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. Author manuscript; available in PMC: 2026 Mar 18.
Published in final edited form as: Aging Ment Health. 2026 Jan 19;30(6):1274–1284. doi: 10.1080/13607863.2026.2612916

Prediction of burnout and psychosocial differences among sandwich generation and other informal caregivers

Erika A Fenstermacher 1, Montgomery T Owsiany 1, Catherine H Ju 1, Sabine Lohmar 1, Barry A Edelstein 1
PMCID: PMC12994609  NIHMSID: NIHMS2144035  PMID: 41552895

Abstract

Objectives:

Previous research indicates that burnout is higher among sandwich generation than among caregivers of children only and parents only. This study sought to identify the strongest predictors of burnout in different groups of caregivers. Further, this study aimed to confirm previous findings on the differences between caregivers of children only, parents only, and both children and parents (i.e. the sandwich generation).

Method:

Participants (N = 415) recruited from Prime Panels answered questions related to burnout and psychosocial variables. Correlational analyses, a one-way ANOVA, and two multiple linear regressions were completed.

Results:

Predictors of burnout differed between caregiving groups. In sandwich generation caregivers, positive and negative relationship quality were significant predictors of caregiver burnout. In parent-only caregivers, unique predictors of burnout included insomnia, distress tolerance, and neuroticism. In child-only caregivers, depressive symptoms and negative relationship quality significantly predicted caregiver burnout. Caregiver burnout and both positive and negative quality of the caregiving relationships differed significantly between the groups. Caregiver burnout was significantly higher in sandwich generation and parent-only caregivers compared to child-only caregivers. Positive relationship quality was highest among child-only caregivers, followed by sandwich generation and parent-only caregivers. Negative relationship quality was highest among sandwich generation, followed by parent-only caregivers and child-only caregivers.

Conclusion:

Individuals caring for parents, especially those in the sandwich generation, face unique challenges including higher levels of burnout and depressive symptoms. Relationship quality is important in predicting burnout among individuals caring for parents.

Keywords: Burnout, informal caregiving, sandwich generation, relationship quality, older adults

Introduction

Approximately 53 million individuals provide unpaid care for someone in the United States (AARP & National Alliance for Caregiving, 2020). A greater percentage of women (25.4%) provide care than men (18.9%) and approximately 24.0% of caregivers are ages 45 to 64, and around 18.8% are over 65 years old (Centers for Disease Control and Prevention, 2019). The racial/ethnic breakdown of caregivers is similar in race and ethnic composition to the demographics of United States citizens at large (AARP & National Alliance for Caregiving, 2020). Understanding the psychosocial experiences of informal caregivers is relevant for improving the quality of life for these caregivers.

Informal caregiving generally refers to assistance given without pay by someone close to the individual, which can include helping with daily tasks, handling finances, coordinating external support, or simply making regular visits (AARP & National Alliance for Caregiving, 2020). Informal caregiving places individuals at higher risk of burnout (Gérain & Zech, 2021). Burnout can be conceptualized along three dimensions: emotional exhaustion, depersonalization, and reduced sense of personal accomplishment (Maslach, 1998). Emotional exhaustion refers to feeling emotionally stressed because of a heavy workload. Depersonalization, which can result from emotional exhaustion, occurs when individuals feel detached from or negatively toward individuals they are interacting with as part of their responsibilities. Finally, when individuals have a reduced sense of personal accomplishment, they feel more incompetent and find their work, in this case caregiving duties, less fulfilling and meaningful.

A conceptual model that discusses burnout in the context of informal caregiving is the Informal Caregiving Integrative Model (ICIM; Gérain & Zech, 2019). Contributors to burnout, according to the ICIM, are caregiver characteristics, stressors of the caregiving setting, and the social environment. Caregiver characteristics include psychological factors, such as physical health status. Stressors in the caregiving setting are important to consider, and attention should be paid to both primary (i.e. objective burden) and secondary (e.g. reduced social life of the caregiver due to caregiving responsibilities) stressors. The model also suggests that the social environment is an important determinant of caregiver burnout and includes elements such as informal support (e.g. from the partner of a caregiver), professional support (e.g. respite services), and the sociocultural environment (e.g. cultural expectations of the caregiving role). These determinants affect burnout through subjective appraisals of the caregiving situation and the quality of the relationship between the caregiver and the care-recipient. Finally, the model describes how burnout can affect general outcomes such as the caregiver’s mental health and the well-being of the care-recipient. The effects of these outcomes, as well as burnout, often circle back to the front of the model and affect the caregiver, the caregiving setting, and the social environment.

When considering types of informal caregivers, Schulz and Tompkins (2010) have identified three distinct groups of informal caregivers, based roughly on the age of the care recipients: those who care for children, adults, and older adults. Most of the literature on informal caregiving, and its impact on caregivers, appears to focus on the provision of care for adults or older adults with disabilities. Yet, there is a growing group of caregivers who simultaneously provide care for both their own children and their aging parents, which has become known as the sandwich generation (Miller, 1981). In the United States, around 2.5 million people are a part of the sandwich generation (Lei et al., 2023).

