A 6-year-old female came to clinic who was well-known to the practice for a fever and earache for 1 day. She previously had rhinorrhea for 3 days, and was otherwise well. The past medical history was non-contributory. The pertinent physical exam showed a healthy female with temperature of 39.4°C with other vital signs and growth parameters normal. She had copious clear rhinorrhea, slightly erythematous pharynx and a left ear with erythema, pus and immobile tympanic membrane. The right ear had a splayed light reflex and opaque fluid behind the tympanic membrane with a fluid level. The diagnosis of left otitis media was made. The grandmother remarked that she was now happier because she had recently gained legal custody of the girl and her 8 year old brother. She now could make decisions for them without seeking permission through the foster care system. She said she felt relieved because “now my babies are legal and well taken care of.” She denied any significant stress and felt currently supported through the social service system. She said that she would contact the clinic if she had any medical or social concerns.
Grandparents provide an important and unique role in children’s lives, providing continuity across generations. Grandparents often provide indirect (i.e.suprvising and interacting with the children along with other adults) and direct childcare (being the sole care provider). The childcare arrangements may be informal or formal. In addition to regular child safety issues in any home, grandparent homes need particular attention in a few areas. Medications need to be properly locked out of reach of the children. Walking aids and other mobility equipment should be moved out of the child’s play area if possible. Handrails and bars in bathrooms should be covered with soft material if children will be bathed there. Furniture which may have been used in the past should be checked to see if it meets current safety standards and has nothing broken or loose.
One study evaluating health of caregiving grandmothers found that rural and urban grandmothers both had similar and good levels of personal physical and mental health. Another study of grandparenthood satisfaction found grandmothers and grandfathers were very satisfied (53%) or satisfied (41%) with their grandparent role. Contact with grandchildren, grandparents own self-esteem and identity were important contributors to their satisfaction as grandparents. For grandmothers, only the role of parent and friend were more important than being a grandparent. For grandfathers, only the roles of parent and spouse were more important than being a grandparent.
For children under age 18 in the United States:
- 50% live with two biological parents
- 1.3 million live with their grandparents as parents
- 670,000 live with grandparents in their parent-headed home
- 2.5 million live with one or more parents in their grandparent-headed home
About 800,000 children are in the US foster care system during a year (moving into and out of). At any one time about 500,000 are in the system. It is estimated that about 4x that number of children are in informal kinship care which is often grandparental care. Kinship care is good in that children acquire a permanent home more quickly than those in non-kinship care. It also preserves ties to siblings and other family members.
Children living with a non-parental household are more likely to live with smokers though. Grandparent homes (53.4%) have at least one adult smoker compared to 34.4% of all children in an epidemiological study. When asked about guardianship planning, parents with HIV chose grandparents most often (36%), followed by another relative (34%) and only 17% chose the other biological parent. Young parents and those preferring to speak Spanish were also more likely to choose grandparents as guardians. Grandparents who are the legal guardians themselves also need to consider their own guardianship planning for their grandchildren.
Questions for Further Discussion
1. What are the legal procedures for placing children into kinship care in your location?
2. What are the legal procedures for adoption in your location?
3. What social services are available locally for grandparents who want to learn more about grandparenting or parenting?
- Disease: Ear Infections
- Age: School Ager
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Reitzes DC, Mutran EJ. Grandparenthood: factors influencing frequency of grandparent-grandchild contact and grandparent role satisfaction. J Gerontol B Psychol Sci Soc Sci.2004;59 (1):S9-S16.
Conway T, Hutson R. Is Kinship Care Good For Kids? Center for Law and Social Policy, March 2007. Available at http://www.clasp.org/publications/is_kinship_care_good.pdf.
Cowgill BO, Beckett MK, Corona R, Elliott MN, Parra MT, Zhou AJ, Schuster MA. Guardianship planning among HIV-infected parents in the United States: results from a nationally representative sample. Pediatrics. 2007 Feb;119(2):e391-8.
Cohen GJ. The Prenatal Visit. Pediatrics. 2009;124:1227-1232.
King K, Martynenko M, Bergman MH, Liu YH, Winickoff JP, Weitzman M. Family composition and children’s exposure to adult smokers in their homes. Pediatrics. 2009 Apr;123(4):e559-64.
Lumby J. Grandparents and grandchildren: a grand connection. Int J Evid Based Healthc. 2010 Mar;8(1):28-31.
HealthyChildren.org. Different Types of Families: A Portrait Gallery
Available from the Internet at http://www.healthychildren.org/English/family-life/family-dynamics/types-of-families/pages/Different-Types-of-Familes-A-Portrait-Gallery.aspx? (rev. 6/11/2010, cited 7/18/2011).
Bigbee JL, Musil C, Kenski D. The health of caregiving grandmothers: a rural-urban comparison. J Rural Health. 2011 Jun;27(3):289-96.
Healthy Foster Care America. Facts and Figures. Available from the Internet at http://www.aap.org/fostercare/facts_figures.html (cited 7/18/2011).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital