Family and Friends as Respite Providers

Abstract

Consumer-directed service options in home- and community-based care are increasingly available to adults with chronic conditions and cognitive impairments and to their family caregivers. Few studies, however, examine the experience of family caregivers who, when given a choice of providers of respite assistance (i.e., relief from the stress of providing constant care), prefer to hire family or friends rather than service providers. This study describes the in-home respite experience of family caregivers served by California's Caregiver Resource Centers “direct-pay” program who hire family or friends (n = 39) or service providers (n = 77) to provide in-home respite assistance. Findings revealed similarities between the two groups with few exceptions: caregivers who hired family or friends reported poorer physical health, were slightly more satisfied with the respite assistance, and received more hours of respite at a lower unit cost. These findings lend support to consumer-directed respite service options where family caregivers are given flexible alternatives that may act to remove barriers to respite service availability and use.     

Caregiver substance abuse among maltreated children placed in out-of-home care.

Child protective services (CPS) case records of 639 children placed in out-of-home care due to maltreatment were reviewed, and substance abuse by the child's caregiver prior to the child's placement was evaluated systematically. Based on several different sources of information, 79% of the caregivers were found to meet the criteria for caregiver substance abuse (CSA). Children with and without evidence of CSA differed on age, ethnicity, family composition, and type of maltreatment. The importance of operational specificity in defining CSA and implications for policy and service delivery are discussed.     

Mental health outcomes among child welfare investigated children: In-home versus out-of-home care

BackgroundChild welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care.ObjectiveTo evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care.Design/methodsWe examined a cohort of children (aged 1.5–18 years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18 months for children who remained in-home with parent training versus those placed in stable OOH care.ResultsAmong the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (p = .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p = .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (p = .008).ConclusionsFor school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.     

The transition from in-home services to out-of-home care: A Danish register-based study

Objective

This register-based study describes the transition from in home-based care to placements in out-of-home care. It also describes whether children who enter care directly differ from children who enter care after episodes of in home-based care.

Method

The study includes all children who entered the child protection system of a larger regional social service system in Denmark from 1993 to 2006 (N = 9961). Graphs of cumulative incidences were used to describe transitions into out-of-home care within two years after in home-based care started. Cox regression models are used to estimate the impacts of child and parental characteristics. In addition, Chi² tests are used to identify differences between children who enter care directly and children who receive in home-based care.

Results

Results indicate that the majority of children do not enter out-of-home care but that risks differ among age groups. Covariates did not predict transitions into out-of-home care for those who entered in-home care after becoming teenagers. Especially for those who entered in-home care before entering their teens, the psychiatric histories of the mothers and the children predicted the transitions into out-of-home care. Immigration background was a protective factor for those who entered in-home care as pre-scholars. Depending on the age group, low birth weight, children's fathers' and mothers' psychiatric histories, and single parentship were all characteristics more likely to be associated with children who entered care directly. Children who entered care directly differed from children who entered care within two years after an in home-based service had been initiated on covariates that described psychiatric history.     

Children's Appraisals of their Experiences in Out-of-Home Care

Few studies have asked children directly about their experiences in out-of-home care. This study uses data collected from 180 nine- to-11-year-old children currently in out-of-home care who were asked about their perceptions and appraisals of out-of-home care. Analysis of variance and chi-square analyses were used to examine whether children's appraisals of their lives following removal from their families of origin differ as a function of age, gender, race/ethnicity, type and severity of maltreatment, length of time in out-of-home care, placement type, attachment to current caregivers, and rating of current caregiver/home. Youth who were sexually and emotionally abused, youth who were satisfied with their current caregivers and placements, and girls were more likely to state that their lives would have been worse had they remained with their families of origin. Youth who were physically abused were more likely to report that their lives would have remained the same. Children living in group care were more likely than those living in family foster care or with kin to report that their lives would have been better had they remained with their families of origin. Differences were not found between children living in family foster care and those living with kin nor did children's appraisals differ based on age, race, ethnicity, length of time in out-of-home care, neglect, or severity of maltreatment.     

Upping the ante: relative caregivers' perceptions of changes in child welfare policies

Thirty-five caregivers of related children who were in the custody of the child welfare system were interviewed individually or in focus groups as the state child welfare system implemented new federal and state policies encouraging these caregivers to adopt or assume guardianship of the children in their care. Interviews were transcribed and analyzed using qualitative methods. Issues of concern included emergency entrance into caregiving; the simultaneous satisfaction and burden of caregiving; obstacles to caregiving, adoption, or guardianship; complex changes in family dynamics following placement of children; sources of support; and caution regarding adoption or guardianship. The caregivers also offered recommendations for the child welfare system. Policy, practice, and research implications are discussed.     

Criteria for placement decisions with cocaine-exposed infants.

