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. Author manuscript; available in PMC: 2011 Oct 1.
Published in final edited form as: J Pediatr Nurs. 2009 Apr 8;25(5):352–359. doi: 10.1016/j.pedn.2009.02.021

Grandparent Health & Functioning after a Grandchild’s Death

JoAnne M Youngblut 1, Dorothy Brooten 1, Kathleen Blais 1, Jean Hannan 1, Theophile Niyonsenga 2
PMCID: PMC2936719  NIHMSID: NIHMS98454  PMID: 20816557

Abstract

Approximately 160,000 grandparents experience the death of a grandchild each year; this represents a permanent, irrevocable loss for the grandparent resulting in physical and emotional responses. Grandparents who lose a grandchild experience increased alcohol and drug use, thoughts of suicide, and pain for their adult child who is also grieving. Supportive resources available to grieving grandparents, the effects of the grandchild’s death on the grandparent-parent relationship and the influence of race/ethnicity on grandparent grieving are discussed. Despite about 40,000 child and infant deaths each year, knowledge about grandparent health and functioning following the death of a grandchild is limited.

In 2002, 40,000 infants and children – 28,034 infants (less than 1 year old), 4,858 children from 1–4 years old, and 7,150 children from 5–14 years of age – died in the United States (National Center for Health Statistics, 2005). Leading causes of death were congenital malformations, prematurity and its complications, and sudden infant death syndrome (SIDS) for infants; unintentional injuries and malformations for children from 1–4 years old; and unintentional injuries and cancer for children 5–14 years old (National Center for Health Statistics, 2005). Grandparents describe the devastation of a grandchild’s death as: “like a part of you has been not just lost, but torn out of you…” (Fry, 1997). The limited research to date in this area indicates grandparents experience physical symptoms, anxiety, bitterness, exhaustion, depression, helplessness, and disbelief that the grandchild died before the grandparent, increased alcohol and drug use, thoughts of suicide, and pain for their child (grandchild’s parent) (DeFrain, Jakuls, & Mendoza, 1991–92; Ponzetti & Johnson, 1991). And while the deaths of 40,000 infants and children annually in the United States (National Center for Health Statistics, 2005) affect a minimum of two parents (not including step-parents), they affect a minimum of four grandparents (not including step-grandparents) at a stage in life when they are more vulnerable to health problems. Despite the changing racial/ethnic mix of the US population, even less is known about this phenomenon in diverse cultural groups. Such data are important in understanding health and functional effects for grandparents and are basic to identifying those at greatest risk for adverse outcomes and developing interventions to minimize health problems and maximize functioning. The purpose of this manuscript is to describe the impact of a grandchild’s death on grandparent grief, physical and mental health, and functioning after a grandchild’s death.

The increased life expectancy of Americans during the 20th century especially following World War II has enabled more people to experience the role of grandparent and to spend more time in grandparenting than previous generations (Eliopoulos, 2005). The American Association of Retired Persons (AARP) Grandparent Study 2002 reported that the average age of a first time grandparent was 48. In addition, more than 90 million Americans - one in three individuals - was a grandparent (AARP, 2002). Being a grandparent is important to many adults, providing them with social and emotional rewards and ensuring the future of their families. A growing number of grandparents provide full-time custodial care for their grandchildren because of absence of the grandchild’s parent(s), and many view this responsibility as stressful. However, in the few studies of grandparent bereavement of a grandchild, the grandparent’s caregiving status to the deceased grandchild is not considered. Studies have found negative effects on grandparents related to loss of contact with their grandchild through divorce and geographic separation. Death of the grandchild represents a permanent, irrevocable loss of contact for the grandparent, and up to 160,000 grandparents experience this loss each year.

