability to replicate theglobal scores of the SF-36 (Ware, Kosinski, & Keller, 1996).

Caregiver age and gender were also included as covariates in the re-gression.

Household characteristics. Household-level variables included inthese analyses were number of people in the household and family in-come. Caregivers reported on total monthly income by all family mem-bers from a variety of sources including earned income; foster familypayments, income support programs (i.e., WIC, food stamps, TANF);federal support for disabled persons (i.e., SSI, SSDI); worker’s com-pensation; unemployment compensation; pensions, retirement, invest-ment, or savings income; Social Security; and unreported or otherincome.

Analyses

First, descriptive statistics were used to describe the sample and testitem-level differences between parents and kinship caregivers. Next,multiple regression was used to determine the effects on the three di-mensions of caregiver strain of adding relationship to child to a regres-sion model controlling for other child and family variables. The steps inthe regression analyses were (1) child variables, including demograph-ics and child problems, demonstrated by the CBCL and CIS; (2) care-giver and household variables including demographics, mental healthstatus, number of people in the household, and total monthly family income;

and (3) the relationship of the caregiver to the child (parent vs. other rel-ative).

RESULTS

The children in the study were 11 1/2 years on average (see Table 1),with no significant differences on child demographics or emotional/be-

TABLE 1. Characteristics of the Sample

Living with ParentsN = 539

Living with OtherRelativesN = 109

% Ages 4-8 Years 16.0% 13.8%

% Ages 9-11 Years 33.2% 33.0%

% Ages 12-17 Years 50.8% 53.2%

Mean Age in Years 11.6 11.5

Gender (% Female) 30.1% 30.3%

Race/Ethnicity

% African American 44.4% 51.9%

% Hispanic 1.9% 4.6%

Emotional/Behavioral Problems

Mean CBCL T-Score- Internalizing (S.D.) 64.2 (11.8) 65.6 (12.0)

Mean CBCL T-Score Externalizing (S.D.) 67.1 (11.7) 67.4 (12.2)

Mean CIS Score 24.7 (10.5) 24.8 (11.3)

Caregiver/Household

Mean Age in Years 35.9 52.6**

Gender (% Female) 96.1% 95.4%

Caregiver Strain

Mean Objective Strain Score (S.D.) 2.24 (1.04)* 2.03 (.90)

Mean Subjective - Externalizing Score (S.D.) 2.00 (.89) 1.86 (.94)

Mean Subjective - Internalizing Score (S.D.) 3.21 (1.13)* 2.93 (1.01)

Mean SF-12 Mental Health Score 47.2 52.8*

Number of People in Household 4.3 4.3

Total Monthly Family Income $1380 $1569

**p < .01, *p .05

havioral problems between the two groups. Both groups of children,however, demonstrated significantly high levels of problems, with boththe CBCL and the CIS mean scores falling above the clinical cutoffsrecommended by their respective authors.

Caregivers were primarily female. The kinship caregivers were sig-nificantly older than the parents, since most were the grandparents, withan average age of 52.6 years, and had higher income with a self-reportedtotal monthly income of $1,569. Other relatives also had a significantlyhigher mental health status score, indicating healthier functioning. Onunadjusted mean differences in caregiver strain scores, the parents re-ported significantly higher objective and subjective-internalizing strainthan the other relatives.

Table 2 shows the mean item scores on CGSQ items by group andTable 3 reports the proportion of caregivers who reported high levels ofstrain by item, distinguished by the highest ratings on the Likert scale (4and 5). After using the stringent Bonferoni-adjusted alpha level, therewere significant differences on only two of the items, with parents con-sistently reporting higher levels of strain. Parents consistently ratedfeelings of worry about the family and guilt about their children’s prob-lems than did the other relative caregivers. What is noteworthy, how-ever, is the similar and high levels of strain reported by these kinshipcaregivers overall. On 11 of 21 items, at least 25% of one or both groupsof family caregivers reported high levels of strain associated with caringfor their child with SED.

Next, the results of the multiple regression analyses are presented(see Table 4). In only one of the three caregiver strain subscales did theinformation on relationship to the child (parent vs. other relative addedin Block 3) significantly add to the prediction of caregiver strain. Beinga parent was a significant predictor of strain only for the subjective in-ternalizing scale, where we saw in Table 1 that parents reported higherstrain. The regression model for subjective-internalizing strain ac-counted for 35% of the variance. In the regression models for objectiveand subjective-externalizing strain, accounting for 46% and 23% of thevariance, relationship to child was not a significant predictor of strain.