Informal caregiving by the sandwich generation is typically unpaid and is often associated with a variety of negative outcomes. For example, compared to caregivers of only an older adult, sandwich generation caregivers are twice as likely to report financial difficulty (Lei et al., 2023). Caring for parents and children simultaneously can also lead to an emotional toll. In a study of female sandwich generation caregivers (Stephens et al., 2001), 33% reported clinically relevant depressive symptoms. Sandwich generation caregivers are also more likely to experience stress than those providing care for only a child or an older adult (Halinski et al., 2018). Another significant outcome of sandwich generation caregiving is burnout. Although there has been little research on burnout in sandwich generation caregivers, Owsiany et al. (2023) found that sandwich generation caregivers and caregivers of parents experience greater levels of burnout than caregivers of children.

The overall aim of the present study was to determine predictors of burnout among caregivers of children only, parents only, and sandwich generation caregivers. To address the lack of research on sandwich generation caregivers, the present study sought to investigate the relevance of the ICIM to this population. The first goal was to determine which variables predicted burnout among caregivers of children only, parents only, and caregivers of both children and parents (i.e. the sandwich generation). In line with the ICIM and existing research, depression, suicidality, self-efficacy, distress tolerance, and personality traits were examined as ‘psychological variables’ and predictors of burnout (Gérain & Zech, 2019, 2022; Shaffer et al., 2016; Solimando et al., 2022; Tan et al., 2021). Again, in line with the ICIM and previous research, insomnia was investigated as a ‘physical health variable’ and a predictor of burnout (Starr et al., 2023). The second goal was to examine differences in burnout and other psychosocial variables in each of the three caregiver groups, which could help connect these groups with appropriate resources and support.

Method

Participants

Participants were recruited via CloudResearch Prime Panels, an aggregator of online research recruitment panels, in September, October, and November of 2023. All participants were compensated for their participation. Participants needed to be 18 and older, in the United States, able to read English, and endorse being an informal caregiver (i.e. ‘Do you provide unpaid care for your parent(s)?’ yes/no and ‘Do you provide unpaid care for your child or children?’ yes/no). Participants self-reported their caregiver status, and three separate participant groups were created: sandwich generation caregivers (n = 111), parent-only caregivers (n = 122), and child-only caregivers (n = 182). Utilizing G*Power 3.1, the total number of participants per group was deemed adequate to power the present analyses (Faul et al., 2007).

Measurement instruments

Copenhagen Burnout Inventory (CBI)

The CBI is a 19-item, self-report assessment instrument that assesses burnout symptoms using three subscales: personal burnout (CBI-P), work-related burnout (CBI-W), and client-related burnout (CBI-C; Kristensen et al., 2005). Based on the study’s aims, only the CBI-C and CBI-P were used in this study, as was the case in Owsiany et al. (2023). Each subscale consists of six items, yielding scores ranging from 0 to 100 with higher scores reflecting greater levels of burnout in the respective subscale domain. Personal burnout is defined as the physical fatigue, psychological fatigue, and exhaustion one experiences. Client-related burnout refers to the physical fatigue, psychological fatigue, and exhaustion one experiences related specifically to their work with clients (Kristensen et al., 2005). In line with instructions from Kristensen et al. (2005) and consistent with Owsiany et al. (2023), the word ‘client’ was replaced with ‘care recipient’ on all 6 items to measure informal caregiver burnout related to the care recipient. Thus, for ease of reading, CBI-C is referred to as ‘caregiver burnout’ rather than client-related burnout. The Cronbach’s alpha for the present study was 0.91 for the CBI-C and 0.92 for the CBI-P.

Center for Epidemiologic Studies Depression Scale (CES-D)

The CES-D is a 20-item, self-report measure of depressive symptoms experienced over the previous week (Radloff, 1977). Scores range from 0 to 60, with higher scores indicating a greater number of endorsed depressive symptoms. Cronbach’s alpha for the present study was 0.95.

Suicide Behaviors Questionnaire-Revised (SBQ-R)

The SBQ-R is a 4-item, self-report assessment instrument of suicidal ideation and behaviors (Osman et al., 2001). Items assess lifetime previous, recent, and the threat of future suicidal ideation and behaviors. Scores range from 3 to 18, with higher scores suggesting higher suicide risk. Cronbach’s alpha for the present study was 0.85.

Coping Self-Efficacy Scale (CSES)

The CSES is a 26-item, self-report assessment instrument that measures an individual’s confidence using coping strategies when faced with a life challenge (Chesney et al., 2006). Scores range from 0 to 260, with higher scores indicating greater confidence in using coping skills. Cronbach’s alpha in the present study was 0.98.

Distress Tolerance Scale (DTS)

The DTS is a 15-item, self-report assessment instrument that measures one’s ability to experience and withstand negative psychological states (Simons & Gaher, 2005). Scores range from 15 to 75, with higher scores indicating worse distress tolerance. Cronbach’s alpha in the present study was 0.92.

Quality of Carer-Patient Relationship Scale (QCPR)

The QCPR is a 14-item, self-report measure of a caregiver’s perception of the relationship between a care-recipient and the caregiver (Spruytte et al., 2002). There are two subscales: positive (QCPR-Pos) and negative (QCPR-Neg). Scores on the QCPR-Pos range from 8 to 40 with higher scores denoting greater belief that the relationship between caregiver and care recipient is positive. Scores on the QCPR-Neg range from 6 to 30 with higher scores indicating greater belief that the relationship is negative. Cronbach’s alpha in the present study was 0.94 for the QCPR-Pos and 0.86 for the QCPR-Neg.