Grandparenthood

Meaning of grandchildren to grandparents

Grandparenthood can span a large portion of an adult’s life, especially for those who become grandparents as young as their 30s. Grandparenthood allows grandparents to enjoy, play with, and indulge their grandchildren without the responsibilities of parenting and discipline. Most grandparents report having an emotionally close relationship with their grandchildren (Harwood, 2001; Silverstein & Chen, 1999). Grandchildren see grandparents as role models, teachers, advisers, and sources of inspiration and they enjoy grandparents’ personalities and the activities they share with them (Kennedy, 1991). This provides grandparents with feelings of being valued and useful, perhaps adding another purpose to their lives. Indeed, Black1 grandmothers reported deriving social and emotional rewards from their grandchildren (Barer, 2001). Grandchildren also can represent opportunities for grandparents. To some, grandchildren mean continuation of the family line (Hagestad & Lang, 1986). Reed (2003) reports that for some grandparents, the grandchild may be a namesake who carries the grandparent’s name. African American grandmothers report that grandchildren represent the ability to live on after their own deaths (Timberlake & Chipungu, 1992). Hagestad and Lang found that grandchildren allowed grandmothers to relive their parenthood, perhaps to do things differently or better than they did with their own children. For African American grandmothers, grandchildren provide the opportunity to give of one’s self and to have an effect on the lives of others (Timberlake & Chipungu).

Most (68%) grandparents see one of their grandchildren once every one or two weeks (AARP, 2002). “Living too far away” was cited by 45% of grandparents as the most frequent barrier to seeing their grandchildren. Indeed, the largest percentage of grandparents across all age groups (33–75%) in the AARP Grandparent Study 2002 lived more than 200 miles from their grandchildren. Grandparents engage in a wide variety of activities with their grandchildren, including eating at home or going out to eat (86%); reading to or with them (75%); shopping (75%), cooking (67%), going to parks and playgrounds (63%) and gardening (41%) with them; attending religious activities (59%) and school events (57%); exercising or playing sports together (53%), going to sports events (50%), and helping with school work (41%) (AARP). Grandparents may share parenting roles with the parents of their grandchildren to include teaching family history and values, taking children to cultural events, entertaining or having fun with their grandchildren, listening to grandchildren’s problems, teaching religion and spirituality to their grandchildren, helping with school work, reprimanding or disciplining grandchildren, and giving special treats or gifts (AARP). Many grandparents reported providing financial support to their grandchildren to assist with educational expenses (52%), living expenses (45%), and to help with medical or dental expenses (25%) (AARP).

Grandparents raising grandchildren

Nearly 6 million grandparents live with their grandchildren under age 18, and grandparents head 2.5 million households containing children (US Census Bureau, 2004; 2005). Of the grandparents (any age) living with their grandchildren, more than 40% were the grandchild’s primary caregiver. Among grandparents aged 65 and over living with grandchildren, more than 25% were caregivers for their grandchildren. Further, one-third of these grandparents live in households with no parents present, referred to as “skipped generation” households (US Census Bureau, 2007).

Grandparents often assume responsibility for raising their grandchildren when the parent cannot care for them because of young age, emotional problems, drug and alcohol problems, mental illness, neglect/abuse, and incarceration. Placement of children with their grandparents helps to avoid placing the children in foster care (Nunn, 2002) Single nonwhite grandmothers are more likely to be raising grandchildren than single white grandfathers (Blustein, Chan, & Guanais, 2004). The US Census Bureau (2004) reports that the majority of grandparents living with their grandchildren were non-Hispanic White. However, they comprised only 2% of the non-Hispanic White population over 30 years of age. In contrast, 6% to 10% of grandparents from other racial and ethnic groups lived with their grandchildren. Among Black, American Indian and Alaska native, and Hispanic populations, 8% of adults age 30 or over lived with their grandchildren. However, in these groups, Hispanics were less likely than Blacks or American Indians and Alaska natives to be caregivers for their grandchildren. It is important to note that 19% of grandparent caregivers were living in poverty in 1999, with the highest percentage living in the South (21%). Most grandparent caregivers (60.3%) were less than 60 years of age; however, grandparent caregivers greater than 60 years of age were more likely to have cared for their grandchildren for five years or longer.

