Introduction

Evidence-based parenting programs (EBPPs) help improve the emotional, social, and behavioral outcomes of children, typically by providing positive parenting knowledge and skills to parents (Collins et al. 2000). EBPPs are programs that have been rigorously evaluated through randomized control trials and show increased positive parenting practices and reduced ineffective disciplinary practices. EBPPs produce better mental health and developmental outcomes in children than do comparison conditions, such as care as usual, no treatment, or wait-list control conditions (Kirby and Sanders 2012). Research has found that both mothers and fathers have a significant positive influence on their child’s behavior (Fletcher et al. 2011; Lamb 2004; Lundahl et al. 2008). Although working with mothers and fathers is the most important avenue for assisting children (Sanders 2012), it has been argued that the field of parenting take a greater social ecological perspective and consider the impact that outside influences such as grandparents have on the emotional and behavioral development of children (Barnett et al. 2010; Lussier et al. 2002). This notion supports Bronfenbrenner’s (1979) social ecological framework, which postulates that an expansive view of possible influential factors needs to be considered in relation to child behavior (Garbarino 1995; Lussier et al. 2002). Consequently, it is important to move beyond the child’s immediate home environment with their parents, and evaluate the impact that other family members (e.g., grandparents), friends (e.g., neighbours) and environments (e.g., school) can have on child behavior. A growing number of researchers have identified that the grandparent–grandchild relationship influences children’s adjustment either directly (e.g., providing support) or indirectly (e.g., supporting the parent; Attar-Schwartz et al. 2009; Coall and Hertwig 2010).

The trend of grandparents providing regular child care is common in the United States, with approximately 23.7 % of all children under five receiving child care from their grandparents (Laughlin 2013). This trend of grandparent care is also echoed in Australia where approximately 25 % of children 12 years or younger receive regular child care from their grandparents (ABS 2012), and across Europe it is estimated that 40 % of children receive regular child care from their grandparents (Glaser et al. 2013). Thus, it is important that the field of parenting and family psychology examine the impact that grandparents can have on family functioning. This paper seeks to extend the existing literature on grandparenting by examining the following five key areas: (a) the role of grandparents in Western Cultures; (b) the relationship between grandparents’ and parents; (c) interventions that are available for grandparents to assist them in their caregiving roles and whether they are effective; (d) provide recommendations to EBPPs in order to modify to the population of grandparents; and (e) discuss clinical and ethical implications of working with grandparents.

The Role of Grandparents in Western Cultures

The involvement of grandparents in families varies on a continuum from custodial grandparenting to situations where grandparents have no involvement in the lives of their grandchildren (Cherlin and Furstenberg 1986; Kivnick 1982). As such, there is great heterogeneity amongst the grandparenting population. Some grandparents start their role very young (for example in their 30 s), whereas others become grandparents for the first time quite late in life (in their 70 s) having already given up the notion of ever becoming a grandparent (Rosenthal and Moore 2012). Given the heterogeneity of the grandparent population, it can be difficult to categorize grandparents into different groups. However, there appears to be two distinct groups, custodial grandparents, and informal grandparent caregivers (Kirby and Sanders 2012). The major distinction between custodial versus informal grandparent caregivers is that the former are the primary caregivers of their grandchildren, and the latter are secondary caregivers. As a result both groups face different challenges, and intervention goals that aim to assist these two populations of grandparents need to reflect these differences. To best understand how to assist grandparents and grandchildren in these situations, we must first determine the impact of care has on grandparents and grandchildren.

Caring and the Impact on Grandparents and Grandchildren

Impact on Grandparents

There are many positive and negative impact on grandparents who provide care to their grandchildren. Some of the more important outcomes are detailed in Table 1. For both custodial grandparents and grandparents providing informal care, many of the positives and negatives relate to aspects of the parenting role. Grandparents reported specific positives as being given a second chance at successful parenting (Erhle and Day 1994); feeling more useful and productive as individuals (Hayslip and Kaminski 2005); and gaining a higher sense of satisfaction from life (Ochiltree 2006). Grandparents reported some of the negatives as losing friendships (Erhle 2001); finding it difficult to manage more than one grandchild at a time (Ochiltree 2006); and feeling as though they were being taken for granted by the grandchild’s parents (Goodfellow and Laverty 2003).