This study explored the criteria for placement decisions concerning cocaine-exposed infants used by child protection workers in three suburban Chicago counties. Content analyses uncovered a complex decision-making process that demonstrated consistency across geographic regions. A number of primary factors influence decisions for in-home or out-of-home care for the infant, with the availability of support systems for the parents and infants a critical factor in deciding placement.     

Action-oriented evaluation of an in-home family therapy program for families at risk for foster care placement

The purpose of this study was to conduct an action-oriented evaluation of an in-home family therapy program serving families deemed at risk for the placement of children in foster care. In this study, feedback was solicited from both clients and therapists. Results indicate "duality" associated with several aspects of in-home family therapy, including the opportunity to observe families in their own homes versus the vulnerability some families feel when therapy is conducted in-home; therapists suggesting that sufficient training is required for in-home family therapy to be effective versus clients' opinions that therapists' lived experiences are more relevant; and the importance of the therapeutic alliance versus feelings of abandonment upon termination. Implications for researchers and practitioners are discussed.     

Dignity in dementia: Person-centered care in community

Drawing on Kitwood's [Ageing Soc. 13 (1993) 51] theory of person-centered care and the interpersonal process of caregiving, this article offers an alternative to the image of the family caregiver as victim through an exploration of the lived experience of caring for a person with dementia in community. Extending care beyond coping, the act of giving care is promoted as a worthy activity and reciprocal social opportunity. Three nonfamily caregiver “portraits” are offered in an arts-informed representational form. The relational processes of caregiving are explored from the vantage point of personal experience and theoretical knowledge. Dignity emerges as the resonant quality, essential value, and guiding principle in an ethic of dementia care. Implications about the direction of research about care and caregiving and research accessibility and usefulness are explored.     

Effects of kinship care on behavioral problems by child age: A propensity score analysis

When a child must be removed from the family home, placement with a relative is often sought because kinship care is the least restrictive and most family-like out-of-home placement. Although kinship care has become a preferred option in most U.S. child welfare systems, this preference is often based on “soft evidence” rather than rigorous evaluation of the risks and benefits of kinship care. Therefore, an evaluation of the impact of kinship care on child behavioral problems is needed to guide child welfare practice and policy. In addition, given that children of different ages and in different developmental stages are likely to have varying placement experiences, the evaluation of kinship care should explore the effect of kinship care on child behavioral problems across age groups. To fill these knowledge gaps, we compare the behavioral problems of 584 children in kinship care with those of 470 children in non-kinship care. Moreover, we examine the impact of kinship care on behavioral problems in 2 age groups: younger children (0 to 5 years) and older children (6 to 17.5 years). The analysis uses data from Waves 1 and 2 of the National Survey of Child and Adolescent Wellbeing, and applies propensity score methods to account for selection bias. Results show that older children in kinship care had significant lower levels of externalizing, internalizing, and total behavior problems. However, for younger children, the effects of kinship care on child behavioral problems did not reach statistical significance. The implications for practice, research and policy are discussed.     

African American Informal Support Networks

Abstract

This study examined African American informal support network functioning utilizing Vaux's (1998) reciprocal exchange model. Ten African American caregivers of relatives with severe mental illness and their main informal helpers were interviewed using a semi-structured questionnaire. In 8 of the 10 African American families interviewed, one close relative, called a “main supporter,” assumed major responsibility, comparable to that of the primary caregiver, for care and supervision of the family member with mental illness. Main supporters felt that their family helper role, although stressful at times, gave meaning and purpose to their lives. Five main supporter-primary caregiver pairs formed 'joint households' to share economic and human resources and to facilitate caregiving duties. Social work intervention for caregiving families should provide assistance to both primary caregivers and their informal supporters, particularly main supporters.     

Explaining the disparity in placement instability among African-American and white children in child welfare: A Blinder-Oaxaca decomposition

African-American children in the child welfare system are at disproportionate risk of adverse experiences including placement instability. This article compares placement instability among African-American and white children in the National Survey of Child and Adolescent Well-Being and identifies mechanisms underlying racial disparities using a Blinder-Oaxaca decomposition. The type of initial out-of-home placements contributes significantly to the racial gap in placement instability. However a large amount of racial disparity remains unexplained. Additional factors, not captured by these analyses, apparently explain African-American's increased risk of placement instability. Predictors of placement instability differ between racial groups. Among African-Americans, older age, initial placement in a setting other than kinship care, and having a higher externalizing CBCL score at baseline are associated with greater instability. Among white children, however, only initial placement in a foster care setting predicted placement instability.     