Although some grandparents characterize their experience of raising grandchildren as a positive one (Gibbons & Jones, 2003),Musil, Youngblut, Ahn, and Curry (2004) found that grandmothers raising grandchildren reported more overall parenting stress and parental distress than mothers. Indeed, most studies of grandparents raising grandchildren find negative effects for the grandparent’s health. Custodial grandparents reported compromised health, especially in problems with physical functioning, depending on age and gender (Gibbons & Jones). Musil and Ahmad (2002) found that grandmothers who are primary caregivers for their grandchildren report worse self-assessed health and partial/supplemental caregivers report more depression than non-caregivers. Depression was related to primary responsibility for caregiving and greater parenting stress (referring to parenting the grandchild) (Musil, 2000). In a sample of African-American grandmothers raising grandchildren with disabilities, grandmothers who were under 60 years old, not married, unemployed, and with a high school education reported greater depression (Kolomer, McCallion, & Janicki, 2002). Burnett (1999) found that Latino grandparents reported substantial unmet needs, exacerbated by their low education, poor health, high levels of life stress, and lack of reliable help with childrearing.

Grandparent loss of contact

Grandparents may lose contact with their grandchildren due to geographic separation, divorce of the grandchild’s parents, family feud (long-term family dysfunction without divorce), or death of the grandchild. Research on loss of contact with grandchildren has focused on the effects of divorce on the grandparent’s ability to maintain contact with the grandchildren of that union. Loss of contact is especially likely for grandparents whose adult child is the non-custodial parent (generally the paternal grandparents) (Kruk, 1995), since the custodial parent (generally the mother) decides if and when the grandparents see the grandchildren. These studies find negative effects of loss of contact through divorce on the grandparents’ emotional and physical health (Drew & Smith, 1999; 2002). Drew and Smith (2002) found that grandparents’ grief and reports of symptoms of post-traumatic stress disorder were higher when loss of contact was related to family feud or divorce than when resulting from geographic separation. In addition, a higher proportion of grandparents who lost contact with their grandchild because of family feud (89%) and divorce (78%) reported their health had been negatively affected by the loss compared to 56% of grandparents who lost contact because of geographic separation (Drew & Smith, 2002). If loss of contact is related to geographic separation, grandparents can look forward to renewed contact or can maintain contact through telephone and the internet. When associated with divorce or family feud, hope of renewed contact with the grandchild can be maintained, no matter how likely. However, when the grandchild dies, hope for renewed contact is extinguished.

Grandchild Death

A grandchild embodies the grandparents’ immortality and their legacy to the world (Reed, 2003); therefore, grandparents may feel that the loss of a grandchild through death is a loss of part of themselves resulting in a deep grief. Yet, only a handful of studies have focused on death of a grandchild and the effects this loss might have on the grandparent’s grief, health, and functioning. Most of these studies were done in the 1990s.

Grandparent Grief

Often the “forgotten grievers” (Ponzetti & Johnson, 1991), grandparents grieve for themselves as grandparents, for the missed opportunities of their grandchild, and for their own adult children (the grandchild’s parents) whose child has died (Oikonen & Brownlee, 2002; Ponzetti & Johnson). Grandparents report a wide variety of negative emotional responses after a grandchild’s death, including bitterness, exhaustion, anger at God, sadness due to loss of a future relationship with the grandchild, frustration if the cause of death cannot be identified, disbelief that the grandchild died before the grandparent, depression, helplessness, and sorrow (DeFrain et al., 1991–92). Grandparents report feeling jealous of others with grandchildren, regret at the limited time they had with their grandchild, anxiety about the future, and concern about their adult children and their other grandchildren. After a grandchild’s death due to SIDS (sudden infant death syndrome), 29% of the 80 grandparents in that study blamed themselves for the grandchild’s death (DeFrain et al.). In Fry’s qualitative study (1997) of 12 Canadian grandmothers and 5 Canadian grandfathers, the grandmothers reported that the grandchild’s death shattered their whole world and disrupted their belief system. Grandparents in two studies (Fry; Galinsky, 2003) experienced “survivor guilt” – feelings of guilt that they had survived rather than the grandchild, beliefs that they should have died in place of the grandchild because the grandchild’s life was just beginning while they had had their lives and/or that their own death would have made more sense than the grandchild’s death.