Table 1 Positive and negative impact on grandparents providing care
Full size table

Impact on Grandchildren

The impact grandparents have on childhood well-being varies depending on the type of care the child is receiving. Children in custodial grandparent care are likely to originate from family units where there have been parental difficulties (e.g., drug problems, child abuse/neglect, incarceration, death), and as a result have higher reported levels of emotional and behavioral problems compared to the general population (Smith and Palmieri 2007). Smith and Palmieri (2007) compared children in custodial grandparent arrangements (n = 733, average age 9.8 years) to children in normal parental living arrangements (n = 9,878) on the Strengths and Difficulties Questionnaire (SDQ). Custodial grandchildren fared significantly worse than children from typical parenting arrangements across all domains measured by the SDQ subscales, regardless of the child’s gender. This result is not surprising, as for many grandparents becoming a custodial grandparent is developmentally off time, unplanned, ambiguous, and undertaken with considerable ambivalence (Edwards 1998; Landry-Meyer and Newman 2004). As a result, custodial grandparents typically show elevated rates of anxiety, irritability, anger, and guilt (Burnette 1999; Kelley 1993; Minkler and Fuller-Thomson 1999; Szinovacz et al. 1999). Importantly though, children in custodial grandparent care have lower rates of emotional and behavioral problems compared to children in out-of-home foster care arrangements (Tarren-Sweeney and Hazell 2006).

Unlike custodial grandparenting, there is limited research investigating the impact of grandparents providing regular child care has on children’s emotional and behavioral problems. Coall and Hertwig (2010) conducted a systematic review examining the influence that grandparents providing child care in Western cultures can have on grandchildren. Inclusion criteria for the systematic review were: (a) the study provided direct measures of grandparental investment; (b) the study provided direct measures of grandchild outcome (e.g., school performance, behavioral development); and (c) the study investigated low-risk families in Western cultures. Thirteen studies were identified with only four publications meeting eligibility criteria. Two of the reported studies had an educational focus (Falbo 1991; Scholl Perry 1996) with both these studies concluding that grandparent involvement with families had associated academic benefits for the grandchildren. Although, Coall and Hertwig (2010) noted that neither study documented what grandparents did to achieve these results. A third study focused on infant mental development (7-month olds) and grandparent contact, and found that greater grandparent contact was associated with greater infant mental development (Tinsley and Parke 1987).

The final study included in the review was by conducted by Fergusson et al. (2008) and it is of high relevance, as they investigated both the extent of grandparent care in the UK and the psychological impact that grandparents can have on grandchildren. Data was collected from 8,752 mothers who completed a range of measures, one of which was the SDQ, at four time points: 8-, 15-, 24-months, and 4-years. Based on their large sample they found that 45 % of children were regularly cared for by their grandparents at each time point. Fergusson et al. (2008) found that grandchildren who received child care from their grandparents, compared to children who received no grandparent care, were associated with elevated rates of hyperactivity and peer difficulties at age four. Although the study was not able to determine why this association existed, the authors suggested this is likely due to the family of origin characteristics (e.g., younger mothers, less educated backgrounds), as opposed to grandparent influence.

In a final study, Attar-Schwartz et al. (2009) investigated the association between degree of grandparent involvement and adolescents’ behavioral and emotional adjustment in the United Kingdom, as a function of three family structures: two-parent biological families, lone-parent families, and families with one step-parent. Data was collected from 1,515 secondary school students (aged 11–16) who completed the SDQ. Attar-Schwartz and colleagues found that greater grandparent involvement with families was associated with significantly fewer emotional problems and with significantly more prosocial behavior. However, these results were not found in two-parent biological families. The results obtained by Attar-Schwartz et al. (2009) led Coall and Hertwig (2010) to postulate that in situations of possible duress, grandparent involvement could offer a potential ‘buffering’ effect for grandchildren against developing emotional and behavioral problems.

The Relationship Between Grandparents’ and Parents

Mason et al. (2007) suggested that grandparents do not stop being parents simply because their children have had children, indeed parenting is a lifelong journey. However, being a parent to an adult, who themselves is a parent, requires a different skill-set than being a parent to a child. There are significant differences the challenges that custodial grandparents face compared to informal grandparent caregivers. Thus, the goals of interventions for custodial grandparents and informal grandparent caregivers differ, and Table 2 highlights some of these key differences.

