Children and Youth Services Review 127 (2021) 106103

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Associations between family resilience and health outcomes among kinship

caregivers and their children
Anthony Gómez
School of Social Welfare, UC Berkeley, 120 Haviland Hall, Berkeley, CA 94720, USA

A R T I C L E I N F O A B S T R A C T

Keywords: The health and mental health of kinship caregivers and their children have been the foci of substantial research
Kinship care and intervention over the last four decades. While evidence suggests the challenging circumstances surrounding
Relative care kinship care may be linked with suppressed health outcomes, we have yet to examine how family resilience,
Health
defined as the transactional, intrafamilial processes that promote a family’s ability to weather and grow through
Mental health
Parenting stress
adversity, might shape multigenerational health and mental health outcomes in kinship families. Using data from
Survey the 2017–2019 National Survey of Children’s Health, the current study examines associations between family
resilience and health outcomes among kinship caregivers and their children. Weighted multiple linear regression
analyses revealed family resilience was positively associated with global ratings of caregiver health, caregiver
mental health, and child health. Family resilience was also negatively associated with parenting stress. Weighted
logistic regression analyses revealed family resilience was associated with decreased odds of children having
behavioral problems but was not associated with the odds of children having an internalizing disorder. Findings
suggest kinship families that regularly engage in mutual support and problem solving may be better positioned to
promote multigenerational health and mental health outcomes.

1. Introduction food insecurity and unemployment at higher rates than biological and
non-relative foster parents (Ehrle & Geen, 2002), creating an ecological
Kinship care is a rapidly growing option for children requiring out- context that has been linked with poor health, mental health, and
of-home care. Approximately 2.7 million children in the United States increased parenting stress (Hong et al., 2011; Lee et al., 2016). In
are raised by their grandparents (Kids Count, 2019), with increasing addition to these ecological stressors, the health and mental health of
numbers of aunts, uncles, and adult siblings stepping into caregiving children in kinship care may also suffer in the wake of child maltreat­
roles (Kiraly et al., 2020). Although children may be in kinship care for ment, parental substance use, or parent incarceration that may have
various reasons, it often follows instances of parental incarceration, preceded their kinship care arrangement (Szilagyi et al., 2015). While
substance use, or child maltreatment (Lee et al., 2020). Most kinship children in formal kinship care have greater access to medical and social
care arrangements are negotiated privately within families or “volun­ services by way of their involvement in the child welfare system (Xu,
tarily” by child protection services, resulting in informal placements that Bright, Ahn, et al., 2020), children in informal kinship care arrange­
are generally unmonitored by child welfare agencies (Berrick & Her­ ments are often unable to access these necessary services (Berrick &
nandez, 2016). In contrast, formal kinship care placements are arranged Hernandez, 2016). Moreover, kinship caregivers across arrangements
and monitored by child welfare agencies and may require relative may be hesitant to seek services in fear that their demonstrated need
caregivers to become licensed foster parents in order to care for the might result in child removal (Pittman, 2015). Therefore, understanding
child, receive foster care payments, and access medical and social ser­ how kinship families mitigate and resolve the array of ecological and
vices (Xu, Bright, Ahn, et al., 2020). caregiving challenges that can threaten their physical and mental well-
Research documents the prevalence of health and mental health being is crucial to building services that foster optimal outcomes.
problems among kinship caregivers and their children (Cuddeback, Family resilience is the capacity for families to weather and grow
2004; Szilagyi et al., 2015; Xu & Bright, 2018). Kinship caregivers through adverse circumstances by way of transactional, intrafamilial
disproportionately live under the federal poverty line, and experience processes that promote mutual support and problem solving (Patterson,

E-mail address: [email protected].

https://doi.org/10.1016/j.childyouth.2021.106103
Received 8 February 2021; Received in revised form 5 April 2021; Accepted 31 May 2021
Available online 2 June 2021
0190-7409/© 2021 Elsevier Ltd. All rights reserved.
A. Gómez Children and Youth Services Review 127 (2021) 106103