Ponzetti and Johnson (1991) found that 56% of their sample of 45 grandparents (93% Caucasian) reported feelings of shock, numbness, and disbelief. These feelings were associated with experiencing physical symptoms, a greater need to make sense of the death, and the sudden death of the grandchild. Grandmothers were more likely than grandfathers to report feelings of shock, numbness, and disbelief; physical symptoms; and a desire to talk about the deceased grandchild. Grandmothers and grandfathers did not differ in their feelings of anger and helplessness, feelings toward their adult child (the deceased grandchild’s parent), and their need to make sense of the death. There were also no differences between maternal and paternal grandparents, although most of the grandparents who participated were maternal grandparents. Fry (1997) found that grandparents’ feelings of shock, numbness, and disbelief were not related to the sex or age of the grandchild. In a study of 28 Caucasian grandparents and 36 Caucasian parents of 21 deceased children (ages 1 month to 30 years), Ponzetti (1992) found that mothers and grandmothers reported a greater need to talk than fathers and grandfathers. About half of the parents (56%) and grandparents (53%) reported a change in their feelings toward the other, but far fewer reported a change in their interactions. The direction of this change (better or worse) was not identified.

Few grandparents reported positive responses to their grandchild’s death. For those who did, the positive feelings stemmed from pride in how their adult child (the grandchild’s parent) was handling the situation (DeFrain et al., 1991–92). Grandparents reported that reminiscing about the grandchild, remembering the past and reconciling it with the present aided in their recovery from the grandchild’s death (Fry, 1997). Grandparents also found attending the grandchild’s funeral to be healing (DeFrain et al.).

In several studies, the grandparent’s grief was affected by their perceived responsibilities for the family after the grandchild’s death. Grandparents in Fry’s qualitative study (1997) reported suppressing their grief to protect their adult child (the grandchild’s parent) and their surviving grandchildren. Reed (2003) describes the grandparents’ burden of providing strength for the entire family while trying to deal with their own deep grief. Grandparents wanted to be available and helpful to the grieving parents and siblings of the deceased grandchild, but sometimes they were seen as interfering. Easthope (2003) states that sets of grandparents may consciously and unconsciously become competitive with each other as they try to help their grieving adult children. They may want to “help” by making funeral arrangements, paying for the funeral, ordering the family flowers or offering burial space in their own cemetery plots. Grandparents may also feel isolated as the grandchild’s parents try to protect their parents, believing that they are too old or too frail to face the loss.

Grandparent Health and Functioning

Ponzetti and Johnson (1991) found that 64% of the 45 grandparents (93% Caucasian) in their study experienced physical symptoms after their grandchild’s death. In another study, Ponzetti (1992) found that 59% of the 28 Caucasian grandparents reported experiencing physical symptoms, most often sleep disturbance. In secondary analysis of a large longitudinal study of adults 55 years and older from Kentucky, Murrell, Himmelfarb, and Phifer (1988) found that the best predictor of the health of bereaved adults was pre-event health. The sample included adults who experienced an “attachment bereavement” defined as death of a parent, child, or spouse; a “non-attachment bereavement” defined as death of a sibling, grandchild, or friend; other losses including separation or divorce, relocation of a child or friend, or loss of a house, job, business, pet, or a decrease in money for living expenses; or none of these losses or deaths. However, since adults experiencing loss of a sibling, grandchild, or friend were combined into one group, the contribution this study can make to understanding grandparent health after death of a grandchild is limited.

Bereaved grandparents reported intrusive thoughts, avoidance, and hyperarousal – symptoms that characterize post-traumatic stress disorder (PTSD). Ponzetti and Johnson (1991) found that 19% of the 45 grandparents in their study reported thinking they saw or heard the grandchild after his/her death. Thirteen percent felt their grief would never resolve. DeFrain et al. (1991–92) reported that 51% of their 80 grandparents had flashbacks of the death (vivid, recurring, painful memories). For some, these flashbacks and nervousness were triggered by everyday events that also happened around the time of the death. One grandmother reported continuing anxiety when the phone rings at work since that was where she received the call about the grandchild’s death. She also reported nervousness if it “rings too long” (DeFrain et al.). Half of the grandparents in that study thought their memories of the death would not fade; 42% wished they would go to sleep and wake up after the pain was gone; 6% reported increased alcohol and other drug use; 4% considered suicide; and 1% experienced violence in their homes related to the grandchild’s death (DeFrain et al.).