In each of the regression models, some child and caregiver variableswere significantly associated with increased caregiver strain. As inother studies (Angold et al., 1998; Brannan & Heflinger, 2001;Brannan, Heflinger, & Bickman, 1997; Yatchmenoff et al., 1998), thechild’s emotional/behavioral problems were significant predictors ofcaregiver strain, with a greater level of externalizing and communityproblems associated with a higher level of caregiver strain. The child’s

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CBCL externalizing and CIS scores were predictive on all scales. TheCBCL internalizing scores influenced caregiver strain in opposite di-rections for two of the scales. For subjective-externalizing strain–wherecaregivers report negative feelings about the child’s problems such asanger, resentment, and embarrassment–higher child internalizing prob-lems were associated with lower levels of strain. For subjective-inter-nalizing strain–where caregivers report anxiety and worry–similartypes of child internalizing problems led to increased caregiver strain.

The caregiver SF-12 mental health scores were significant predictorsof strain on all subscales with poorer mental health status associatedwith greater caregiver strain. This is consistent with the literature thathas found that caregiver’s psychological distress is correlated withhigher levels of strain (Brannan, Heflinger, & Bickman, 1997; Heflinger &Brannan, in review; Noh & Turner, 1987). This relationship is notstraightforward, however, as there is evidence that caregiver strain may

TABLE 4. Regression Results Predicting Objective, Subjective-Externalizing,and Subjective-Internalizing Caregiver Strain

Objective Strain Subjective -Externalizing Strain

Subjective -Internalizing Strain

Independentvariables

BlockR2

Beta* p BlockR2

Beta* p

Child (Block 1) .426 < .001 .215 < .001 .302 < .001

Age .014 .647 .123 .001 .034 .314

Gender (Male) .008 .801 �.034 .346 .010 .753

Race (African-American)

�.131 < .001 �.040 .265 �.050 .135

CBCL- Internalizing .046 .228 �.176 < .001 .116 .006

CBCL- Externalizing .259 < .001 .308 < .001 .167 < .001

CIS .350 < .001 .234 < .001 .257 < .001

Caregiver (Block 2) .456 < .001 .231 .024 .347 < .001

Age �.027 .488 .014 .771 .027 .528

Gender (Male) .012 .675 �.013 .711 .009 .779

SF-12 Mental Health �.167 < .001 �.114 .003 �.205 < .001

# People in Household �.044 .155 .048 .197 �.077 .024

Total Family Income .036 .252 .005 .899 .097 .004

Parent (Block 3) .458 .049 .196 .233 .055 .220 .353 .102 .014

*Standardized Beta

mediate the relationship between child symptoms and psychologicaldistress (Brannan & Heflinger, 2001).

The older the child, the higher the caregiver strain reported only on thesubjective-externalizing subscale. Household size and total family incomewere predictive of strain on the subjective-internalizing scale. These find-ings are also consistent with the kinship care literature (Musil & Ahmad,2002; Pruchno, 1999).

Limitations of the Current Study

This study is the first of its kind to look at the strain experienced byrelative caregivers of children with SED. However, since this study wasdone with a Medicaid population, results may not be generalizable toother groups of kinship caregivers and the children in their care. Thisrepresents a group of poor children and families, since they meet the in-come eligibility of the Medicaid program, and a population that relieson the publicly-funded service sector. The publicly-funded service sec-tor is often the focus of research in this field. More research is neededabout this phenomenon in other populations.

Although this study’s yield from recruitment is low by traditionalsurvey research standards, they are comparable to other mail-based re-cruitment strategies with Medicaid enrollees (Rohland & Rohrer, 1996;Rubin et al., 1996) and we reached our expected sample size. Examina-tion of differences between consenting and non-consenting participantswas conducted using Medicaid data that allowed comparison of demo-graphics and service use patterns. Our sample tended to have youngerchildren, thus including age in the regression models helps to control forthose differences (Saunders, 1998); however, study participants maystill differ in some unmeasured ways.

DISCUSSION

The results of this study document the existence of caregiver strainamong kinship caregivers of a child with serious emotional disorders.While caregiver strain has been increasingly recognized as an importantaspect of parent experience, it is important to verify that this phenome-non also applies to other relatives caring for children. On both the objec-tive and subjective-externalizing strain subscales, relative caregiversexperienced levels of strain similar to parents, and they reported signifi-cantly lower levels of subjective-internalizing strain than did parents in

both the descriptive and multivariate analyses. We had initially won-dered, however, if kinship caregivers would report higher levels ofstrain in general when taking on the care of a child with SED. However,the non-significant differences document an important finding–thatkinship caregivers are experiencing similar levels of caregiver stain toparents and that strain is predicted by similar variables. Thus, kinshipcaregivers need to be considered for the same types of supports as par-ents.