Gender and intimate caregiving for the elderly in Hong Kong

This paper analyzes the special challenges posed by caregiving provided by adult children to their physically impaired parents and in-laws, particularly as they relate to the issues of gendered eldercare and caregiving stress. Through the use of 16 semi-structured intensive interviews conducted in Hong Kong, we find that the discourses on sexualized and gendered bodies create formidable obstacles to the caregiving process. The sexual taboo in its various manifestations induces discomfit and even repulsion in situations where private parts of the body of the elderly are exposed and touched. Such hindrances create conflicts and stress for caregivers and care receivers alike, especially for women caregivers due to the social expectation that they are “natural” caregivers. Our study suggests that the key to overcoming such obstacles depends on a strong sense of filial gratitude, as well as the successful development of a respectful caregiving relationship between children and parents.     

Factors Associated With Caregivers’ Use of Support Services and Caregivers’ Nonuse of Services Sought

Informal caregivers may face barriers accessing services like respite care, training, and support groups. Using multinomial logistic regression, I modeled caregivers’ probability of using all services sought (“all services used”) and nonuse of any services sought (“any unused services”) as a function of caregiver and care-recipient characteristics. Care-recipient health and function, especially dementia and need for medical task assistance, were associated with all services used and any unused services, and any unused services were more likely among adult children caring for their parents, caregivers of Black and Hispanic older adults, caregivers providing intensive care, caregivers living in metropolitan areas, and residents of states that spend more on increasing access to caregiver services under the National Family Caregiver Support Program. Regularly scheduled caregiving was associated with higher likelihood of all services used, but not with any unused services. Steps should be taken to increase access for caregivers who provide intensive care, care to dementia patients, or assistance with medical tasks and for Hispanic families.     

Factors predicting placement of urban American Indian/Alaskan Natives into out-of-home care

American Indian/Alaskan Native children have disproportionately been placed into out-of-home care compared to White children in the child welfare system. What were the factors that child protective services (CPS) workers considered when deciding to remove a child from the home? Utilizing data from the National Survey of Child and Adolescent Well-Being, this study examined out-of-home care factors for 2215 urban American Indian/Alaskan Native (AI/AN) and White children. In the urban sample, children from White families were younger and were more likely to be investigated for lack of supervision, while AI/AN families were investigated for physical neglect. In the placement regression models, urban AI/AN children came from homes where caregivers had greater alcohol, drug and mental health problems. Decisions by CPS workers to place AI/AN children may have been influenced by racial bias. A CPS system that acknowledges culture and race may reduce overrepresentation in placement. Efforts to work with AI/AN families prior to a child's removal may prove to be beneficial and less expensive.     

Children in self-care: An examination of research confounds

Families using self-care, in-home, and out-of-home child care arrangements were compared on a number of demographic variables. Certain variables (e.g., family income; marital status) were, as expected, related to the type of child care in use. However, one unexpected trend also was identified: regardless of the type of child care arrangement reported by parents, as the age of children increased across the out-of-home, in-home, and self-care family groups so too did the number of hours children spent at home alone. This trend is discussed in relation to two confounding areas of which researchers should be aware when conducting school-age child care needs assessment surveys and conducting self-care studies: (a) the context within which the self-care decision is made; and (b) the reasoning that goes into making the self-care decision.     

Three phase development of caring capacity in primary caregivers for relatives with Alzheimer's disease

Multiple, open-ended, qualitative interviews were conducted with 16 primary caregivers for relatives with Alzheimer's disease in order to describe caregiver self-development through the caregiving journey. Caregiver change is traced up to five years after the care recipient's death. Caregivers' capacity for caring was found to be at the core and to unfold in three phases: development of caring capacity for the care recipient, development of capacity for self-care, and development of caring capacity for others. The four elements of caring capacity (perception, motivation, competency, action) are expressed in relation to the care recipient, to the self, and to less familiar “others”. The caregiving experience tends also to prompt caregivers to become caregivers for humanity and to expand their sense of self. This may lead to the development of the altruistic self, which incorporates both a selfless concern for the welfare of others and a self-directed concern for one's own welfare.     

Behaviorally impaired children in out-of-home care.

This study was undertaken to determine the nature of the out-of-home care placement experience for 131 behaviorally impaired children entering care over the course of a year in Nebraska. Variables analyzed included behavioral impairment, age at entry, age at termination, gender, race/ethnicity, family violence, geographical area before and at termination, closeness to home of most recent placement, and length of time in care. Multiple regression analysis showed that behavioral impairment was the strongest predictor of length of time in care, accounting for 2.4% of the variability.     

Fostering homeless children and their parents too: the emergence of whole-family foster care.

Children should not be placed in out-of-home care simply because their families lack the means to provide for their basic needs, yet this practice continues nationwide. A new program based in St. Paul, MN, gives county social service departments the placement option of whole-family foster care. The target population is adult parents and minor children without stable residences, where the children are at risk of placement in out-of-home care. Although the parents and children may have special needs, there are no safety risks that would necessitate separating children and parents. The program's design is described and policy questions discussed.