Table 2 Intervention goals for custodial grandparents and informal grandparent caregivers
Full size table

Custodial Grandparent–Parent Relationship

In custodial arrangements there can be deleterious effects in the grandparent–parent relationship when grandparents take on the custody of their grandchild. Indeed, the circumstances that lead to custodial grandparent care can often be a result of the substance problems in the birth parents, child abuse/neglect, or incarceration, and as a result there are pre-existing conflicts between parents and grandparents, and the custodial role may exacerbate these conflicts further (Kiraly and Humphreys 2011). Moreover, custodial grandparents face boundary ambiguity of family roles, norms, and resources and this can lead to anger towards the parents (Bartram 1996; Smith et al. 2008). Indeed, Hayslip and Kaminski (2005) found that the relationship with the parent is the most negatively affected relationship when grandparents assume custodial arrangements. Therefore, a key intervention goal for custodial grandparents (as seen in Table 2) is to provide assistance with managing this relationship, and strategies focused on effective communication skills, problem solving, acceptance, and coping skills could be effective (Hayslip 2003; Kirby and Sanders 2012; Smith et al. 2008).

Informal Grandparent–Parent Relationship

The relationship between informal grandparents and parents can also experience conflict over a multitude of different scenarios, such as what parenting strategies are used by each party, what expectations people have, how people communicate with each other, and what ground rules to set. The underlying premise behind these challenges has been referred to as the double-bind effect (Thomas 1990). The double-bind effect occurs when grandparents attempt to meet the parents expectations, and parents expectations are such that they expect the grandparents to be simultaneously supportive without interfering (Thomas 1990). This has also been referred to as the norm of non-interference and the norm of obligation (Aldous 1995). The norm of non-interference emphasizes that grandparents are reluctant to get involved in the affairs of their offspring who have established their own household rules and have children (Cherlin and Furstenberg 1986). The norm of obligation emphasizes that despite the norm of non-interference, grandparents also feel obligated to help out if their offspring need help (Rossi and Rossi 1990). Consequently, the involvement of grandparents in child care, can lead to, or exacerbate, conflict and tension between the grandparents and parents (Mason et al. 2007).

The difficulty grandparents face in providing care, whilst not interfering is illustrated in research by Thomas (1990) and Mason et al. (2007). In the study conducted by Thomas (1990) 69 mothers (52 married and 17 divorced) were asked to describe the advantages and disadvantages of having grandparents in the family. Both married and divorced mothers agreed that grandparents’ childrearing advice and their interference in childrearing were the worst aspects of having grandparents in the family. This finding was replicated in a study conducted by Mason et al. (2007) where 46 grandparents were interviewed about their caregiving role. Based on the thematic analysis of the study, two major themes emerged for grandparents (a) ‘being there for parents’ and (b) ‘not interfering’. Mason et al. (2007) drew the conclusion that the grandparent role is characterised by ambivalence and this can lead to confusion, frustration, and tension in the grandparent–parent team. As a result, a key intervention goal for informal grandparent caregivers (as seen in Table 2) is to provide strategies aimed at communication skills, and this can be one way at attempting to overcome discrepancies between parent and grandparent expectations (Thomas 1990).

Interventions Available to Grandparents and are they Effective?

To determine whether interventions are effective for grandparents providing care, whether it be custodial care or informal caregiving, it is important to clearly detail what outcomes should be examined. However, these selected outcomes will be contingent on the intervention type delivered. For grandparent based interventions effectiveness can be best operationalized as whether the intervention provided improvement in four key areas: (a) grandparent parenting behavior (i.e., parenting style, parenting confidence), (b) grandparent distress levels (i.e., depression, anxiety, and stress), (c) grandparent–parent relationship satisfaction (i.e., communication, perceived support), and (d) grandchild social, emotional and behavioral outcomes. The intervention should then be evaluated through a randomized controlled trial attempting to measure these outcome areas through self-report measures or observation based outcomes.