Two common roles for grandparents are employee and spouse/partner. Very little research has investigated the effects of a grandchild’s death on the grandparent’s ability to function in these two important roles. None of the studies specifically investigated the grandparents’ ability to function in their employment. However, Fry (1997) found that Canadian grandfathers (n=5), more than Canadian grandmothers (n=12), focused on their employment to help them cope with their grief. Only one study investigated the effects of a grandchild’s death on the grandparent-partner couple relationship. In that study, DeFrain et al. (1991–92) found that 68% of their 80 grandparents reported that the grandchild’s death neither strengthened or weakened their marriage; 29% thought it strengthened their marriage; and only 3% thought it weakened their marriage.

Supportive Resources

To deal with a grandchild’s death, bereaved grandparents turn to others for support and to religious beliefs for meaning, coping, and comfort. Only one study (DeFrain et al., 1991–92) reported grandparents’ sources of support. These grandparents most often turned to their spouse (48%), followed by the grandchild’s mother (40%), friends (34%), other relatives (19%), religious professionals (14%), the grandchild’s father (13%), and professional counselors (2.5%) (DeFrain et al.). The two studies that compared grandmothers’ and grandfathers’ grief found that men tended to be “strong and silent” and women preferred talking through their grief (DeFrain et al.; Ponzetti & Johnson, 1991). Grandmothers who are unable to speak with their husbands may find this “devastating,” especially those whose marriages span several decades (Galinsky, 2003). Although 40% of the grandparents turned to the grandchild’s mother for support, other grandparents were reluctant to express their pain to the grandchild’s parent (their adult child), fearing it would make things worse for their adult child. The grandparents often felt compelled to “be there” for their child (the grandchild’s parents) (DeFrain et al.). Indeed, 55% of grandparents who had surviving grandchildren took responsibility for talking with their surviving grandchildren about the deceased grandchild’s death (DeFrain et al.).

Religious beliefs often are an energizing force for grandparents (Schmid, 2000). In one study, despite reporting feelings of anger toward God for the grandchild’s death, an overwhelming majority of grandparents (90%) reported that their religious beliefs were helpful (DeFrain et al., 1991–92). Fry (1997) found that Canadian grandmothers tended to find spiritual meaning in the grandchild’s death, describing a process of spiritual reappraisal and that their religious beliefs were strengthened. One third of the participants in Galinsky’s study (2003) described finding solace in churches. However, one grandmother chose a different religion based on how some of its members responded to questions about death and the afterlife. Other participants continued to attend church but stated that their faith had been shaken. In another study (Ponzetti & Johnson, 1991), 42% of 45 grandparents (93% Caucasian) described their religious faith as comforting and that it helped them to deal with the grandchild’s death. However, feelings of shock, numbness, and disbelief did not differ for grandparents who described their faith as helpful and those who did not (Ponzetti & Johnson, 1991).

Grandparents also attended bereavement support groups (DeFrain et al., 1991–92). In Galinsky’s study (2003), the only grandparent who attended a support group described discomfort at being the only grandparent attending. Reed (2003) found that grandparents are reluctant to speak in a group without others “who have experienced the same type of grief” (p. 3).

Grandparents and Parents

The death of a child may also disrupt the parents’ relationship with their own parents (the child’s grandparents). Parents describe a child’s death as “the most devastating and difficult experience they [have] ever faced” (Oliver & Fallat, 1995). They report a wide variety of responses, including feeling numb or in a state of shock (Saiki-Craighill, 2001a; Wheeler, 2001), being preoccupied with the pain the child experienced before death (Saiki-Craighill, 2001b), feeling out of control, and wanting to die (Wheeler, 2001). Parents also reported feeling loneliness, guilt, emptiness (Laasko & Paunonen-Ilmonen, 2001; Wood & Milo, 2001); pain, malaise, fatigue; depression, sense of failure, anger (Heiney, Ruffin, & Goon-Johnson, 1995; Laasko & Paunonen-Ilmonen, 2001); sorrow and regret (Wheeler, 2001). Most parents experienced symptoms of depression and/or PTSD in response to their child’s death, with the degree of symptoms being proportional to the intensity of their grief (Uten & Wastell, 2002). In a number of studies, mothers’ grief, depression, and PTSD scores are higher than fathers’ scores (Murphy, 1997; Znoj & Keller, 2002). In addition, parents experienced greater depression for older deceased children (Wyngaards-de Meij, Stroebe, & Stroebe, et al, 2008). Parents whose interpersonal relationships are characterized by being wary of closeness or intimacy may be less resilient, unable to use defense mechanisms effectively and may be considered a high risk subgroup (Wyngaards-de Meij, Stroebe, Schut, et al 2007). Research by Wyngaards-de Meij and team (2008) indicated two factors related to parent’s level of grief: whether parents said farewell to the child (before or after death) and whether the child was laid out at home. The latter provided time to confront the death and facilitate acceptance of the death.