2002; Walsh, 2016b). Family resilience is a multidimensional construct unemployed, and more likely to experience food insecurity (Ehrle &
consisting of a family’s belief systems, organizational processes, and Geen, 2002; Hong et al., 2011; Strozier & Krisman, 2007). Combined
problem-solving strategies (Walsh, 2016a). Among non-kinship sam­ with the fact that the majority of kinship caregivers are unable to access
ples, family resilience has been linked to parents’ improved emotional financial or social services due to their lack of formal involvement in the
coping, increased odds of healthy exercising habits in children, and child welfare system (Xu, Bright, Ahn, et al., 2020), kinship caregivers’
decreased instances of childhood asthma and anxiety, suggesting family health, mental health, and parenting stress may suffer as they strain to
resilience may play a role in creating health-promoting family envi­ meet their family’s needs (Berrick et al., 1994; Musil et al., 2011;
ronments (Burns et al., 2020; Kim et al., 2020; Nabors et al., 2020; Strozier & Krisman, 2007). In one mixed methods study, grandparent
Walsh, 2016b). Despite the myriad adversities experienced by kinship caregivers not only reported increased levels of parenting stress
families, little research has examined the relationship between family compared to other relative caregivers, but also reported much of their
resilience and health outcomes in this population. Qualitative research parenting stress stems from raising a child on a fixed income and limited
in this area has mostly focused on the strategies that licensed foster possibilities for cash aid (Lee et al., 2016). Another study examining
caregivers use to promote family resilience, but do not explicitly tie kinship caregiver parenting stress during the COVID-19 pandemic found
them to kinship families’ health or mental health (Lietz et al., 2016; material hardship was associated the increased odds of experiencing
Schneiderman et al., 2012). Existing quantitative research has found a elevated levels of parenting stress (Xu, Wu, Levkoff, et al., 2020).
positive relationship between kinship caregivers’ meaning making, a Altogether, the well-being of kinship caregivers may be impacted by
component of family resilience, and caregiver well-being, but it is still numerous individual-, family-, and system-level factors.
unclear whether this relationship would hold if family resilience were The combination of multiple caregiving challenges and limited
measured more holistically, or if family resilience is related to the well- government support often prompts kinship caregivers to turn to their
being of children in kinship care (Cavanaugh et al., 2020). Using data families to acquire the financial support, child care, and other resources
from the National Survey of Children’s Health (NSCH), the current study needed to raise a child (Lietz et al., 2016; Pittman, 2015). The intra­
addresses these gaps by examining associations between family resil­ familial processes by which families coordinate these resources cannot
ience and the health and mental health outcomes of kinship caregivers be overstated: families must effectively communicate, make meaning of
and their children. challenges, collectively devise solutions, and continuously rebalance
individual responsibilities to meet the ever-changing needs of the family
1.1. Kinship caregiver health, mental health, and parenting stress unit (Walsh, 2016a). Families that successfully enact these processes can
swiftly deploy new routines that address the demands placed on the
Research documents the high prevalence of health and mental health family system without overwhelming any particular individual (Henry,
concerns among kinship caregivers (Cuddeback, 2004). Grandparents Hubbard, Struckmeyer, & Spencer, 2018; Patterson, 2002). While the
that are the primary caregivers for their grandchildren experience resulting network of caregiving support likely eases caregivers’ burden,
greater mobility issues and consistently report poorer physical health it is unclear whether these intrafamilial processes may also be associated
compared to their non-caregiving peers (Cuddeback, 2004; Musil et al., with improved kinship caregiver health, mental health, and parenting
2011). In one study, caregivers reported their health problems not only stress. Given health and mental health problems are more common
interfere with caregiving responsibilities but also frequently go unad­ among overwhelmed caregivers (Monahan et al., 2013), kinship families
dressed to preserve economic resources for children’s needs (Monahan that regularly deploy processes of collective problem solving and mutual
et al., 2013). Research also notes poor mental health among kinship support may also provide respite and resources that can alleviate
caregivers (Doley et al., 2015; Garcia et al., 2015), with some studies stressors that would otherwise erode kinship caregivers’ health and
finding that more than one in four kinship caregivers exceed the clinical mental health.
cut-off for depression (Kelley et al., 2000; Minkler, 1997). Among
mental health outcomes, parenting stress has been the subject of a 1.2. Health and mental health of children in kinship care
growing body of kinship literature given its associations with parenting
behaviors (Xu, Wu, Jedwab et al., 2020). Clinically significant levels of The health and mental health of children in kinship care have been
parenting stress among kinship caregivers are common, with one study widely studied since the expansion of kinship care in the 1980s (Berrick,
reporting that 94% of their sample surpassed the clinical cut-off (Har­ 1998). Children in formal and informal kinship care generally experi­
rison et al., 2000; Kelley et al., 2000; Lee et al., 2016; Ross & Aday, ence poorer health than children living with their biological parents
2006). (Bramlett et al., 2017; Bramlett & Blumberg, 2007), although some
Scholars offer several explanations for the increased prevalence of studies report minimal differences (Scannapieco, Hegar, & McAlpine,
poor health, mental health, and parenting stress outcomes among 1997; Solomon & Marx, 1995). Studies note children in kinship care
kinship caregivers. Given kinship caregivers tend to be older, age likely have similar health profiles as children in non-relative foster care, and
plays a role in elevated physical health concerns (Doley et al., 2015; are more likely to have chronic illnesses, special health care needs, and
Strozier & Krisman, 2007). Even so, the challenges associated with greater dental problems than children living with their biological par­
caregiving may also cause caregivers’ health to be compromised ents (Bramlett et al., 2017; Bramlett & Blumberg, 2007; Leslie et al.,
compared to their non-caregiving peers (Musil et al., 2011; Strozier & 2002). The increased prevalence of health problems may be linked to the
Krisman, 2007). The transition to being a kinship caregiver is often circumstances that led to children’s out-of-home placement (e.g., child
unexpected and caregivers may have little time to prepare for this role maltreatment and economic hardship) and barriers to adequate health
(Berrick et al., 1994). Further, the circumstances leading to a kinship care (Bramlett et al., 2017; Szilagyi et al., 2015). As a result, kinship
care arrangement may be fraught with familial tension, which has been families often contend with challenges associated with their children’s
linked to increased parenting stress and emotional strain (Grinstead health.
et al., 2003; Pittman, 2015). Child health and mental health problems Children in kinship care generally experience fewer mental health
have also been linked to kinship caregiver anxiety and depression (Doley problems compared to children in non-relative foster care (see Xu &
et al., 2015). Several studies note the relationship between child exter­ Bright, 2018 for a review). Existing evidence suggests selection bias may
nalizing problems and high levels of kinship caregiver parenting stress play a role in this difference (Font, 2015; Xu & Bright, 2018). Case­
(Harrison et al., 2000; Lee et al., 2016; Mackintosh et al., 2006). Finally, workers may be more likely to recommend a relative placement when
the ecological context surrounding kinship caregivers likely plays a role children have fewer mental health concerns, and/or caregivers may be
in determining caregiver health outcomes. Compared to non-relative more likely to accept responsibility of children with fewer mental health
foster caregivers, kinship caregivers are disproportionately poor, problems (Jedwab et al., 2020). Children in kinship care also access