Quality of Relationships Inventory (QRI)

The QRI is a 25-item, self-report measure of relationship quality (Pierce et al., 1991). A study by Verhofstadt et al. (2006) evaluated the factor structure of the QRI and confirmed three subfactors: support, conflict, and depth. The QRI was added as an additional measure of relationship quality to add information about specific aspects of relationship quality for those caring for parents only and sandwich generation. In the present study, composite subscale scores were created for each of the three factors identified by Verhofstadt et al. (2006) subscales. Scores on the QRI-Support range from 7 to 28, with higher scores indicating greater perceived social support in the relationship. Scores on the QRI-Conflict range from 12 to 48, with higher scores indicating higher levels of perceived conflict in the relationship. Scores on the QRI-Depth range from 6 to 24, with high scores indicating higher perception of the relationship being positive, important, and secure. Cronbach’s alpha was 0.91 for QRI-Support, 0.91 for QRI-Conflict, and 0.81 for QRI-Depth. The QRI was not given to the child-only caregivers, as the items were not relevant to relationships between adults and their young children.

Mini-International Personality Item Pool (MINI-IPIP)

The MINI-IPIP is a 20-item, self-report measure of the Big Five traits: extraversion, agreeableness, conscientiousness, neuroticism, and openness (Donnellan et al., 2006). It is a validated, brief adaptation of the 50-item International Personality Item Pool-Five-Factor Model (IPIP-FFM; Goldberg, 1999). On the MINI-IPIP, there are four items for each Big Five trait subscale, and scores are calculated per trait. Scores for each subscale range from 4 to 20, with higher scores indicating higher levels of the designated trait: extraversion (MINI-E), agreeableness (MINI-A), conscientiousness (MINI-C), neuroticism (MINI-N), and openness (MINI-O). In the present study, Cronbach’s alphas in the present study were 0.77 for the MINI-E, 0.74 for the MINI-A, 0.72 for the MINI-C, 0.78 for the MINI-N, and 0.78 for the MINI-O.

Athens Insomnia Scale (AIS)

The AIS is an 8-item, self-report measure of perceived sleep quality (Soldatos et al., 2000). Scores range from 0 to 24, with higher scores signifying worse sleep quality. Scores equal to or greater than 6 is indicative of insomnia. Cronbach’s alpha for the present study was 0.90.

Data collection and analysis

The present study was approved by the Institutional Review Board of West Virginia University. Demographics were collected to describe the sample. Participants were also asked questions about their care recipients, but these questions did not include information regarding the care recipients’ functional or cognitive status. Following completion of the survey, participants were given a list of national mental health resources including multiple resources for suicide prevention. Participants who responded incorrectly to one or more validity check questions were excluded from analyses. All analyses were completed using IBM SPSS (Version 28.0). Composite scores were only calculated if the participant answered every question on the assessment. Otherwise, those participants were not included in analyses utilizing that assessment. Correlational analyses were completed for the total sample. Following this, a one-way ANOVA was conducted to calculate mean score differences among the three participant groups. Then, assessment composite scores were centered. Lastly, two multiple linear regression analyses were completed with CBI-C as the dependent variable. Predictor variables were chosen based on significant correlations with CBI-C scores. The QRI subscales were not included due to them not being administered to child-only caregivers. The CBI-P was not included in the regression analyses due to multicollinearity concerns with the CES-D. The SBQ-R was not included, as suicide risk was conceptualized as a possible outcome of burnout, not a predictor. All variables were entered into the regression model at the same step. These included AIS, BJSM, CES-D, CSES, DTS, MINI-A, MINI-C, MINI-N, MINI-O, and QCPR-Pos. In the second regression, QCPR-Neg was entered instead of QCPR-Pos. Separate regressions were conducted due to multicollinearity concerns between the two QCPR subscales. The regression output was separated by group, meaning that separate results were obtained for sandwich generation caregivers, parent-only caregivers, and child-only caregivers, to assess for differences among the groups.

Results

The two aims of the present study were to determine whether differences existed between informal caregivers of child-only, parent-only, and both (i.e. sandwich generation) with regard to the included psychosocial factors and to identify predictors of burnout for each of these groups.

Participant demographics are displayed in Table 1. The sandwich generation sample’s age, race, and gender were similar to a nationally representative sample (Lei et al., 2023). Mean scores for the overall sample and for each individual group are found in Appendix A. The scores on the following variables were significantly correlated with caregiver burnout: depressive symptoms (r=0.49, p < 0.001), self-efficacy (r=−0.36, p < 0.001), relationship support (r=−0.43, p < 0.001), relationship conflict (r=0.59, p < 0.001), relationship depth (r=−0.45, p < 0.001), positive relationships (r=−0.44, p < 0.001), negative relationships (r=0.57, p < 0.001), openness (r=−0.10, p=0.035), conscientiousness (r=−0.30, p < 0.001), agreeableness (r=−0.20, p < 0.001), neuroticism (r=0.36, p < 0.001), distress tolerance (r=−0.39, p<0.001), personal burnout (r=0.56, p < 0.001), insomnia (r=0.44, p < 0.001), and suicidality (r=0.34, p < 0.001).

Table 1.

Participant demographics.