In the midst of these physical and mental health challenges, Easthope (2003) found that adult children may feel the need to protect their parents when a grandchild dies. They may believe that their parents are too old to deal with the loss. Parents may resent grandparents attempts to help with arrangements, feeling that they are interfering or “taking over.” Galinsky (2003) describes her own need to plan the funeral of her stillborn daughter as she felt it was the only act of mothering allowed for her.

Influences of Race/Ethnicity

All of the studies of grandparents’ responses to the death of a grandchild had predominantly White samples, so the effects of race and ethnicity on grandparents’ responses are not known. Research that compares different racial/ethnic groups on their responses to death of a family member also is very limited. Talamantes, Lawler, and Espino (1995) identified similarities during the period preceding the death in case studies of a Mexican American family, a Cuban American family, and a Puerto Rican family experiencing the death of a family member, including the caregiver’s not wanting to burden or impose on the family, experiences of depressive symptoms, and reliance on faith, hope, and prayer to cope with the impending death. In another case study, Rivera-Andino and Lopez (2000) reported that Hispanics believe it is detrimental to the patient to let him/her know about the seriousness of the illness, to spare the patient unnecessary pain, and that it is the family’s obligation to take over control of the situation. African Americans may hold mistrust of the health care system, especially regarding advanced directives and end-of-life care. In the African American community death of an extended family member may cause higher levels of distress than is seen in the Caucasian culture (Laurie & Neimeyer, 2008). Both African Americans and Mexican Americans verbalize a preference for decision making surrounding the death as a family (Fletcher, 2002; Waters, 2001).

Latino death rituals are heavily influenced by Catholic beliefs: strong preference for burial rather than cremation, novenas for 9 days, mass for the deceased during the first year and then yearly, family gatherings with food (like a wake), and lighting candles. Overt expressions of grief, especially crying, are very common and generally accepted for men and women, especially for deceased adults. Some discourage crying for deceased children because it will wet their angel wings and prevent their flying to heaven (Munet-Vilaro, 1998). Death rituals for those practicing Santeria are governed by the saints or orishas as told by the santero (a clergy or holy man) and often include animal sacrifice (Grossman, 1997). Younoszai (1993) asserts that Mexicans have more understanding and acceptance of death because their country is primarily rural, poor, religious, and very young on average. Death is portrayed in Mexican statues, art, literature, and history, and Mexican children are socialized early to accept death, giving Mexicans a “cultural familiarity with death.” Mexicans and other Latinos celebrate “Dia de los Muertos” (Day of the Dead) to remember and honor the dead (Talamantes et al., 1995).

Death rituals for Black Americans vary widely, perhaps because of the diversity in religious affiliations, geographic region, education and economics (Perry, 1993). Large gatherings and an expressed obligation to pay respects to the deceased are common. Emotional expression varies, with some Black Americans crying and wailing while others are silent and stoic (Hines Smith, 2002; Lobar, Youngblut, & Brooten, 2006). Southern and rural Blacks may maintain the custom of having the corpse at the house for the evening before the funeral. Caribbean Blacks may insist on being with the body and preparing it for viewing including cleansing, dressing, and styling the hair (Lobar et al., 2006). Friends and family gather at the house to help out where they can. Church “nurses” help family members to view the body. Women “flower girls” escort the casket with the pallbearers and pay special attention to the family (Lobar et al., 2006; Perry, 1993). Strong religious beliefs – seeing the death as a reflection of God’s will or plans, believing the deceased is in God’s hands, and being reunited in heaven after death – help many black Americans move through their grief while maintaining a connection with the deceased (Hines Smith, 2002; Hines Smith, 1999; Laurie & Neimeyer, 2008). Bereaved African Americans are more likely to seek help from clergy than health care professionals (Neighbors, Musick, & Williams, 1998). In seeking professional mental health services, grieving African Americans may be going against community values thus adding to their level of distress (Laurie & Neimeyer, 2008).