There are a variety of intervention types available that target some of these key outcome areas for grandparents including: enrichment programs/support groups (i.e., provide social support, information on possible services to access); psychoeducational groups (i.e., provide specific information regarding issues, such as childhood development, working with schools, coping strategies for distress); parenting education groups (i.e., EBPP that provide strategies for enhancing the relationship with grandchildren and the parents), and combinations of these variants (i.e., EBPP that also includes social support, coping strategies, and information on other related issues). Table 2 documents the intervention goals for custodial and informal grandparent caregivers across these areas. Grandparents experiencing low levels of distress and difficulties would benefit from attending low-intensity based interventions, such as social support groups, self-directed programs, or brief psychoeducation seminars on a particular topic (e.g., working with schools). However, if grandparents are facing significant distress and challenges with their role, and with the relationships with parents and grandchild/ren, more high-intensity based interventions would be appropriate, such as 8–10 sessions of a group based EBPP or modules focused on building a positive parenting team with the parents.

Currently many educational and parenting interventions are being designed to assist grandparents in their role as caregivers, however many programs have not been rigorously evaluated to assess for their effectiveness or efficacy (Parke 2008). Programs to date have focused on assisting custodial grandparents; consequently, there is a paucity of literature examining the effectiveness of intervention programs for grandparents providing informal child care. Despite this, much can be gleaned from the intervention work that has been researched and trialled with custodial grandparents and this will be discussed.

Presently, one of the most popular forms of intervention for custodial grandparents are support groups (Strom and Strom 2000). Although support groups may alleviate feelings of loneliness and isolation for many grandparents, they are not well supported as an effective long-term strategy (e.g., Strom and Strom 2000; Wohl et al. 2003). It has been argued that support groups often fail because they tend to allow members to vent endless frustrations and complaints without moving on to a more positive and constructive focus (Strom and Strom 2000). Accordingly, Strom and Strom (2000) and other researchers such as Hayslip and Kaminski (2005) recommend that aspects of support and education be combined within the one intervention, with a specific focus on educating grandparents in respects to contemporary child-rearing issues.

In terms of grandparent programs some of the notable interventions published in the literature include: Project Healthy Grandparents (PHG; Kelley et al. 2001); Becoming a Better Grandparent, and Achieving Grandparent Potential (Strom and Strom 1997); The Parental Skills/Psychosocial Skills Training Program (PSPSTP; Hayslip 2003); and Grandparent Triple P (GTP; Kirby and Sanders 2014).

Project Healthy Grandparents (PHG) is an example of a high intensity psychoeducation based program combined with support group activity for custodial grandparents. PHG is a 6-month, home-based intervention, aimed to reduce psychological stress, improve physical and mental health, and increase the social support and resources of grandparents raising grandchildren. The program is a multimodal based program including the involvement of registered nurses, social workers, legal assistants, and social support group meetings. In PHG each grandparent receives individual case management from a social worker. The social worker visits the grandparent family monthly and assists in developing a strength-based action plan in order to resolve identified problems by the grandparent. The social worker also organises a six-session, monthly support group for grandparent participants. The aim of the support group is for grandparents to discuss common issues related to raising their grandchildren. Registered nurses conduct ongoing assessments of participants’ physical health and provided guidance on health problems as well as health promotion for both the grandparent and grandchild. Finally, third-year law students, under the supervision of an attorney, screened families for issues related to custodial arrangements, and provided assistance to grandparent families with these custodial issues.

The initial efficacy of PHG was measured through a pre-post test, with 25 grandparents (mean age 55.7 years) completing the program, who cared for on average 2.7 grandchildren who had a mean age 6.8 years (Kelley et al. 2001). Grandparents completed a range of measures at pre and postintervention that aimed at assessing their psychological distress, their perceptions of support, their perceptions on the helpfulness of support; and their perceptions of their physical and mental health. At post-intervention results revealed that grandparents reported significant improvements in psychological distress for interpersonal sensitivity and hostility, however, not for anxiety and depression. A significant reduction in grandparents self-reported perceptions of mental health was also achieved, but not physical health; grandparents reported a significant increase in perceived helpfulness of social support, however no change in their perceptions of the resources available to them.

The strengths of the PHG are the multimodal nature of the intervention and the home visitation component of the intervention. However, there are several limitations to the evaluation of the program including the small sample size, the non-random allocation of participants, and the lack of a comparison group. Moreover, as PHG is a 6-month home-based intervention the cost-effectiveness of the intervention is questionable, however, no cost-effectiveness data was reported in the study. Most importantly grandchild outcomes were not measured by this program, which is the biggest limitation of this initial evaluation.