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mental health services at lower rates than children in non-relative foster involve service agencies and other community resources that increase
care, although it is unclear whether this is a result of the aforementioned the likelihood of positive adaptation (Walsh, 2016b).
selection bias, barriers to mental health services faced by kinship fam­ Research using non-kinship samples suggests family resilience may
ilies, or caregivers not deeming their children’s psychological issues be related to mental health and, albeit to a lesser extent, health out­
sufficiently problematic to warrant intervention (Barth, 2008; Ehrle & comes for caregivers and children. Family resilience has been linked to
Geen, 2002). parents’ ability to emotionally cope with the challenges of having a child
Potential benefits of kinship care notwithstanding, children in with a mental health disorder (Herbell et al., 2020). Among parents of
kinship care experience greater internalizing and externalizing problems children with developmental disorders, greater family resilience has
than children living with their biological parents (Bramlett & Blumberg, been linked to decreased parenting stress and psychological distress
2007). Scholars link the increased prevalence of mental health problems (Kim et al., 2020; Suzuki et al., 2018). Studies have also found high
to the circumstances that led to their kinship care arrangement (e.g., family resilience is associated with greater odds of children attaining
child maltreatment, parent death, parent substance abuse) and inade­ sufficient exercise and decreased odds of children having anxiety and
quate access to mental health services (Szilagyi et al., 2015). Children in asthma (Burns et al., 2020; Nabors et al., 2020). Turning to the broader
informal kinship care—who constitute the vast majority of children in caregiving literature, research ties family resilience with improved
kinship care overall—are ineligible for most of the mental health ser­ health and attainment of routine health care among adults caring for a
vices offered to children in formal foster care placements, meaning that relative with dementia (Henry et al., 2018). Taken together, these
their caregivers may have limited options in supporting children findings suggest families that effectively recruit mutual support and
through the feelings of loss, rejection, and confusion that can accompany mobilize resources are better positioned to maintain their health and
separation from their biological parents (Szilagyi et al., 2015; Xu & mental health.
Bright, 2018). Given kinship families are more likely to live in poverty Although research attests to the challenges associated with kinship
than non-relative foster families, financial barriers also impede access to care, the literature has yet to note whether family resilience is related to
mental health services (Lin, 2018). In sum, child mental health problems health and mental health outcomes in this population. Previous research
are a common concern among children in kinship families and may be has focused on the strategies foster families employ to build family
difficult to address in the absence of adequate supports. resilience and adapt to the challenges of fostering (Lietz et al., 2016;
Evidence suggests children in kinship care may fare better when Schneiderman et al., 2012). For instance, Schneiderman and colleagues
there is increased opportunity for their families to glean support from found that foster caregivers’ optimism and willingness to seek support
relatives. Caregiver social support and engagement have emerged as from formal and informal sources was conducive to acquiring necessary
protective factors for health and mental health outcomes among chil­ health and mental health care services for the children in their care
dren in kinship care (Lin, 2018; Xu, Bright, Huang, et al., 2020). Simi­ (Schneiderman et al., 2012). Other qualitative studies identify foster
larly, children report fewer internalizing and externalizing problems caregivers’ consistent, empathetic communication with family members
when kinship caregivers live closer to a child’s original neighborhood and caseworkers as a key factor in ensuring family functioning and
and involve biological parents in their care (Gleeson & Seryak, 2010; Xu service acquisition (Geiger et al., 2016; Lietz et al., 2016). Although this
& Bright, 2018). Nevertheless, the benefits of increased opportunity for preliminary evidence suggests family resilience may play a role in
support are likely predicated on families’ ability to effectively commu­ shaping kinship family well-being, these studies feature small sample
nicate with one another, appraise challenges, and reallocate family re­ sizes and do not measure the impact of family resilience on health and
sources to meet the current demands placed on the family system. mental health outcomes. One study found that meaning-making—using
Without these exogenous transactions, families cannot mobilize on their value-based reflection to make sense of adversity and appraise its
social capital to alleviate the stressors that may compromise child health manageability—was positively associated with overall kinship caregiver
and mental health (Patterson, 2002; Walsh, 2016b). The relationship well-being (Cavanaugh et al., 2020). Nevertheless, additional research is
between these intrafamilial processes and the well-being of children in needed to examine whether family resilience measured more holistically
kinship care, however, has not been tested. might offer benefits to caregivers and children. Such research could
provide useful insights in understanding how kinship families withstand
1.3. Associations between family resilience and health outcomes and grow through ecological and caregiving challenges that might
otherwise threaten their physical and psychological well-being (Ehrle &
Family resilience refers to a family’s capacity to weather and emerge Geen, 2002).
from adversity “strengthened and more resourceful” (Walsh, 2016a).
Unlike other conceptualizations of resilience that focus on individual- 1.4. Current study
level factors that promote well-being in the face of adversity, family
resilience emphasizes the transactional, intrafamilial processes The purpose of the present study is to examine whether family
employed to navigate challenging circumstances (Walsh, 2016b). Walsh resilience is associated with health and mental health outcomes among
sorts these continuous processes into three broad categories: belief kinship caregivers and their children. This study aims to address the
systems (the ability for families to remain optimistic and make meaning following research questions: (1) Is family resilience associated with
of challenges), organizational processes (strategies that families employ kinship caregivers’ health and mental health? (2) Is family resilience
to adapt to adversity while recruiting instrumental and emotional sup­ associated with kinship caregivers’ parenting stress? (3) Is family resil­
port), and problem-solving processes (strategies families use to resolve ience associated with the health of children in kinship care? And (4) Is
problems). These processes allow families to recalibrate imbalances family resilience associated with internalizing disorders or behavior
between their capabilities and stressors, and establish new routines that problems in children? Based on my theoretical framework, I hypothesize
effectively manage adversity and family needs (Henry et al., 2018; family resilience will be positively associated with kinship caregiver’s
Patterson, 2002). Family resilience processes vary widely by family and health and mental health. Second, I hypothesize family resilience will be
are inextricably linked to a family’s cultural and ecological context negatively associated with kinship caregivers’ parenting stress. Third, I
(McCubbin & McCubbin, 2013). For instance, family resilience pro­ predict family resilience will be positively associated with children’s
cesses may be bounded by the physical household among those that health. Finally, I hypothesize family resilience will be associated with
subscribe to euro-centric formulations of the nuclear family, whereas decreased odds of children having an internalizing disorder and
families from collectivist cultures may engage wider networks of behavioral problems, respectively.
extended family to formulate efficacious responses to stressors (Robbins,
Robbins, & Stennerson, 2013). Family resilience processes may also

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2. Methods Caregivers responded using a five-item scale: (1) excellent, (2) very
good, (3) good, (4) fair, and (5) poor. While single item physical health
2.1. Participants measures may exhibit bias, research suggests they offer comparable
reliability and validity to lengthier health measures (Macias et al.,
The current study analyzes data from the NSCH, an annual survey 2015). Once again, scores were reverse coded such that higher scores
conducted by the U.S. Census Bureau to gather information about child corresponded to better physical health.
and caregiver health from a representative, randomly selected sample of
households with children ages 0–17 years (U.S. Census Bureau, 2020a). 2.2.4. Parenting stress
Upon confirming the presence of a child in the household, caregivers Parenting stress was measured using three survey items that assessed
respond to questions pertaining to their and the target child’s health, the extent to which parents experienced emotional distress related to
mental health, family life, and sociodemographic characteristics (see U. caregiving. Caregivers responded to the following three items: “During
S. Census Bureau, 2020a for survey methodology). In households with the past month, how often have you felt 1) that this child is much harder to
multiple children, survey administrators selected the target child and care for than most children his or her age? 2) this child does things that really
the caregiver responded to the survey as they pertained to that child. bother you a lot? and 3) angry with this child?” Caregivers rated their
Caregivers and their children were included in the current analytic responses on a five-item scale: (1) never, (2) rarely, (3) sometimes, (4)
sample if a) the primary caregiver was a grandparent, aunt or uncle, usually, or (5) always. Responses across all three items were summed,
other relative, or non-relative, b) the child’s secondary caregiver (if with sample scores ranging from 3 to 15, with higher scores indicating
available) was also a grandparent, aunt or uncle, other relative, or greater parenting stress. Cronbach’s alpha for the parenting stress scale
non-relative, and c) the household was led by the kinship (respondent) was 0.80, indicating good internal reliability.
caregiver. Given the NSCH was not designed to collect data from kinship
caregivers, data from 2017, 2018, and 2019 were combined to increase 2.2.5. Child health
the sample size (U.S. Census Bureau, 2020b). It is unknown whether Child health was measured using a single-item global health mea­
participants were involved in the child welfare system, which may in­ sure. Caregivers were asked, “In general, how would you describe this
fluence caregiver and child health outcomes (Lin, 2018). Among the child’s health?” Caregivers rated their child’s health on a five-point scale:
sample of kinship caregivers, 12.6% of participants had missing data on (1) excellent, (2) very good, (3) good, (4) fair, and (5) poor. To facilitate
at least one study variable and were excluded from analysis. The final interpretation, scores were reverse coded such that higher scores rep­
analytic sample for this study consists of 2,635 kinship caregiver-child resented higher ratings of physical health.
dyads, which constitute approximately 3.23% of the total dyads sur­
veyed across 2017, 2018, and 2019 (total sample n = 81,562). 2.2.6. Child internalizing disorders
Child internalizing disorders were measured using a dichotomous
2.2. Measures composite variable created by combining two survey items assessing
depression and anxiety in the target child. Caregivers were asked to
2.2.1. Family resilience indicate if a doctor or other health care provider ever told them that the
Kinship caregiver family resilience was measured using four survey target child has depression or anxiety. A composite variable was created
items assessing the frequency with which kinship caregivers engage in in which children whose caregivers indicated “yes” to either question
intrafamilial processes of mutual support and problem solving when were categorized as having an internalizing disorder. This variable was
confronted with challenges. The four items asked were, “When your dummy coded for analysis with (0) indicating the child does not have an
family faces problems, how often are you likely to do each of the following: 1) internalizing disorder and (1) indicating the child has an internalizing
talk together about what to do, 2) work together to solve our problems, 3) disorder.
know we have strengths to draw on, and 4) stay hopeful even in difficult
times.” Caregivers used a four-point scale to indicate whether they 2.2.7. Child behavioral problems
engaged in each behavior (1) all of the time, (2) most of the time, (3) Child behavioral problems were measured using a dichotomous
some of the time, or (4) none of the time. To facilitate interpretation, variable. Caregivers were asked to indicate if a doctor, other health care
scores were reverse coded and summed such that higher scores indicate provider, or educator ever told them that their child had behavioral or
higher family resilience. Sample scores ranged from 4 to 16. Cronbach’s conduct problems. This variable was dummy coded for analysis with (0)
alpha for the family resilience scale was 0.90, indicating high internal indicating the child does not have behavioral problems and (1) indi­
reliability. Although this shortened measure does not capture every cating the child has behavioral problems.
dimension of family resilience, this measure is consistent with general
conceptualizations of family resilience and has been used in previous 2.2.8. Covariates
research to examine associations between family resilience and health Analyses controlled for covariates that are related to caregiver or
outcomes (Kim et al., 2020; Nabors et al., 2020; Walsh, 2016b). child outcomes. Covariates included caregiver age, caregiver sex, care­
giver marital status, caregiver education level, caregiver relationship to
2.2.2. Caregiver mental health the child, child adverse childhood experience (ACE) scores, child age,
Kinship caregiver mental health was assessed using a one-item global child sex, child race, child ethnicity, number of children in the house­
measure asking, “In general, how is your mental or emotional health?” hold, the number of total family members in the household, and income
Caregivers responded using a five-item scale: (1) excellent, (2) very as a percentage of the federal poverty level. The model predicting
good, (3) good, (4) fair, and (5) poor. Although single item mental parenting stress also included caregiver mental and physical health as
health measures lack specificity, evidence suggests they are valid, reli­ covariates given past reports documenting the associations between
able, and correlate with more extensive measures of psychological health and parenting stress (Hayslip et al., 2015, 2019; Kelley et al.,
functioning (Ahmad et al., 2014). To facilitate interpretation, scores 2000). In order to protect the confidentiality of respondents, the U.S.
were reverse coded such that higher ratings corresponded with better Census Bureau does not report caregiver race, ethnicity, or income in
mental health. public use microdata. Child race, child ethnicity, and income as a per­
centage of the federal poverty level are used as approximate covariates.
2.2.3. Caregiver physical health Income as a percentage of the federal poverty level was categorized into
Kinship caregiver physical health was assessed using a one-item four groups: <100%, 100–199%, 200–399%, and > 400%. As recom­
global measure asking, “In general, how is your physical health?” mended by the U.S. Census Bureau (U.S. Census Bureau, 2020b), income