In summary, death of a grandchild is a devastating experience for grandparents. Some grandparents are able to grieve, adapt, and move on with their lives, while others are severely affected for years. Despite nearly 40,000 child and infant deaths each year (National Center for Health Statistics, 2005), the science base on grandparent health and functioning following the death of a grandchild is limited. Very few studies have been reported in this area, and the body of this work was conducted in the 1990s. These studies agree that death of a grandchild is devastating and that grandparents experience a number of primarily negative responses. Some grandparents experience negative health effects and symptoms of PTSD (DeFrain et al., 1991–92; Ponzetti & Johnson, 1991; Ponzetti, 1992). The one study of the grandparents’ couple relationship found that the grandchild’s death either strengthened or had no effect on their marriage (DeFrain et al.). Social support and religious beliefs are important resources that grandparents name as helping them through the experience (DeFrain et al.; Fry, 1997; Ponzetti & Johnson; Ponzetti).

Although the limited number of studies in this area provides important information about the effects of a grandchild’s death on grandparents, the many gaps in the literature make the need for further research in guiding clinical practice imperative. Findings about factors that influence the grandparent’s grief, physical health, mental health, and role functioning following their grandchild’s death are limited. Only two small studies compared grandmothers’ and grandfathers’ responses. Research on the impact of these differences on the grandparent-partner couple relationship has not been reported. Despite the changing demographic make-up of the US, research on cultural differences and similarities in grandparent health and functioning after the grandchild’s death, the effects of level of acculturation, and the overlap between culture and religion is extremely limited.

Implications for Practice

Nurses who work with children know that providing support and information for parents is important, but may be less attuned to the needs of the grandparents. Grandparents also need support, especially when the grandchild has a grave or terminal diagnosis or has died. Grandparents may not verbalize their feelings because they want to appear strong to support their adult children, the parents of the deceased grand/child, or their silence may reflect a cultural norm. As an example, African Americans may prefer contact with other family or community members or clergy. However, it is essential to remember the need for individual assessment of the entire family unit since there can be much variability within families and within cultures.

Including grandparents in discussions where they feel comfortable voicing their questions or concerns may assist them in coping with their feelings and thereby decrease stress on the entire family. When grandparents display behaviors that indicate grieving, they may benefit from referrals for grief counseling, remembering that grandparents often prefer to participate in a different bereavement group than parents. These referrals can also be done in anticipation of grieving before it becomes apparent. For some grandparents, referral to their spiritual advisor (minister, priest, rabbi, imam, etc.) may provide comfort. Nurses may ask the grandparents if they would like to speak to a spiritual advisor and assist them with the contact. Referral to parent/grandparent bereavement groups such as Compassionate Friends (www.compassionatefriends.org) or Bereaved Parents of the USA (www.bereavedparentsusa.org) or websites dedicated to bereavement of grandparents and/or elders (www.aarp.org) also may be helpful. Such organizations have chapters throughout the United States and some offer specific support groups for bereaved grandparents. Nurses who work in children’s hospitals may develop grandparent support groups designed to meet the specific needs of grieving grandparents throughout their community.

Nurses also need to observe for signs of physical illness in grandparents that may be a result of stress and grieving and to encourage them to see their health care provider for their own health. In communicating empathy, Hardy-Bougere (2008) suggests attentive listening, eye contact, and avoiding phrases like “I know how you feel” or “I know what you are experiencing.” Based on research to date, grief may be greater the older the deceased child and the greater the contact or care giving of the grandparent, putting this group at potentially greater risk in coping with the death. Additionally, exploring whether the grandparents have had an opportunity to say goodbye to the deceased child can be helpful in assisting them in finding a symbolic way to say farewell. Recognizing that grandparent grieving may be different from parent grieving, nurses can provide support for both groups, thereby strengthening the family’s coping with their tragic loss.

Acknowledgments

Supported in part by a SCORE grant from the MORE division of the National Institute of General Medical Sciences, S06 GM008205.

Footnotes

1

Since the terms “Black” and “African American” are not interchangeable, we have used the term that was used in the specific article.

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