Becoming a Better Grandparent and Achieving Grandparent Potential (Strom and Strom 1997) is an example of an enrichment based program with support group assistance for custodial grandparents. Unfortunately, this program has yet to be evaluated; however, it covers a broad range of topics. Each course consists of 12 weekly sessions that present family issues as perceived by grandparents, parents, and grandchildren. The lessons in Becoming a Better Grandparent focus on: (a) keeping up with the times; (b) giving and seeking advice, (c) respecting the individuality of relatives, (d) communicating from a distance; (e) watching television together; (f) building healthy self-esteem; (g) developing values and morals; (h) helping single parents and blended families; (i) understanding the thinking of children and adolescents; (j) recognising the value of play; (k) deciding about drugs and sex; and (l) learning about goal setting and responsibility. Strom and Strom recommend that grandparents who complete Becoming a Better Grandparent go on and complete the Achieving Grandparent Potential Class. The second course follows the same procedure of examining events from the standpoint of three generations. Some example topics for the second course include: (a) living alone and widowhood; (b) learning in later life; (c) recognising parent success; and (d) child abuse and peer abuse. The strengths of Strom and Strom’s (1997) proposed programs are the breadth of topics covered and the approach of examining events from the grandparent, parent, and grandchild perspective. However, the serious limitation for the current program is the lack of evaluation it has been subjected to, therefore it is unknown whether the program is effective at aiming to assist custodial grandparents.

The Parental Skills/Psychosocial Skills Training Program (PSPSTP; Hayslip 2003) is an example of a combined parenting education, psychoeducation, and support group assistance program for custodial grandparents. The PSPSTP program has also been subjected to a randomized controlled trial (RCT) evaluation. PSPSTP involves custodial grandparents attending six 90-min sessions, which focus on the development of parenting skills, and how to handle grief, depression, sex, drugs, and the school system. In a randomized controlled trial (RCT), 18 grandparents were randomly assigned to the treatment group, and 18 to a waitlist control group. All participants in the study were Caucasian, with 4 males and 14 females in each group (mean age = 55.5 years). Participants were measured on a range of self-report questionnaires. Short-term results from the RCT found that grandparents in the intervention group had higher reported levels of parental self-efficacy, had an improved relationship with their grandchild, and had a greater tolerance for negative grandchild behaviors. However, the intervention group was also associated with increased rates of depressive symptoms and parental strain. Hayslip suggested the increased rates of depressive symptoms and parental strain by the intervention group could be the result of grandparents gaining a better insight and awareness into the difficulties of the custodial grandparenting role over the course of the program. The strengths of this program is the inclusion of parenting skills and strategies to manage unhelpful emotions (e.g., depression), moreover it has been subjected to a rigorous evaluation in terms of an RCT. However, three notable components were not measured by this study, dysfunctional parenting strategies by grandparents, changes in child emotional and behavioral problems, and long-term findings. Despite these limitations, the results obtained from this study provide preliminary support for the view that programs including parenting skills training can be beneficial for grandparents who provide care to grandchildren.

Finally, Grandparent Triple P (GTP; Kirby and Sanders 2014) is an example of a combined parenting education, psychoeducation, and support group based program for grandparents providing regular child care. GTP is a variant of the Level 4 Triple P-Positive Parenting Program which has been tailored to the concerns and needs of grandparents who provide care to their grandchildren (Kirby and Sanders 2014). The aim of GTP is to provide a refresher course in parenting strategies, help improve the relationship between grandparents and parents, and provide coping strategies to manage stress and tension that can arise from the grandparenting role. GTP is a nine-week intervention that consists of six group sessions lasting 120 min and three telephone consultations lasting between 20 and 30 min, Table 2 describes the session content of the program (Table 3).

Table 3 Description of GTP session content
Full size table

GTP was evaluated in a foundation trial with 54 grandparents who provided predominantly between 12 and 20 h of care per week to a grandchild aged between 2 and 9 years (Kirby and Sanders 2014). No custodial grandparents were involved in this trial. Families were randomly allocated to either receiving GTP or to a care-as-usual condition. Grandparents were assessed on a range of outcomes including, child behavior, parenting style, parenting confidence, psychological adjustment, and relationship satisfaction with the parent. Despite the parents not participating in the program they were also assessed on child behavior and relationship satisfaction with the grandparent. Grandparents and parents were assessed at preintervention, postintervention, and 6-month follow-up. Relative to the care-as-usual group, grandparents in the intervention condition reported short-term improvements, including a reduction in child behavior problems; improved parenting confidence; reduction in depression, anxiety, and stress; and improved relationship satisfaction with the parent. Parents also reported significant child behavior problem reductions. These obtained short-term intervention effects were maintained at 6-month follow-up.