Total (N = 415) Child-only caregivers (n = 182) Parent-only caregivers (n = 122) Sandwich caregivers (n = 111)
Age, mean (range) 40.21 (20–70) 39.16 (21–70) 41.83 (20–69) 40.14 (23–67)
Years of education, mean (range) 15.66 (8–26) 15.56 (10–24) 15.61 (10–24) 15.86 (8–26)
n (%) n (%) n (%) n (%)
Gender
 Men 138 (33.3) 60 (33.0) 51 (41.8) 27 (24.3)
 Women 269 (64.8) 119 (65.4) 68 (55.7) 82 (73.9)
 Genderqueer/-fluid 5 (1.2) 2 (1.1) 2 (1.6) 1 (0.9)
 Other 3 (0.7) 1 (0.5) 1 (0.8) 1 (0.9)
Race/ethnicity
 White 307 (74.0) 135 (75.8) 91 (74.6) 78 (70.3)
 Black 53 (12.8) 21 (11.5) 16 (13.1) 16 (14.4)
 Asian 8 (1.9) 3 (1.6) 3 (2.5) 2 (1.8)
 Hispanic/Latine 17 (4.1) 7 (3.8) 4 (3.3) 6 (5.4)
 Native American 2 (0.5) 1 (0.5) 0 1 (0.9)
 Prefer not to answer 2 (0.5) 1 (0.5) 0 1 (0.9)
 Multi-racial/other 26 (6.3) 11 (0.6) 8 (6.6) 7 (6.3)
Marital status
 Married 229 (55.2) 118 (64.8) 46 (37.7) 65 (58.6)
 Divorced 33 (8.0) 19 (10.4) 7 (5.7) 7 (6.3)
 Widowed 1 (0.2) 0 1 (0.8) 0
 Separated 10 (2.4) 2 (1.1) 3 (2.5) 5 (4.5)
 Living with partner 62 (15.2) 25 (13.7) 20 (16.4) 18 (16.2)
 Single, never married 77 (18.6) 17 (9.3) 45 (36.9) 15 (13.5)
 No answer 2 (0.5) 1 (0.5) 0 1 (0.9)
Sexual orientation
 Straight 351 (84.6) 160 (87.9) 104 (85.2) 87 (78.4)
 Gay/Lesbian 14 (3.4) 5 (2.7) 6 (4.9) 3 (2.7)
 Bisexual 40 (9.6) 12 (6.6) 11 (9.0) 17 (5.3)
 Pansexual 7 (1.7) 5 (2.7) 0 2 (1.8)
 Asexual 3 (0.7) 0 1 (0.8) 2 (1.8)
Currently employed
 Yes 343 (82.7) 145 (79.7) 101 (82.8) 97 (87.4)
 No 72 (17.3) 37 (20.3) 21 (17.2) 14 (12.6)
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A one-way ANOVA was computed to assess the differences in burnout and other psychosocial variables among the three informal care groups. The results indicated that caregiver burnout (F[2, 412] = 13.89, p < 0.01), positive relationships (F[2, 405] = 18.17, p < 0.01), and negative relationships (F[2, 404] = 10.59, p < 0.01) differed significantly among the three caregiving groups. Tukey’s HSD test for multiple comparisons was calculated to determine significant group mean differences. For caregiver burnout, mean values were significantly higher in sandwich generation than in child-only caregivers (p < 0.01, 95% C.I. = [4.82, 17.90]) and significantly higher in parent-only than in child-only caregivers (p < 0.01, 95% C.I. = [5.91, 18.34]). For positive relationships, mean scores were significantly lower in sandwich generation than in child-only caregivers (p < 0.01, 95% C.I. = [−5.56, −1.64]) and significantly lower in parent-only than in child-only caregivers (p < 0.01, 95% C.I. = [−6.41, −2.60]). Lastly, for negative relationships, scores were significantly higher in sandwich generation than in child-only caregivers (p < 0.01, 95% C.I. = 1.35, 4.55]) and significantly higher in parent-only than in child-only caregivers (p < 0.01, 95% C.I. = [0.48, 3.57]). All other variables in the one-way ANOVA were not statistically significant.

To determine which variables predicted burnout for each of the caregiver groups, a multiple regression analysis was run for each caregiver group. Positive and negative relationships displayed multicollinearity. Thus, separate regression analyses were conducted. In this first regression model, positive relationships were included. All other variables met acceptable standards for multicollinearity via indices of tolerance (below 0.10) and VIF (above 10; Hair et al., 2014). Results of the first multiple regression analysis with caregiver burnout as the criterion variable are presented in Table 2. For sandwich generation caregivers, the overall model was significant (R2 = 0.558, F[9, 75] = 10.517, p < 0.001). Positive relationships predicted caregiver burnout (b = −0.353, p < 0.001). For parent-only caregivers, the overall regression model was significant (R2 = 0.511, F[9, 99] = 11.501, p < 0.001). Positive relationships predicted caregiver burnout for this group as well (b = −0.511, p < 0.001). Also, insomnia (b = 0.191, p < 0.05), depressive symptoms (b = 0.288, p < 0.05), distress tolerance (b = −0.209, p < 0.05), and neuroticism (b = −0.257, p < 0.05) predicted caregiver burnout. Lastly, for child-only caregivers, the overall model was significant (R2 = 0.368, F[9, 146] = 9.436, p < 0.001). Depressive symptoms predicted caregiver burnout for this group (b = 0.386, p < 0.01). Also, agreeableness predicted caregiver burnout (b = −0.152, p < 0.05).

Table 2.

Linear regression including QCPR-Posa with CBI-C as the criterion variable.