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as a percentage of the federal poverty level was imputed using multiple I report an adjusted 95% odds ratio (OR) for each logistic model.
imputation given the high level of missingness across the variables they
used to create this measure. Child ACE scores were measured by asking 3. Results
caregivers to indicate (yes or no) whether a child had experienced any of
the following eight adverse childhood experiences: parent or guardian 3.1. Demographic characteristics
divorce, parent or guardian death, parent or guardian incarceration,
witnessed domestic violence, experienced violence, lived with someone Kinship caregiver demographic characteristics generally mirrored
who experienced mental health problems, lived with someone who had those of other kinship caregiver samples (Table 1; Berrick et al., 1994;
substance use problems, or experienced discrimination due to their race Strozier & Krisman, 2007). Caregivers were mostly women (75.68%)
or ethnicity. Presumably due to the sensitive nature of these questions, and predominately grandparents of the target child (73.53%). Approx­
8.16% of respondents were missing data on at least one of the eight imately 61.48% of caregivers were either married or living with their
items. Following a procedure similar to Houtepen and colleagues, cases partner and just over half had a high school diploma or less (51.41%).
were retained if caregivers answered 50% or more of the ACE items Caregivers were 55.25 years old on average and 62.83% of caregivers
(Houtepen et al., 2018). Each reported ACE was scored as “1′′ and a total lived below 200% of the federal poverty level. Households had an
ACE score was calculated by summing the eight ACE items, with the average of 4.06 members. Children in the current sample were equally
resulting sample scores ranging from 0 (no reported ACEs) to 8 (eight split by sex (51.01% girls) and were approximately 8.57 years of age.
reported ACEs). For models predicting caregiver outcomes, child health Most children were either white (51.01%) or Black (33.10%), and
and mental health were included as covariates given evidence citing 22.83% were Latinx. Approximately 11.90% of children had been
their influence on kinship caregiver outcomes (Doley et al., 2015). diagnosed with an internalizing disorder and 15.23% had been diag­
Caregiver health and mental health were included as covariates in nosed with an externalizing disorder. These rates were significantly
models predicting child outcomes in light of evidence citing their in­ higher (p < .001) than those of the greater NSCH sample (internalizing:
fluence on child health and mental health outcomes (Garcia et al., 2015; 9.12%; externalizing: 7.54%), which is consistent with prior research
Xu & Bright, 2018). (Bramlett & Blumberg, 2007).