The results from this foundation RCT provided support for the initial efficacy of the GTP program. GTP has since been evaluated in another RCT with Hong Chinese families, where 56 grandparents who provided regular child care to their grandchildren participated in the program (Leung et al. 2014). The results from this replication trial in Hong Kong provided further evidence for the impact of the GTP program on producing significant decreases in child behavior problems and grandparents reporting increased parenting self-efficacy. The strengths of GTP are that it has been evaluated in two RCTs; it has obtained corroborating evidence from the parents of the grandchildren; that it has produced three-generational effects from a single parenting intervention; and the program was a modification of a current evidence-based parenting program built on social learning principles (i.e., Triple P). The limitations of GTP are the duration of the program (it is a nine-week course, with six-sessions lasting 120 min) and that it has not been trialled with custodial grandparents.

Collectively, these five different programs demonstrate that the evidence supporting grandparenting programs are still within their infancy. Further research needs to rigorously evaluate the aforementioned programs, with greater sample sizes, and with a greater focus on child social, emotional, and behavioral outcomes. However, the PSPSTP and GTP programs, both focusing on parenting skills training and additional coping skills support, show encouraging results and provide support for the further pursuit of parent based intervention programs for grandparents.

Recommendations to EBPPs to Modify to Grandparents

EBPPs seem to provide an appropriate pathway to help assist grandparents providing both custodial care and informal caregiving to grandchildren (Kirby and Sanders 2014), particularly as they target parenting behavior, and grandchild social, emotional, and behavioral outcomes. It could be argued that grandparents need to be offered better access to existing EBPPs. However, delivering existing EBPPs to grandparents may not be the best solution, and could potentially be detrimental to the grandparent–parent relationship. Researchers have found that one of the aspects parents disliked most about grandparent involvement in child care is receiving unsolicited parenting advice from grandparents (Mason et al. 2007; Thomas 1990). Providing current EBPPs to grandparents could potentially increase relationship conflict between grandparents and parents, as grandparents could pass on the new acquired parenting knowledge to parents. Grandparents may also view receiving existing parenting programs with resistance, as it could be taken to imply that they may not have adequately parented their own adult children (Dolbin-MacNab 2006; Hayslip and Kaminski 2005). Therefore, in terms of developing a program specifically for grandparents, both Campbell and Miles (2008) and Parke (2008) highlight that the best approach would be to adapt an evidenced-based parenting program, as these programs have been demonstrated to work previously, are more likely to succeed in the long term, and are likely to be more economical and cost-effective.

Parenting programs based on social learning principles have been widely recognized as the ‘gold standard’ in promoting childhood wellbeing and preventing behavioral problems (United Nations 2009; World Health Organization 2009). The most empirically supported programs to date include The Incredible Years Program (Webster-Stratton 1998), Parent–Child Interaction Therapy (Fernandez and Eyberg 2009), the Oregon model of Parent Management Training (Forgatch and Patterson 2010) and The Triple P-Positive Parenting Program (Sanders 2008). All of these EBPPs have the potential to be successfully modified to a grandparent population; however, if EBPPs are willing to undertake such an endeavour a series of recommendations are suggested.

Recommendation 1: Involve the Consumer in the Program Adaptation Stage

When considering applying existing interventions to a new population it is important to gauge the perspective of the new consumer group (e.g., custodial grandparents), as their views could impact on engagement with and uptake of the program (Sanders and Kirby 2012). It has been argued previously that better engagement with consumers has the potential to improve the quality and ecological fit of interventions and their evaluation with specific target groups (Sanders and Kirby 2012). There are many avenues available to program developers to increase the engagement of consumers and one such way is to provide population specific variants of existing EBPPs (Mazzucchelli and Sanders 2010).

There are a number of theories postulating the components necessary for effective consumer involvement in program design. Two notable theories are the participatory action research paradigm (PAR; Whyte et al. 1989) and Diffusion of Innovations theory (Rogers 1995). Both theories argue that in order for a program to have success there needs to be a participatory process where consumers and developers are involved in a synergistic exchange of ideas to produce meaningful products, programs, or services for a particular target group. Qualitative research methods (e.g., focus groups, key stakeholder feedback, web surveys) provide a particularly useful framework for engaging in this participatory exchange.