Sandwich
 Parent-only
 Child-only
B SE b t p B SE b t p B SE b t p
Constant 0.447 2.025 0.221 0.826 2.141 1.684 1.271 0.207 −5.057 1.552 −3.259 0.001
AIS 0.868 0.545 0.197 1.593 0.115 0.808 0.404 0.191 1.998 0.048 0.040 0.387 0.010 0.104 0.917
CES-D 0.241 0.225 0.146 1.072 0.287 0.454 0.216 0.288 2.096 0.039 0.603 0.201 0.386 3.004 0.003
CSES 0.038 0.054 0.090 0.711 0.479 0.028 0.046 0.074 0.610 0.543 −0.013 0.040 −0.034 −0.323 0.747
DTS −0.257 0.200 −0.135 −1.286 0.202 −0.352 0.158 −0.209 −2.224 0.028 −0.205 0.158 −0.122 −1.301 0.195
QCPR-Pos −1.080 0.265 −0.353 −4.081 <0.001 −1.424 0.227 −0.511 −6.276 <0.001 −0.257 0.275 −0.067 −0.934 0.352
MINI-O −0.993 0.632 −0.143 −1.572 0.120 0.273 0.496 0.043 0.549 0.584 0.206 0.394 0.036 0.523 0.602
MINI-C −0.684 0.680 −0.099 −1.005 0.318 −0.312 0.530 −0.044 −0.589 0.557 −0.230 0.476 −0.037 −0.483 0.630
MINI-A −0.201 0.642 −0.027 −0.313 0.755 −0.658 0.517 −0.103 −1.272 0.206 −1.065 0.505 −0.152 −2.111 0.036
MINI-N 0.669 0.862 0.096 0.776 0.440 −1.520 0.610 −0.257 −2.491 0.014 0.162 0.625 0.030 0.259 0.796
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Note. CBI-C as dependent variable. Sandwich: R2 = 0.558, F(9, 75) = 10.517, p < 0.001; Parent-Only: R2 = 0.511, F(9, 99) = 11.501, p < 0.001; Child-Only: R2 = 0.368, F(9, 146) = 9.436, p < 0.001.

a

Given the concern for multicollinearity between QCPR-Pos and QCPR-Neg, separate linear regression analyses were completed with only one variable in the model at a time.

AIS = Athens Insomnia Scale, CBI-C = Copenhagen Burnout Inventory-Client-Related, CES-D = Center for Epidemiologic Studies Depression Scale, CSES = Coping Self-Efficacy Scale, DTS = Distress Tolerance Scale, MINI-A = Mini-International Personality Item Pool-Agreeableness, MINI-C = Mini-International Personality Item Pool-Conscientiousness, MINI-N = Mini-International Personality Item Pool-Neuroticism, MINI-O = Mini-International Personality Item Pool-Openness, QCPR-Pos = Quality of Carer-Patient Relationship Scale-Positive.

A second regression analysis was completed with negative relationships included in the model to assess group differences in the prediction of burnout. Again, acceptable standards for multicollinearity were met via tolerance and VIF. Results of this multiple regression analysis are found in Table 3. For sandwich generation caregivers, the overall regression model was significant (R2 = 0.625, F[9, 73] = 13.490, p < 0.001). Negative relationships predicted caregiver burnout (b = 0.526, p < 0.001). For parent-only caregivers, the overall model was significant (R2 = 0.493, F[9, 97] = 10.482, p < 0.001). Negative relationships predicted caregiver burnout (b = 0.464, p < 0.001) for this group. Also, insomnia (b = 0.242, p < 0.05) and neuroticism (b = −0.240, p < 0.05) predicted caregiver burnout. Lastly, for child-only caregivers, the overall regression model was significant (R2 = 0.385, F[9, 148] = 10.293, p < 0.001). Negative relationships (b = 0.169, p < 0.05) and depressive symptoms (b = 0.378, p < 0.05) predicted caregiver burnout for this group.

Table 3.

Linear regression including QCPR-Nega with CBI-C as the criterion variable.

Sandwich
 Parent-only
 Child-only
B SE b t p B SE b t p B SE b t p
Constant 0.263 1.890 .139 0.890 4.080 1.696 2.405 0.018 −4.742 1.477 −3.211 0.002
AIS 0.825 0.506 0.187 1.630 0.107 1.045 0.418 0.242 2.502 0.014 0.073 0.378 0.018 0.194 0.846
CES-D −0.012 0.216 −0.007 −0.055 0.957 0.202 0.226 0.124 0.893 0.374 0.612 0.199 0.385 3.082 0.002
CSES −0.037 0.051 −0.085 −0.726 0.470 −0.037 0.043 −0.096 −0.849 0.398 −0.018 0.040 −0.045 −0.439 0.661
DTS −0.277 0.190 −0.145 −1.452 0.151 −0.201 0.168 −0.116 −1.193 0.236 −0.246 0.154 −0.146 −1.599 0.112
QCPR-Neg 1.994 0.347 0.526 5.741 <0.001 1.809 0.314 0.464 5.767 <0.001 0.738 0.303 0.169 2.437 0.016
MINI-O −0.524 0.612 −0.075 −0.856 0.395 0.325 0.510 0.051 0.637 0.526 0.111 0.390 0.019 0.286 0.776
MINI-C −0.506 0.650 −0.072 −0.779 0.439 0.082 0.557 0.011 0.148 0.883 0.031 0.474 0.005 0.065 0.948
MINI-A 0.190 0.626 0.025 0.303 0.763 −0.850 0.534 −0.130 −1.593 0.114 −0.858 0.484 −0.122 −1.771 0.079
MINI-N −0.218 0.834 −0.031 −0.262 0.794 −1.435 0.648 −0.240 −2.214 0.029 −0.008 0.620 −0.001 −0.012 0.990
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Note. CBI-C as dependent variable. Sandwich: R2 = 0.625, F(9, 73) = 13.490, p < 0.001; Parent-Only: R2 = 0.493, F(9, 97) = 10.482, p < 0.001; Child-Only: R2 = 0.385, F(9, 148) = 10.293, p < 0.001.

a

Given the concern for multicollinearity between QCPR-Pos and QCPR-Neg, separate linear regression analyses were completed with only one of those two variables in the model at a time.