2.3. Analytic plan 3.2. Associations between covariates and key study variables

Data were analyzed using Stata 16.0 (StataCorp, 2019). Given the Caregivers that were grandparents reported significantly higher
relatively low amount of missing data (3.28% or less for any variable of levels of family resilience than other relative caregivers (β = 0.23; p =
interest), cases with missing data from study variables were omitted .03). On average, grandparents’ estimated family resilience was 0.23
from analyses. A comparison of cases with missing and complete data standard deviations greater than that of other relative caregivers.
revealed significant differences across five variables: caregiver mental Caregiver mental health (β = 0.11; p = .31), caregiver physical health (β
health, family resilience, caregiver education, child race, and income as = − 0.16; p = .12), caregiver parenting stress (β = − 0.11; p = .14), child
a percentage of the federal poverty level. Caregivers included in the health (β = 0.01; p = .94), child internalizing disorder (OR = 0.20; p =
study had higher self-reported mental health (p = .04) and family .39), and child behavioral problems (OR = − 0.19; p = .39) did not differ
resilience (p = .01). Caregivers with education beyond a high school significantly across caregivers’ relationship to the child. Caregivers’
diploma were more likely to be included in analyses (p = .03). Care­ partner status (β = 0.15; p = .12), family size (β = 0.02; p = .70), and
givers with children who were Native Hawaiian or Pacific Islander (p = child age (β = − 0.11; p = .08) were not associated with family resilience.
.02) or identified as another race (p = .02) were more likely to be
dropped from analyses. Greater proportions of caregivers with incomes 3.3. Associations with caregiver health outcomes
<100% (p < .001) were dropped from analyses, whereas greater pro­
portions of caregivers with incomes within 200–399% (p < .001) of the 3.3.1. Caregiver mental health
federal poverty level were retained in analyses. These differences sug­ Controlling for covariates, family resilience was positively associated
gest that the current findings may not be generalizable to the most with kinship caregiver mental health (β = 0.26, p < .001; Table 2). For
vulnerable kinship families. each standard deviation increase in family resilience, kinship caregiver
Prior to hypothesis testing, a series of regression analyses were mental health increased by 0.26 standard deviations. Among covariates,
conducted to assess relationships between key study and demographic caregiver age (β = 0.08, p = .04), child health (β = 0.25, p < .001), and
variables. Given the majority of kinship research involves grandparent having an income within 200–399% (β = 0.35, p < .001) and >400% (β
caregivers, I performed linear and logistic regressions to examine = 0.38, p = .001) of the federal poverty level were positively associated
whether the dependent and independent variables differed across with caregiver mental health. Child ACE scores (β = − 0.12, p = .006)
caregivers’ relationship to the child (grandparent or another relative). were negatively associated with caregiver mental health.
Additionally, caregivers with partners or larger households may have
increased possibilities for the exogenous transactions needed to build 3.3.2. Caregiver health
family resilience. Therefore, linear regression was used to determine if Controlling for covariates, family resilience was positively associated
partner status or family size was associated with family resilience. As­ with kinship caregiver health (β = 0.12, p = .001; Table 2). For each
sociations between child age and family resilience were also examined standard deviation increase in family resilience, kinship caregiver health
given children may partake in family resilience processes as they grow increased by 0.12 standard deviations. Among covariates, child ACE
older (Henry et al., 2018). Linear regression was used given Stata is score (β = − 0.10, p = .04), and Black racial identity (β = − 0.25, p =
unable to render correlation coefficients using imputed survey data. .006) were negatively associated with caregiver health. Child health (β
Controlling for covariates, I used multiple linear regression to examine = 0.28, p < .001) and having an income within 200–399% (β = 0.42, p
associations between family resilience and kinship caregiver health, < .001) and > 400% (β = 0.42, p = .001) of the federal poverty level
mental health, parenting stress, and child health. Because Stata does not were positively associated with caregiver health.
provide R2 for models using imputed survey data, continuous variables
in linear regression models were standardized to enable the interpreta­ 3.3.3. Parenting stress
tion of regression coefficients as effect sizes (i.e., standard deviations). I Controlling for covariates, family resilience was negatively associ­
used logistic regression to test if family resilience decreased the odds of ated with kinship caregiver parenting stress (β = − 0.15, p < .001;
the target child having an internalizing disorder or behavioral problems. Table 2). For each standard deviation increase in family resilience,

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Table 1 with four or more children were replaced with 4, and households with eight or
Weighted descriptive statistics for overall sample (N = 2,635). more individuals were replaced with 8; 2Partnered caregivers reported being
married or living with a partner; 3Caregivers who reported attending vocational
Variable % M 95% CI Range
school, having some college credit, an associate degree, bachelor’s degree,
Dependent variables master’s degree, or doctorate were grouped into the greater than high school
Caregiver mental health diploma category.
Poor 0.91
Fair 5.50
Good 18.72 kinship caregiver parenting stress decreased by 0.15 standard de­
Very good 35.27 viations. Among covariates, caregiver age (β = 0.06, p = .022), child
Excellent 39.60 health (β = − 0.10, p = .001), child behavioral problems (β = 0.93, p <
Caregiver physical health
Poor 2.65
.001), child ACE score (β = 0.12, p = .003), child age (β = 0.07, p =
Fair 13.10 .012), and Asian racial identity (β = 0.43, p = .004) were positively
Good 31.12 associated with parenting stress. Caregiver mental health (β = − 0.09, p
Very good 36.80 = .01) was negatively associated with parenting stress.
Excellent 16.34
Caregiver parenting stress 5.07 [4.91–5.22] 3–15
Child health 3.4. Associations with child health outcomes
Poor 0.20
Fair 2.24
3.4.1. Child health
Good 15.83
Very good 30.46 Controlling for covariates, family resilience was positively associated
Excellent 51.27 with child health (β = 0.07, p = .04; Table 3). For each standard devi­
Child internalizing disorder ation increase in family resilience, child health increased by 0.07 stan­
Yes 11.90
dard deviations. Among covariates, caregiver mental health (β = 0.19, p
No 88.10
Child behavioral problems
< .001), caregiver physical health (β = 0.12, p = .004), and caregiver
Yes 15.23 education (β = 0.18, p = .006) were positively associated with child
No 84.77 health. Child ACE score (β = − 0.12, p = .003) and child age (β = − 0.12,
Independent variables p < .001) were negatively associated with child health.
Family resilience 13.57 [13.30–13.84] 4–16
Caregiver age1 55.25 [54.08–56.42] 18–75
Number of children1 2.11 [2.02–2.19] 1–4 3.4.2. Child internalizing disorder
Household size1 4.06 [3.92–4.20] 1–8 Controlling for covariates, family resilience was not significantly
Caregiver sex associated with decreased odds of the target child being diagnosed with
Female 75.68
an internalizing disorder (OR = 0.94, p = .13; Table 3). Among cova­
Male 24.32
Caregiver relation to child
riates, caregiver mental health (OR = 0.68, p = .005), caregiver sex (OR
Grandparent 73.53 = 0.61, p = .049), and having a child of color (Black OR = 0.36, p < .001,
Aunt or uncle 5.67 American Indian or Alaska Native OR = 0.10, p < .001, Asian OR = 0.03,
Other relative 15.36 p = .001, another race OR = 0.21, p = .02, and two or more races OR =
Non-relative 5.45
0.44, p = .02) were associated with decreased odds of being diagnosed
Caregiver marital status2
Partnered 61.48 with an internalizing disorder. Caregiver education (OR = 1.75, p =
Not partnered 38.52 .011), child ACE score (OR = 1.45, p < .001), and child age (OR = 1.15,
Caregiver education3 p < .001) were associated with greater odds of an internalizing disorder
High school diploma or less 51.41
diagnosis.
Greater than high school 48.59
diploma
Child ACE Score 1.73 [1.59–1.88] 0–8 3.4.3. Child behavioral problems
Child age 8.57 [8.09–9.06] 0–17 Controlling for covariates, family resilience was significantly asso­
Child sex ciated with decreased odds of the target child having behavioral prob­
Female 51.01
lems (OR = 0.91, p = .02; Table 3). For each unit increase in family
Male 48.99
Child race resilience, the odds of child behavioral problems decreased by 9%. Child
White 51.01 ACE score (OR = 1.46, p < .001) and having a child that was a boy (OR
Black 33.10 = 3.55, p < .001) were associated with greater odds of having behavioral
American Indian or Alaska 1.69 problems. Children’s Asian identity (OR = 0.05, p = .006) and caregiver
Native
Asian 3.04
mental health (OR = 0.78. p = .049) were associated with decreased
Native Hawaiian or Pacific 0.84 odds of having behavioral problems.
Islander
Other race 3.51 4. Discussion
Two or more races 6.82
Child ethnicity
Non-Latinx 77.17 The current study offers a more robust exploration of the associations
Latinx 22.83 between family resilience and the health outcomes of kinship caregivers
Poverty level and their children. These findings are consistent with previous literature
30.77
<100%
examining the relationships between family resilience and health out­
100–199% 32.06
200–399% 25.07 comes (Burns et al., 2020; Cavanaugh et al., 2020; Kim et al., 2020;
>=400% 12.10 Nabors et al., 2020), and suggest the ongoing, transactional processes of
mutual support and problem solving in the face of adversity are asso­
Notes. M = mean; 95% CI = 95% confidence interval; ACE = adverse childhood
experience; range represents range observed in sample; 1 To protect confiden­
ciated with improved intergenerational health and mental health out­
tiality, NSCH coded all caregivers 75 years of age and older as 75+, households comes in kinship families.
with four or more children as 4+, and households with eight or more individuals Grandparents reported greater family resilience than other relative
as 8+. For analyses, caregivers’ 75 or older were replaced with 75, households caregivers. This finding may be reflective of grandparents’ previous
parenting experience, which might enhance their ability to recruit