Recommendation 2: Consider the Heterogeneity of the Population

The grandparent population is quite heterogeneous with grandparents providing different levels of care to grandchildren. As such, custodial grandparents might require a different level of support to grandparents providing informal child care. Moreover, the cultural backgrounds of grandparents add to the heterogeneity of the population and are an important consideration when developing or modifying programs to grandparents. For example the involvement of grandparents in families may differ depending on cultural norms, such as countries with collectivistic family-based structures (e.g., Hong Kong) and individualistic family-based structures (e.g., Australia, the UK, and the USA). Therefore, it is recommended that the acceptability of the strategies advocated in the program and the cultural acceptability of the program be assessed with grandparents. The aim of assessing the acceptability of grandparenting interventions with grandparents is to determine whether grandparents from different backgrounds and different generational cohorts find the strategies advocated in parenting programs acceptable. A key reason to assess for acceptability of a program from a target group is that individuals are more likely to access treatments that they view as acceptable (Borrego and Pemberton 2007), while treatments that are perceived as unacceptable may not be accessed regardless of their effectiveness (Eckert and Hintze 2000).

Recommendation 3: A Blending of ‘Light Touch’ and ‘High Intensity’ Interventions

Custodial grandparents may require higher intensity interventions compared to grandparents providing informal regular child care. Although GTP was efficacious for grandparents providing regular child care, it is questionable whether grandparents providing regular child care would utilize a nine-week program if disseminated in the community. It is recommended that lighter touch interventions, such as grandparent seminars or discussion groups be developed and evaluated as an alternative intervention. Light touch interventions have been shown to be efficacious for parents in their parenting role in reducing dysfunctional parenting styles and child emotional and behavioral problems (Sanders et al. 2014). Therefore, it is recommended that similar light touch interventions be developed for grandparents providing regular care, as these may provide the “minimally sufficient” amount of intervention required to produce meaningful change. The concept of minimally sufficient interventions, refers to the selection of interventions aimed at achieving a meaningful clinical outcome in the most cost-effective and time-efficient manner (Sanders et al. 2014). Alternatively, it may be necessary to develop more high intensity interventions for custodial grandparents who may have to deal with more severe issues with their grandchild such as managing the grief and loss of a parent (Hayslip 2003). Table 2 provides examples of some of the differences in low and high intensity based interventions for custodial and informal grandparent caregivers.

Recommendation 4: Randomized Controlled Trial Methodology for EBPPs

Modified EBPPs for grandparents would benefit greatly from continued rigorous evaluations through RCTs. Appropriate control conditions would vary depending on the population being examined, and the focus of the research question. However, an example of a control condition for both custodial grandparents and informal grandparent caregivers would be a Grandparent Care-As-Usual (GCAU) condition. A GCAU condition would enable grandparents to continue to access support during the RCT period, however, eligibility criteria should attempt to exclude grandparents currently involved in a parenting based intervention. Importantly researchers should attempt to ask grandparents in the GCAU condition what services they accessed, if any, during the waiting period of the RCT. Having a GCAU condition enables the researchers to demonstrate whether the existing EBPP being evaluated produces meaningful and statistical change above and beyond what other services grandparents could potentially access. Once preliminary evidence has been obtained for the intervention compared to a control condition (such as a GCAU condition), evaluations can be expanded to include active control conditions. For example it would be of interest for the custodial grandparent population to determine the effectiveness of grandparents taking part in a parenting program alone compared to a coping skills program alone compared to a GCAU condition. A three arm evaluation of this nature would enable for the unique contributions of parenting programs compared to coping skills to be examined, and it might shed light on whether one condition is more effective. In terms of follow-up periods, it is fundamental that pre- and post-intervention measurements are taken, and it is also important to gather long-term data. Long-term data should be collected at a minimum 3-months post-intervention, and ideally at 6-, 12-, and 24-months post-intervention. Unfortunately limitations on research funding often impede the ability to gather long-term data. RCTs also need to ensure that a combination of measurement options are included, such as self-report measures, observations, and collateral feedback from parents and or teachers. Finally, modified EBPPs for grandparents need to be evaluated with custodial grandparents, as well as informal grandparent caregivers, in order to determine their effectiveness with both populations of grandparents.