AIS = Athens Insomnia Scale, CBI-C = Copenhagen Burnout Inventory-Client-Related, CES-D = Center for Epidemiologic Studies Depression Scale, CSES = Coping Self-Efficacy Scale, DTS = Distress Tolerance Scale, MINI-A = Mini-International Personality Item Pool-Agreeableness, MINI-C = Mini-International Personality Item Pool-Conscientiousness, MINI-N = Mini-International Personality Item Pool-Neuroticism, MINI-O = Mini-International Personality Item Pool-Openness, QCPR-Neg = Quality of Carer-Patient Relationship Scale-Negative.

Discussion

This study is unique in that it explored predictors of burnout including psychosocial variables (i.e. caregiver burnout, personal burnout, depressive symptoms, suicidality, self-efficacy, distress tolerance, relationship support, relationship depth, positive relationships, negative relationships, personality traits, and insomnia) across three informal caregiving groups. Most notably, this was examined among sandwich generation caregivers, a group that has been understudied. In addition to comparing levels of burnout, depressive symptoms, and relationship quality between these groups, this study also examined which psychosocial variables best predicted burnout in each group. Prior research has found that informal caregiving is associated with burnout, depressive symptoms, and relationship quality (Koyanagi et al., 2018; Owsiany et al., 2023; Tough et al., 2017). Thus, to better understand the unique variables associated with burnout for each caregiving group, the present study examined group differences between these variables and examined potential predictors of burnout for each of these groups.

Comparisons among caregiving groups revealed several significant findings, the most notable being that sandwich generation caregivers reported higher levels of burnout than child-only caregivers. Additionally, caregivers responsible solely for their parents experienced greater burnout than child-only caregivers. In both of these cases, the common element associated with burnout is the responsibility of caring for parents. This is consistent with research by Page et al. (2018), who found that, compared to caring for other age groups (e.g. children under 17 years of age), caring for older adults tends to result in higher emotional burden. The authors suggest that caring for older parents who are closer to the end of life, rather than young children, could increase mortality salience, leading to increased emotional burden. Consistent with work by Owsiany et al. (2023), the present study found that sandwich generation and parent-only caregivers experienced significantly higher levels of burnout than child-only caregivers. Thus, caring for an aging parent appears to be a unique contributor to the experience of burnout in these groups. Another potential explanation may lie in the different expectations and intentions of caregiving between these groups. Parenting is typically a planned, voluntary, and deliberate choice, whereas caring for a parent can be unplanned, involuntary, and sudden. Moreover, the nature of the relationship between caregivers and parents versus caregivers and children is structurally different due to a shift in caregiving roles, which will be discussed further.

Relationship quality significantly differed across caregiving groups. Positive perceptions of the caregiving relationship were significantly lower among sandwich generation and parent-only caregivers than child-only caregivers. Similarly, negative perceptions of the caregiving relationship were significantly higher among sandwich generation and parent-only caregivers than child-only caregivers. These results provide additional support for the finding that caring for a parent presents unique challenges compared to caring for a child. For example, the shift in responsibilities from being a child to being a parent of one’s own parents plays a key role in how relationships change when caring for an aging parent (Conway, 2019). Compared to caregivers of children only, those caring for a parent experience a shift in roles and a loss of the prior relationship that did not involve caregiving (Zarit & Edwards, 2008). Another possible explanation for this finding may be that differences in relationship quality are due to ‘filial obligation’, or responsibility to care for one’s parents, in adult children caregivers (Bastawrous et al., 2015). The impact that filial obligation has on caregiver-recipient outcomes, particularly relationship quality, remains an important question. A review of qualitative studies found that preexisting differences in relationship quality between the caregiver and recipient have a critical impact on a caregiver’s experience (Luiches et al., 2021). Relationships become more strained when providing care for someone who is emotionally ‘closer’ (i.e. spousal caregivers compared to adult children; Pinquart & Sörensen, 2011). Conversely, child-only caregivers need not navigate role reversal, shifting power dynamics, or process the loss of a prior relationship with the care recipient, resulting in a change in relationship quality. Thus, these results support the notion that caring for a parent, whether solely or in addition to children, brings with it unique challenges.