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Table 2
Linear regression analyses for associations between family resilience and ratings of caregiver mental health, physical health, and parenting stress (N = 2,635).
Mental health Physical health Parenting stress

Variables β 95% CI β 95% CI β 95% CI

Family resilience 0.26*** [0.17− 0.36] 0.12** [0.05− 0.19] − 0.15*** [− 0.21− − 0.09]
Caregiver mental health – – – – 0.05 [− 0.01− 0.11]
Caregiver physical health – – – – − 0.09* [− 0.16− − 0.02]
Caregiver age 0.08* [0.00− 0.16] − 0.07† [− 0.15− 0.01] 0.10** [0.04− 0.16]
Number of children 0.07† [− 0.00− 0.14] 0.04 [− 0.04− 0.12] − 0.01 [− 0.06− 0.04]
Household size − 0.02 [− 0.10− 0.06] 0.05 [− 0.04− 0.13] 0.02 [− 0.04− 0.08]
Relation to child
Other relative (reference)
Grandparents − 0.03 [− 0.21− 0.15] − 0.07 [− 0.27− 0.12] − 0.14† [− 0.29− 0.01]
Caregiver sex
Female (reference)
Male 0.13† [− 0.02− 0.29] 0.15† [− 0.02− 0.31] − 0.08 [− 0.19− 0.04]
Caregiver marital status
Not partnered (reference)
Partnered − 0.05 [− 0.21− 0.11] − 0.02 [− 0.17− 0.13] 0.03 [− 0.16− 0.10]
Caregiver education level
High school diploma or less (reference)
Greater than high school diploma 0.06 [− 0.08− 0.19] 0.09 [− 0.05− 0.23] 0.04 [− 0.07− 0.14]
Child health 0.25*** [0.17− 0.33] 0.22*** [0.14− 0.29] − 0.09** [− 0.15− − 0.03]
Child internalizing disorder − 0.14 [− 0.32–0.05] − 0.07 [− 0.25− 0.12] 0.11 [− 0.06− 0.28]
Child behavioral problems − 0.07 [− 0.24− 0.10] − 0.08 [− 0.24− 0.09] 0.92*** [0.76–1.08]
Child ACE score − 0.12** [− 0.20− − 0.03] − 0.10* [− 0.19− − 0.01] 0.11** [0.04− 0.19]
Child age 0.04 [− 0.03− 0.12] 0.01 [− 0.07− 0.08] 0.07* [0.01− 0.12]
Child sex
Female (reference)
Male 0.05 [− 0.08− 0.18] − 0.01 [− 0.14− 0.13] 0.06 [− 0.05− 0.16]
Child Race
White (reference)
Black 0.02 [− 0.15− 0.19] − 0.26** [− 0.44− − 0.07] − 0.07 [− 0.22–0.07]
American Indian or Alaska Native 0.04 [− 0.49− 0.57] − 0.02 [− 0.36− 0.31] 0.02 [− 0.25− 0.28]
Asian − 0.33 [− 0.77− 0.11] 0.04 [− 0.28− 0.37] 0.36* [0.07− 0.65]
Hawaiian or Pacific Islander − 0.27 [− 1.05− 0.52] 0.00 [− 0.49− 0.50] 0.24 [− 0.35− 0.84]
Other Race 0.40† [− 0.03− 0.83] 0.18 [− 0.16− 0.53] − 0.20 [− 0.49− 0.08]
Two or more races − 0.12 [− 0.42− 0.17] − 0.20 [− 0.51− 0.11] − 0.02 [− 0.19− 0.14]
Child ethnicity
Non-Latinx (reference)
Latinx 0.04 [− 0.14− 0.22] 0.04 [− 0.17− 0.25] 0.03 [− 0.11− 0.18]
Poverty level
<100% (reference)
100–199% 0.16 [− 0.03− 0.35] 0.18† [− 0.00− 0.37] − 0.11 [− 0.28− 0.06]
200–399% 0.35*** [0.17− 0.53] 0.42*** [0.20− 0.65] − 0.05 [− 0.23–0.13]
>=400% 0.38** [0.16− 0.60] 0.42** [0.18− 0.66] 0.06 [− 0.13− 0.24]
Constant − 0.24† [− 0.49− 0.01] − 0.23 [− 0.50− 0.05] − 0.10 [− 0.29− 0.10]

Notes. ACE = Adverse childhood experience; †p < .10, *p < .05, **p < .01, ***p < .001.

family support that meets parenting demands. Caregiver’s partner sta­ noted that this relationship may be bi-directional: it is possible care­
tus, family size, and child age were not associated with family resilience. givers with better health have greater capacity to engage in the ex­
Although these findings suggest the main predictor variable was not changes central to promoting family resilience. Future research may
associated with these constructs, it should be noted past research sug­ benefit from methods that can ascertain the directionality of this
gests having a greater number of individuals to turn to in times of need association.
has been linked to greater family resilience (Black & Lobo, 2008). Family resilience was also associated with higher ratings of child
Additionally, children tend to partake in family resilience processes as health. Previous research links family resilience with healthy exercising
they grow older (Henry et al., 2018). habits in children and decreased odds of asthma, suggesting that families
Family resilience was positively associated with higher ratings of with greater resilience might be better poised to promote positive health
kinship caregiver health and mental health, and negatively associated behaviors in children that stave off health problems (Burns et al., 2020;
with parenting stress. These findings corroborate prior explorations of Nabors et al., 2020). Families with greater resilience may also be better
family resilience among foster and kinship caregivers (Cavanaugh et al., prepared to handle acute health concerns (e.g., illnesses or injuries
2020; Schneiderman et al., 2012). Kinship caregivers that regularly turn requiring hospitalization), thereby limiting the long-term effects these
to their families during times of need might receive greater social sup­ episodes can have on children’s health. Family resilience was also
port and perceive greater family resources (Gleeson et al., 2016; Walsh, associated with the decreased odds of children having behavioral
2003). Kinship caregivers may consequently appraise challenging cir­ problems. Families that regularly approach challenges with effective
cumstances as more manageable, which can mitigate psychological problem solving, meaning making, and communication may more
distress and parenting stress (Cavanaugh et al., 2020; Gleeson et al., effectively mitigate the negative effects ecological and caregiving ad­
2016). Similarly, kinship caregivers that endorse greater family resil­ versities might have on children’s behavior. Further, the act of turning
ience may be more likely to seek their families’ support for daily care­ to one another to resolve difficulties may model healthy ways of navi­
giving tasks. Having a larger network of adults that share caregiving gating adverse events and processing negative emotions (Szilagyi et al.,
responsibilities may provide greater opportunity for respite, which has 2015; Xu, Bright, Huang, et al., 2020; Xu & Bright, 2018). Contrary to
been tied to improved well-being (Madden et al., 2016). It should be my hypothesis and evidence from non-kinship samples, family resilience