Recommendation 5: Continued Rigorous Evaluation Research

The final recommendation is the continued rigorous evaluation of developed grandparenting programs. Although many support groups and programs are available, there is a paucity of research evaluating the efficacy and effectiveness of these programs, particularly across all four key target areas of parenting behavior; grandparent distress; grandparent–parent relationship satisfaction; and grandchild social, emotional, and behavioural outcomes. With further evaluations it will become more apparent whether modifications to existing EBPPs have been successful. In addition, the identification of the processes or mechanisms of change would be beneficial in determining what aspects of a grandparenting program are producing the intended change. For example, mediator/moderator analyses could shed light on specific components of programs that achieve desired outcomes. Finally, the comparison of a modified EBPP for grandparents to a typical EBPP would be advantageous, in order to determine whether the modifications are providing anything above a typical EBPP or if they are acceptable to grandparents.

Clinical Implications

There are a number of clinical and ethical implications researchers and clinicians need to be aware of when working with grandparents. Firstly, it is important for clinicians and practitioners to carefully define the custody arrangements with grandparents and obtain appropriate treatment consents for all involved in the intervention (e.g., parents, grandparents). Secondly, clinicians who are attempting to assist families with child behavioral difficulties should consider the involvement of grandparents who are providing regular child care, as they could be a useful treatment option. However, in doing so it is important to inform grandparents of the limits of confidentiality at the outset of the intervention. Thirdly, an important consideration for parenting programs and clinical practice is whether couples who intend to rely on their parents (i.e., the grandparents) for regular child care ask, prior to pregnancy, whether their parents would be in a position to assist.

Interestingly, all of the research reviewed in this paper did not stipulate whether grandparents were asked in advance their capabilities or willingness to provide child care. Parenting programs often include modules on the need for social support (Sanders 2012), and grandparents, as discussed in this paper provide significant amounts of child care. Therefore, parenting programs and couple based programs should consider including a component within their programs about the potential need to ask grandparents in advance whether they are able to help provide child care. Fourthly, a key issue that needs to be further addressed clinically is whether parents and grandparents should attend parenting programs together. The benefits of parents and grandparents attending sessions together is that it provides a medium to discuss expectations, resolve conflicts, problem solve, and discuss potential issues of control and decision making in a safe mediated environment. Another clinical implication that is necessary to address within grandparent based interventions and research is the concept of financial assistance, and whether this is from the parents themselves or from the government.

A further important clinical consideration is the interface between interventions for grandparents compared to interventions for grandchildren. EBPPs are focused on enhancing positive parenting practices and reducing ineffective disciplinary practices, in order to produce better outcomes for children. As a result EBPPs directly target the grandparents, they are viewed as the client, and are seen as the agents of change in order to benefit the grandchildren in their care. This is typically the case for EBPPs that target children between the ages of 0–12 years (Sanders 2012). However, if the grandchild is older (for example 10–16 years) or is experiencing significant distress themselves they may benefit from individual therapy (e.g., child based cognitive behavior therapy), where the child would then be the client. Indeed, grandchildren in custodial grandparent care may benefit from interventions that help support them with their distress, particularly around grieving over the loss of a parent (e.g., death of a parent, incarceration). As a result clinicians should be attuned to whether grandparents and grandchildren might benefit from concurrent assistance through interventions, and clinicians need to collaborate openly with these grandparent families. Finally, the ultimate aim of grandparent based interventions should not to replace parents from attending parenting programs, but to be implemented jointly, in order to increase the exposure of children to the benefits of positive parenting practices. Adopting such an approach would be in alignment with creating nurturing environments for children (Biglan et al. 2012).

Conclusion

Collectively, this review has provided an understanding of the current challenges and strengths the field of grandparenting faces. It has described the high involvement that grandparents have within family life in Western cultures, and identified that grandparents can provide beneficial assistance to not only the grandchildren, but also the parents of the grandchildren they are providing care to. However, these benefits do not come without difficulties, as there can be conflict and tension between grandparent and parents, as well as stress, strain, and frustration for the grandparents providing care. Although many support groups and grandparent programs are available, most have not been extensively evaluated for their efficacy. Modifications to existing EBPPs hold great promise for grandparents. Future research should continue to evaluate modified EBPPs with grandparent populations in order to provide nurturing environments for grandchildren.