This study also found that predictors of burnout differed between caregiving groups. Positive relationship quality predicted lower burnout among sandwich generation and parent-only caregivers. Interestingly, positive relationship quality was not predictive of burnout among child-only caregivers, which could be due to the unique nature of burnout in parents such as child temperament, parents’ stable traits, and family functioning (Mikolajczak et al., 2018). Future studies should consider creating and utilizing an assessment instrument that specifically measures burnout in parents. Negative relationship quality, though, predicted higher burnout in all three caregiver groups. These findings provide evidence for the importance of investigating the unique role of relationship quality in the context of burnout among informal caregivers, as originally postulated by Gérain and Zech (2021). This is also in line with a prior meta-analysis, which found that among adult children providing care for their parents, having better quality relationships was related to lower distress, strain, burden, and depression among caregivers (Bastawrous et al., 2015). Funk and Kobayashi (2009) suggest that motivations for providing informal care for older parents may involve feelings of both choice and obligation. Having a more positive relationship with a parent could result in feelings of closeness and affection, making the decision to care for the parent a more voluntary one, which may result in a reduced sense of burden. The belief that one is providing care for their parents of their own volition could give caregivers a greater sense of control, and perceiving greater personal control in caregiving is related to decreased burden (Reinhard, 1994).

In addition to relationship quality, other variables also uniquely predicted caregiver burnout for each group. Most notably, there were additional predictors of burnout among those caring for parents-only: insomnia, distress tolerance, and neuroticism. These variables did not emerge as significant predictors of burnout among sandwich-generation caregivers or those caring for children-only, which may be due to the different role expectations and responsibilities of each caregiving group. Parenting is a socially expected milestone that most individuals prepare for in advance, which can make its stressors feel less disruptive compared to unplanned caregiving of a parent (Funk & Kobayashi, 2009). For example, insomnia may uniquely predict burnout among caregivers of parents, as sleep deprivation is not anticipated whereas it is among parents of children.

Another explanation may lie in the availability of parenting-related supports such as educational resources, community programs, and peer networks, which offer external resources that may help mitigate the risk of burnout, compared to the relative lack of structured resources for adult child caregivers of aging parents. Distress tolerance may impact burnout more when caregivers have minimal support, such as those caring only for parents who are an only child or are unmarried. Individuals caring for children may be more likely to have multiple caregivers in the home or additional external support, whereas those caring for parents-only may be the sole caregiver. Individuals caring for parents by themselves report more financial difficulty and less informal support than those who have support from siblings (Skoblow & Gilligan, 2025).

Lastly, group differences in predictors of burnout may be explained by variability in caregivers’ sense of purpose and satisfaction as caregivers. Those caring for a child (i.e. sandwich generation and child-only caregivers) may benefit from a unique sense of purpose and role satisfaction. After considering demographic factors, Hammersmith and Lin (2019) found that caregivers of children perceived more meaning from their caregiving roles than caregivers of parents. Their findings also suggest that life satisfaction and well-being are lower among those caring for parents, though these differences may be due to the different stages of life those caring for parents are in (e.g. retirement).

It remains unclear why neuroticism was a unique predictor for caregiver burnout among those caring for parents only. The relation between neuroticism and burnout appears to vary. On the one hand, it is strongly related to burden and depression among informal caregivers (e.g. González-Abraldes et al., 2013). In contrast, several authors have argued for the notion of healthy neuroticism. For example, Friedman (2000) argues that neuroticism can be related to adaptive or maladaptive behaviors, which depends on characteristics of the individual. Similarly, Watson and Casillas (2003) argue that neuroticism can serve as a strategy that protects one from threat and danger.

In child-only caregivers, depressive symptoms were the only significant predictor of burnout. Roskam et al. (2017) found that depressive symptoms are related to parental burnout. However, the present study’s results did not find that depressive symptoms were predictive of burnout in sandwich generation or parent-only caregivers, which is contrary to what previous research has shown (e.g. Chakraborty et al., 2023; Takai et al., 2009). For example, Takai et al. (2009) found that depressive symptoms were correlated with burnout in informal caregivers of older adults with dementia in Japan (Takai et al., 2009). Similarly, Chakraborty et al. (2023) found informal caregiving to be a risk factor for depression and poor health. Contradictory findings could be attributed to the different measures used to assess depressive symptoms, and the racial/ethnic makeup of the participants.

This study has several limitations that should be considered. First, the sample was collected via CloudResearch Prime Panels, and concerns have been expressed by researchers regarding the quality and reliability of data obtained via online sampling. However, existing literature suggests that online samples are reliable when attention checks and validity items are used (Newman et al., 2021). Furthermore, Douglas et al. (2023) found that CloudResearch participants were more likely than MTurk participants to pass validity checks. To enhance the reliability of this study’s findings, the study survey incorporated one validity check item in each assessment measure administered to minimize the likelihood of including participants who exhibited response bias or may have lacked sufficient attention. Next, participants were not asked to qualitatively describe their care recipients’ cognitive or functional status. Differences in care recipients’ abilities could influence the level of care that they require, and subsequently, the stress and potential burnout experienced by their informal caregivers. Also, participants who identified as parent-only caregivers may have had children but did not interpret parenting or the provision of emotional support to older children as constituting ‘caregiving’ within the parameters of this study. Third, this study’s cross-sectional design precludes identification of causal relations between variables. Another limitation is that this study did not include information regarding care recipients’ functional or cognitive status, which can affect levels of reported caregiver burnout (Alves et al., 2019). Lastly, the study’s sample demographics closely align with the racial and ethnic composition of the U.S. population as reported in the 2020 Census. However, certain diverse racial and ethnic groups remain underrepresented in the study’s sample, possibly limiting the generalizability of the study’s findings to underrepresented populations.