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Table 3
Linear and logistic regression analyses for associations between family resilience and ratings of child health, internalizing disorders, and behavior problems (N =
2,635).
Health Internalizing disorders Behavior problems

Variables β 95% CI OR 95% CI OR 95% CI

Family resilience 0.07* [0.00− 0.14] 0.94 [0.87–1.02] 0.91* [0.84− 0.98]
Caregiver mental health 0.19*** [0.11− 0.28] 0.68** [0.52− 0.89] 0.78* [0.62–1.00]
Caregiver physical health 0.12** [0.04− 0.20] 0.89 [0.71–1.13] 0.85 [0.68–1.06]
Caregiver age 0.06 [− 0.02− 0.13] 1.01 [0.99–1.03] 1.00 [0.98–1.02]
Number of children − 0.00 [− 0.07− 0.07] 0.93 [0.70–1.22] 0.90 [0.72–1.12]
Household size − 0.00 [− 0.08− 0.07] 0.93 [0.77–1.14] 0.95 [0.81–1.10]
Relation to child
Other relative (reference)
Grandparent − 0.06 [− 0.23–0.11] 1.32 [0.70–2.49] 0.80 [0.47–1.36]
Caregiver sex
Female (reference)
Male 0.08 [− 0.07− 0.22] 0.61* [0.38–1.00] 0.82 [0.53–1.26]
Caregiver marital status
Not partnered (reference)
Partnered − 0.07 [− 0.23–0.09] 0.98 [0.63–1.51] 1.23 [0.79–1.92]
Caregiver education level
High school diploma or less (reference)
Greater than high school diploma 0.18** [0.05− 0.31] 1.75* [1.14–2.70] 1.12 [0.75–1.66]
Child ACE score − 0.12** [− 0.20− − 0.04] 1.45*** [1.31–1.62] 1.46*** [1.32–1.63]
Child age − 0.12*** [− 0.19− − 0.06] 1.15*** [1.10–1.20] 1.02 [0.98–1.06]
Child sex
Female (reference)
Male − 0.02 [− 0.15− 0.10] 1.50* [1.01–2.22] 3.55*** [2.29–5.51]
Child Race
White (reference)
Black − 0.06 [− 0.23–0.11] 0.36*** [0.21− 0.61] 1.23 [0.77–1.99]
American Indian or Alaska Native 0.18 [− 0.14− 0.49] 0.10*** [0.03− 0.35] 0.78 [0.15–4.04]
Asian − 0.31 [− 0.70− 0.08] 0.03** [0.00− 0.22] 0.05** [0.01− 0.43]
Hawaiian or Pacific Islander 0.02 [− 0.65− 0.70] 0.26 [0.04–1.63] 0.58 [0.16–2.12]
Other Race 0.15 [− 0.11− 0.41] 0.21* [0.06− 0.76] 0.66 [0.17–2.59]
Two or more races 0.05 [− 0.16− 0.25] 0.45* [0.23–0.89] 0.88 [0.49–1.57]
Child ethnicity
Non-Latinx (reference)
Latinx 0.16† [− 0.01− 0.32] 0.96 [0.55–1.66] 0.62† [0.36–1.07]
Poverty level
<100% (reference)
100–199% 0.11 [− 0.09− 0.31] 0.88 [0.51–1.54] 1.23 [0.72–2.13]
200–399% 0.16 [− 0.08− 0.40] 0.67 [0.37–1.23] 0.93 [0.51–1.68]
>=400% 0.18† [− 0.02− 0.38] 0.79 [0.40–1.57] 1.54 [0.80–2.95]
Constant − 0.13 [− 0.38− 0.11] 0.20† [0.04–1.08] 0.73 [0.12–4.39]

Notes. ACE = adverse childhood experience; †p < .10, *p < .05, **p < .01, ***p < .001.

was not associated with the odds of children having an internalizing associated with child health and decreased odds of having an internal­
disorder (Nabors et al., 2020). It is possible turning inward to one’s izing or externalizing disorder, thus bolstering existing evidence that
family does not allow caregivers to acquire the mental health services suggests poor caregiver health and mental health may have a toll on
needed to address children’s internalizing symptoms. Moreover, the child well-being (Xu & Bright, 2018). Similarly, caregiver mental health
high prevalence of internalizing disorders among children in the United was negatively associated with parenting stress. This finding corrobo­
States generally suggests this issue may be fairly normative, regardless rates previous research linking caregiver mental health to parenting
of family resilience (Jamnik & DiLalla, 2019). Consequently, family stress (Hayslip et al., 2015, 2019; Kelley et al., 2000). Child behavioral
resilience may not be a strong predictor of internalizing outcomes. problems were positively associated with parenting stress, which is
Alternatively, evidence suggests caregivers may have greater difficulties consistent with previous research citing the caregiving challenges
detecting internalizing problems compared to behavioral problems associated with raising a child with conduct problems (Suárez & Baker,
(Weissman et al., 1987). Kinship caregivers might positively skew their 1997). Child age was associated with higher parenting stress, poorer
assessments of children’s well-being and therefore not see their child’s child health, and greater odds of being diagnosed with an internalizing
symptoms as sufficiently problematic to warrant consultation with a and externalizing disorder. Children’s health typically worsens as they
professional, thereby decreasing the likelihood of a diagnosis (Barth, get older (Case & Paxson, 2002). This pattern is also reflected among
2008). psychological diagnoses, which become more frequent as children
Several covariates were significant predictors of health and mental develop into adolescents (Kovacs & Devlin, 1998). Taken together, this
health outcomes across models. Child ACE scores were associated with may suggest caregivers of older children in the current sample might
worse health and mental health across kinship caregivers and their experience greater parenting stress as they navigate their children’s
children. This may be indicative of family difficulties that suppress the health and mental health care needs (Raphael et al., 2010). All children
health outcomes of both children and their caregivers (Balistreri & of color (except Native Hawaiian or Pacific Islander children) were less
Alvira-Hammond, 2016). Child health was inversely associated with likely to be diagnosed with an internalizing disorder compared to their
kinship caregiver well-being, corroborating literature that links child white peers. This might be reflective of racism that impedes health and
health issues to caregiver physical and psychological distress (Denby mental health care access and quality (Feagin & Bennefield, 2014).
et al., 2015). Caregiver health and mental health were positively Greater incomes were associated with improved caregiver health and

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mental health, corroborating research noting the relationship between kinship families. Additional mixed-method examinations of family
increased income and well-being (Marmot, 2002). Similarly, caregiver resilience would also be helpful. Family resilience varies as a function of
education was positively associated with child health and the increased myriad ecological factors that are difficult to measure via scales (Walsh,
odds of having an internalizing disorder, which may be indicative 2016b). Interview data that explores how caregivers navigate relational
increased economic resources and access to health care professionals dynamics with family members during times of need might provide
that can diagnose and treat children (Feagin & Bennefield, 2014; complementary information that goes uncaptured by quantitative
Marmot, 2002). scales. Such explorations might also reveal differences across cultures
regarding who families consider as appropriate actors to turn to when
4.1. Limitations adapting to various stressors (Robbins et al., 2013).