A possible explanation for our not finding higher levels of strainamong kinship caregivers is highlighted in one study of grandparents asprimary caregivers that noted that grandparents placed in the situationof caring for their grandchildren already had difficult lives including thecircumstances that led to them caring for the child(ren); therefore theircaregiving role was an additional rather than new burden (Strawbridge,Wallhagan, Shema, & Kaplan, 1997). One study of parental stress ingrandparents versus parents of children with behavior problems did findthat grandparents reported lower levels of stress than single- andtwo-parent respondents (Harrison, Richman, & Vittimberga, 2000). Wealso had a high percentage of African-American caregivers in the cur-rent study, and it has been demonstrated that this group found thecaregiving role less burdensome than their white counterparts (Pruchno,1999). Compared to parents, however, in this study greater proportionsof relative caregivers reported high levels of strain on interruption ofpersonal time (45.9% vs. 37.8%) and financial strain (16.5% vs. 15.8%)[note, these differences were significant at p .05 but did not meet thestricter Bonferoni level of p .002]. The sense of disruption in personaltime has been noted in other literature as related to “off time” events inthe life cycle when grandparents, especially, have thought that theirchildrearing days were over and now find themselves in a parenting role(Minkler & Fuller-Thomson, 2001).

Other studies have shown that child problems are the most powerfulpredictor of caregiver strain with more problems resulting in morestrain (Angold et al., 1998; Brannan & Heflinger, 2001). Parent mentalhealth status has also been shown to influence strain with more healthymental health status associated with less strain (Brannan & Heflinger,2001). In our study, higher numbers of people in the household was as-sociated with lower strain. This may be due to the caregiver(s) feelingthey have more social support (Pruchno & McKenny, 2002; Whitley,Kelley, & Sipe, 2001), and therefore having more assistance with theday-to-day childcare responsibilities. We also found that higher incomewas associated with higher strain on the subjective-internalizing strain

scale. This finding is contrary to most studies (Brannan & Heflinger,2001; Rhoades & McFarland, 1999), perhaps related to the severely de-pressed income bracket of the families in the current study. Higher in-come may result in fewer availability of services if the services arebased on income eligibility requirements. It also may be that caregiversdo not equate financial strain with the child’s problems.

Although the kinship caregivers reported similar levels of strain tothe parents overall, they did report high levels of strain in general. Theitems on the CGSQ that more than one quarter of the other relativecaregivers reported as resulting in “quite a bit” or “very much strain”included: interruption of personal time (45.9%), missing work(26.6%), sadness as a result of the child’s problems (42.1%), worryabout the child’s future (76.8%), strain as a result of the child’sproblems (39.2%), and the toll the child’s problems had on the family(32.7%). These results are consistent with the current research that indi-cates relative caregivers experience psychological, social, and familialstrain as a result of their caregiving role (Kelley, Whitley, Sipe, &Yorker, 2000).

Implications for Social Workers

This study’s unique contribution to the literature is that of highlight-ing a potentially vulnerable subset of relative caregivers. The child wel-fare system, providers of behavioral health services, and policy-makersneed to pay closer attention to this special population of caregivers andthe children in their care. Caregiver strain has been shown to have a neg-ative affect on the caregiver’s health (Musil & Ahmad, 2002; Whitley,Kelley, & Sipe, 2001). Often relative caregivers are of low income and asignificant number are grandparents with their own health concerns(Strawbridge et al., 1997; Thompson et al., 1997; Whitley, Kelley, &Sipe, 2001). Reducing strain and therefore improving or maintainingthe health of the caregiver so that they may continue caring for the childmay insure that the child will avoid entering the non-relative foster caresystem. Caregiver strain also has been shown to influence not only thecaregivers themselves but also the services that their children receive.Higher levels of caregiver strain have been associated with childrenusing more restrictive levels of treatment (e.g., residential versus outpatient)(Bickman, Foster, & Lambert, 1996; Foster, Saunders, & Summerfelt, 1996;Lambert, Brannan, Heflinger, Breda, & Bickman, 1998), having longerlengths of stay (Foster, 1998; 2000), and incurring higher costs of care(Brannan, Heflinger, & Foster, 2003). By providing more support to

caregivers–including those that are relatives other than parents–and re-ducing strain, more expensive and restrictive levels of care could poten-tially be avoided as we work toward supporting children and theirfamilies in community settings.

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