Conclusions and future directions

The most significant findings from the present study suggest that sandwich generation and parent-only caregivers may face unique challenges. Individuals in these groups reported having greater levels of burnout, lower levels of positive relationships, and higher levels of negative relationships compared to child-only caregivers. Additionally, positive relationship quality seems to be especially important for predicting burnout among individuals caring for parents, whether it be for parents-only or both children and parents. Insomnia, neuroticism, and distress tolerance were predictors of burnout uniquely in parent-only caregivers, while depression was a predictor of burnout in parent-only and child-only caregivers. Interestingly, none of these variables predicted burnout in sandwich generation caregivers.

This study highlights several avenues for future research. Examining pathways that explain why factors like depressive symptoms and relationship quality predict burnout in caregiving groups could provide valuable insights. For example, a more nuanced understanding of how each predictor contributes to burnout could facilitate the development of targeted psychosocial interventions. Of these predictors, relationship quality emerged as a significant variable, underscoring its importance in caregiving dynamics. Further research is needed to explore ways to enhance the quality of relationships between caregivers and care recipients, which could potentially mitigate caregiver burden. It is also important to investigate why positive relationship quality serves as a predictor of burnout for caregivers in the sandwich generation and parent-only groups but not for child-only caregivers. Future studies could adopt longitudinal approaches to better capture if and how outcomes related to caregiving change over time. Broadening the diversity of study samples to include more culturally diverse participants would also improve study generalizability. This may also provide insights into how cultural expectations and motivations for caregiving influence relationship quality and burnout. Finally, other variables, such as the number of care recipients and functional status of the care recipients, could be examined to better understand how caregiving responsibilities are distributed and their impact on caregiver stress. Investigating these variables will contribute to a more comprehensive understanding of caregiving dynamics and inform strategies to support caregivers more effectively. The present study created a foundation for investigating the ICIM in sandwich generation caregivers. Future studies should continue to explore the applicability of this model to better understand the lived experiences of caregivers and the challenges and differences among them.

Acknowledgements

We would like to thank those caregivers who took time and energy to participate in our research study. Our data are not currently available for public use as not all planned analyses have been conducted yet for future publications.

Funding

Participant payments were provided through private funds. Authors E. F. and S. L. were supported by a T32 Award from the National Institute on Aging (AG052375).

Appendix A. Mean scores

Measure Total (Mean, SD) Child-only caregivers (Mean, SD) Parent-only caregivers (Mean, SD) Sandwich caregivers (Mean, SD)
CES-D 18.85 (13.86) 17.62 (13.51) 19.05 (13.66) 20.74 (14.57)
CSES 154.91 (55.97) 151.86 (54.58) 154.29 (56.60) 160.93 (57.69)
QRI-Support 18.67 (5.89) N/A 18.31 (5.73) 19.06 (6.05)
QRI-Conflict 28.75 (8.56) N/A 27.94 (8.22) 29.66 (8.87)
QRI-Depth 18.95 (3.87) N/A 18.64 (4.01) 19.29 (3.69)
QCPR-Pos 31.10 (7.15) 33.40 (5.54) 28.89 (7.72) 29.80 (7.75)
QCPR-Neg 15.62 (5.71) 14.25 (4.93) 16.28 (5.71) 17.21 (6.40)
MINI-O 14.87 (3.59) 14.66 (3.64) 15.41 (3.49) 14.60 (3.57)
MINI-C 14.57 (3.31) 14.77 (3.38) 14.80 (3.04) 13.97 (3.44)
MINI-E 10.37 (3.77) 10.16 (3.44) 10.19 (4.13) 10.91 (3.86)
MINI-A 14.97 (3.16) 14.92 (3.01) 15.24 (3.33) 14.74 (3.21)
MINI-N 11.29 (3.74) 11.46 (3.96) 10.91 (3.72) 11.44 (3.39)
DTS 45.91 (13.03) 46.53 (12.81) 46.12 (13.02) 44.65 (13.43)
CBI-P 45.84 (23.78) 44.05 (24.00) 44.26 (23.01) 50.53 (23.81)
CBI-C 40.00 (23.28) 33.39 (22.17) 45.52 (21.35) 44.75 (24.51)
AIS 8.66 (5.51) 8.26 (5.49) 8.45 (5.35) 9.57 (5.64)
SBQ-R 5.39 (3.40) 5.02 (2.85) 5.39 (3.52) 6.01 (4.00)
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Note. AIS = Athens Insomnia Scale, CBI-C = Copenhagen Burnout Inventory-Client-Related, CBI-P = Copenhagen Burnout Inventory-Personal, CES-D = Center for Epidemiologic Studies Depression Scale, CSES = Coping Self-Efficacy Scale, DTS = Distress Tolerance Scale, MINI-A = Mini-International Personality Item Pool-Agreeableness, MINI-C = Mini-International Personality Item Pool-Conscientiousness, MINI-E = Mini-International Personality Item Pool-Extraversion, MINI-N = Mini-International Personality Item Pool-Neuroticism, MINI-O = Mini-International Personality Item Pool-Openness, QCPR-Neg = Quality of Carer-Patient Relationship Scale-Negative, QCPR-Pos = Quality of Carer-Patient Relationship Scale-Positive, QRI-Conflict = Quality of Relationships Inventory-Conflict, QRI-Depth = Quality of Relationships Inventory-Depth, QRI-Support = Quality of Relationships Inventory-Support, SBQ-R = Suicide Behaviors Questionnaire-Revised, SD = standard deviation.

Footnotes

Disclosure statement

No potential conflict of interest was reported by the authors.

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