This study is not without limitations. The NSCH was not designed to
collect data from kinship caregivers, meaning it cannot be assumed that 4.3. Implications for policy and practice
the current sample is representative of kinship caregivers in the United
States. It was also impossible to discern if children were involved in the Kinship caregivers may benefit from services that encourage explicit,
child welfare system. Given the differences in service access and mental thoughtful reflection about who in their familial network they can call
health outcomes between formal and informal kinship caregivers (Lin, on for support. The FOCUS Family Resilience Program, a family-based
2018; Xu & Bright, 2018), additional research is needed to determine intervention aimed to build family resilience after experiences of
whether the relationship between family resilience and health outcomes trauma and loss among military families, might be a fruitful intervention
varies as a function of child welfare system involvement. Moreover, I to pilot among kinship families (Saltzman, 2016). Although current
cannot infer causality due to the cross-sectional and correlational nature evidence attesting to FOCUS’ effectiveness among kinship or child
of the current study. Additionally, health and mental health outcomes welfare populations is limited, its attention to meaning making, healthy
were assessed using one-item self-report measures, which do not provide communication, and family integration may offer a medium through
insight to specific health or mental health outcomes. Future research which kinship families can navigate tensions and uncertainties that
may benefit from incorporating more robust scales of specific diagnoses might inhibit the effective mobilization of support and resources during
and third-party informants to avoid biases associated with self- and times of need (Saltzman, 2016; Saltzman et al., 2013). In addition to
caregiver reports (Barth, 2008; Gorber & Tremblay, 2016). This may be building family resilience, parents and children participating in FOCUS
particularly relevant for child mental health outcomes. High rates of have shown reductions in psychological distress and improved pro-
comorbidity between child internalizing and externalizing disorders are social behaviors (Saltzman, 2016). Given both kinship and military
common (in the current study having an internalizing disorder was families may contend with numerous hardships, the FOCUS Family
associated with greater odds of having an externalizing disorder; OR = Resilience program might offer similar benefits to kinship families.
2.37, p < .001). However, because externalizing and internalizing dis­ Given the potential bidirectional relationships between health and
orders may elicit different family responses and parenting practices family resilience, services that primarily target health and mental health
(Langley et al., 2010; Serbin et al., 2015), nuanced measures of mental may also positively shape family resilience processes. Caregiver support
health diagnoses and the family resilience processes enacted to address groups may be one such option. In addition to providing an opportunity
them are needed to better understand the differential family responses to process emotions with others who are acutely familiar with the dy­
to children’s internalizing and externalizing disorders. namics of kinship care, support groups often create a space of collective
strategizing and resource sharing that is conducive to resolving chal­
4.2. Implications for future research lenges in kinship care (Rushovich et al., 2017). Accordingly, health and
mental health interventions may also promote family resilience
Findings highlight kinship families’ resilience and their ability to processes.
promote multigenerational health and mental health outcomes despite Facilitating the piloting of FOCUS and other innovative kinship
racism, poverty, and adverse childhood experiences. These findings family services inevitably requires policy change that increases funding
corroborate research illustrating the benefits that kinship care can for such services and research. While the Families First Prevention
confer by keeping families together and sustaining children’s relation­ Services Act has spurred research to build the evidence base for kinship
ships with their family members (Kiraly & Humphreys, 2013). However, support services, as of this writing none of the evaluated kinship pro­
some researchers assert that the circumstances that result in kinship care grams have met the evidence threshold required for federal reimburse­
arrangements may be emblematic of family dynamics that are incon­ ment (Title IV-E Prevention Services Clearinghouse, 2021). In both 2018
ducive to successful caregiving (Font, 2015; Kroll, 2007). In order to and 2019, the federal government allotted $20 million for states, tribes,
clarify the social contexts that may promote kinship family resilience and territories to establish, expand, or evaluate kinship navigator pro­
and health outcomes, future research might include explicit measures of grams. Although a promising step, $20 million distributed across 46
the social actors that kinship caregivers turn to when in need. The cur­ states, eight Native American tribes, and two territories will likely not
rent measure asked caregivers if they turn to family during times of provide sufficient financial support to effectively evaluate new kinship
need, but it does not capture who these relatives are nor how relational family services in a timely manner (Beltran, 2019).
quality may shape how kinship caregivers seek support. Further, the
current measure does not indicate if turning to family members results in 5. Conclusion
the recruitment of external support from the larger community, which
would similarly enhance family resilience (Patterson, 2002; Walsh, The current study extends existing family resilience research by
2016b). Social network analysis, a paradigm that maps the actors, re­ examining associations between family resilience and well-being among
lationships, and resources gleaned from an individual’s social network kinship caregivers and their children. Findings suggest family resilience
(McArthur & Winkworth, 2017), may provide a greater understanding may promote health and mental health outcomes among kinship fam­
of who caregivers turn to in times of need, the type of resources they ilies and suggests kinship families benefit when they can engage other
seek and receive from family versus their larger community, and the household members in problem solving and mutual support. While
circumstances that spur support-seeking. Understanding who kinship additional research is needed to examine how family resilience relates to
caregivers turn to during times of need can offer clarification to extant kinship caregivers’ social networks and specific diagnoses, the current
conundrums in kinship care literature (i.e., under what circumstances is study provides a foundation for future research that can inform neces­
parent contact beneficial?) and offer insight to the lived experiences of sary services for kinship caregivers and the children in their care.

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A. Gómez Children and Youth Services Review 127 (2021) 106103

CRediT authorship contribution statement kinship care placements. Maternal and Child Health Journal, 19(3), 459–467. https://
doi.org/10.1007/s10995-014-1525-9
Geiger, J. M., Piel, M. H., Lietz, C. A., & Julien-Chinn, F. J. (2016). Empathy as an
Anthony Gómez: Conceptualization, Formal analysis, Funding essential foundation to successful foster parenting. Journal of Child and Family
acquisition, Investigation, Methodology, Writing - original draft, Studies, 25(12), 3771–3779. https://doi.org/10.1007/s10826-016-0529-z
Writing - review & editing. Gleeson, J. P., Hsieh, C., & Cryer-Coupet, Q. (2016). Social support, family competence,
and informal kinship caregiver parenting stress: The mediating and moderating
effects of family resources. Children and Youth Services Review, 67, 32–42. https://
Declaration of Competing Interest doi.org/10.1016/j.childyouth.2016.05.012
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