Toni Hill, Ph.D., is an Assistant Professor of Family Studies at the University of Nebraska-Kearney. She currently teaches courses focused on intimate relationships and aging.

Fall is a special time for many families, especially family caregivers. Since 1994, when the National Family Care Givers Association began a formal recognition program, many Americans have taken time to celebrate and recognize the more than 65 million family caregivers in this country. In 1997, President Bill Clinton was the first president to sign the now annual presidential proclamation declaring every November as National Family Caregiver Month. The National Family Caregivers Association and other groups use this time to increase awareness and support for family members providing vital care to relatives.

"The true strength of the American family finds its roots in an unwavering commitment to care for one another."
- President Barack Obama, 2009 National Family Caregivers Proclamation 

Defining family is very difficult. I regularly give the task of defining family to university students. On the surface, the task seems simple. The once smiling students often return to the next class period looking perplexed. To add to their confusion, I often read from White and Klein's Family Theories book (2002) a list of family types to challenge the student's often narrow or incomplete definitions of family. As Bogenschneider noted in her book, Family Policy Matters (2002), trying to identify one definition of family does not work, especially with no legal definition of family existing in the U.S. Constitution or in many federal and state statues. Lamanna, Riedmann, and other researchers have noted the complexity of trying to define relationships that exist within families.  

Familial relationships are dynamic and changing as are family memberships. Parent-child relationships continually change over time with caretaking responsibilities typically being reduced as the child enters adulthood. This article explores issues related to the various forms of family caregiving and the impact on intergenerational relationships.

"There are only four kinds of people in this world: Those who have been caregivers; Those who currently are caregivers; Those who will be caregivers; Those who will need caregivers."
- Former First Lady Rosalyn Carter, Helping Yourself Help Others (1994), page 3. 

Caregiving

Most people have or will be impacted by caregiving issues. There are varying needs for both the caregiver and the recipient of care. Many types of caregivers provide many types of care. Family members provide care for a myriad of mental and physical disabilities or limitations. Family caregivers provide care across the continuum from critical care to infrequent instrumental care. They often provide care regardless of their income, education, or their own health issues.

Research on caregiving generally treats caregiving and care receiving as distinct and separate constructs. Hagerty, Lingler et al (2008) noted this separation and that care is often examined as unidirectional with care going from the caregiver to the recipient. It is important to note family caregiving is fundamentally relational and often reciprocal including complex and overlapping components.

Numerous studies exist on caregiver stress and distress as well as caregiver burdens, conflicts, obligations, and resentments.  Far fewer studies have examined the interpersonal relationship between the family caregiver and the care recipient. Caregiving and care receiving have often been explored independently.

Obligations

Family caregiving has relational issues at the core with social norms governing how family members interact. Morgan and Kunkel in their book, Aging, Society, and the Life Course (2007), note several areas of influence on familial interactions, including the specific role of the relationship on the family. A married couple operates under different social norms than a parent-child dyad. Social class, race, ethnicity, religion, and geography also influence familial norms as does the individualism of each family.

Many issues impact a family's level of responsibility to provide care. 

Morgan and Kunkel identify the dynamic of independence or dependence and voluntarism or obligation. In this country, there is an expectation of generational independence. Adult children are expected to live independent of their parents and other relatives. There is a concern that elderly parents are a burden if they are living with their children, and reversely there is assumption there is something wrong if adult children return to their parents' home. While there can be reciprocity across the generations, there is a societal expectation that there is a separation of households and responsibilities. The greater society places a sense of obligation on family to care for other family members, however, if the need arises. Thus, the idea of voluntarily caring for a relative is not the societal norm. Complicated family relationships can be further complicated by caregiving responsibilities or obligations.

Parental caregiving

Many parents face challenges in parenting. Caregiving is an expectation until the child is launched into college, job, marriage, or leaves the nest.

Parents of children with disabilities or limitations often face different challenges. Whether a child does or does not have limitations, parents can expect different challenges at different developmental changes. Ask any a parent of a toddler asserting his/her independence how many times they have heard the common retort, I can do it myself.

Erik Erickson and others highlighted the developmental stages and changes that occur as a child ages. Parental responses and responsibility look different over the child's life course, and parental expectations and involvement look different from toddler to adolescent. A friend relayed a story of secretly watching her severely asthmatic child walk home from school because he wanted to do it himself. Fortunately, it only took one slow and painful walk home for him to realize he could not walk the distance. Parents must balance a child's need and desire for independence with their obligation to provide adequate care, supervision, and guidance.

Spousal caregiving

There are an increasing number of spouses providing care to their partners. Spousal care needs may derive from a variety of sources including work accidents, diseases, or aging aliments. The military wars have increased the number of disabled veterans and correspondently the number of spousal and family caregivers.

Depending on the nature of the care needs, spousal caregivers may experience a loss in the marital relationship. Lindsey Davis et al (2011) found that spousal caregivers reported varied relational losses. Some caregivers reported loss of the intimate connection or the loss of a shared future. Tension was reported based on the care recipient's inability to be a partner in decisions.

Researcher Hill (see "Spousal caregiving in later life: Predictors and consequences"; FF 48, Spring 2011) noted the impact of spousal caretaking on the caregiver. In her study, Hill found spousal caregivers to be older, with worst health, and possess lower incomes when compared to noncaregivers. Unlike other populations, older spousal caregivers can reasonably expect to need care themselves.

Reverse generation caregiving

As the population ages, so does the number of elders needing care. According to the U.S. Census (2005-2009), there are over 52 million citizens 60 years of age and older.  Increasingly adult children are caring for their aging or ill parents.

There is a delicate balance between respecting an elderly parent as both a parent and as an adult. The adult children providing care in some cases need to become like a parent to their parent. As with a traditional parent-child relationship, there is an expectation that the adult child be largely responsible for an aging or ailing parent. Society often questions the family if an elder wanders away from home or suffers an injury. I personally know the pain of suspecting then receiving medical confirmation that a parent can no longer make independent decisions about cooking, driving, or other personal issues. Many others experience this every day.

Sibling, same generation caregiving

Many adult children are also called upon to care for an adult sibling. I am inspired by family friends who split care taking responsibilities for a developmentally disabled sister across several households and across several states. The sister now in her 50's has her own place and space in the homes of several siblings who collectively coordinate her daily needs. The siblings made the decision to remove their sister from institutional care after concerns about her lack of progress and several unexplained infections.

The siblings report improvement in all areas including their sister's demeanor. Caretaking siblings may have to parent their brother or sister and this parental responsibility may impact or alter relations with other siblings, the parents, or other relatives. In home care is not for every family especially siblings still raising their own children. Research shows home care is often the most cost effective for both families and society.

Skipped-generation caregiving

According to Generations United and the U.S. Census (2005-2009), approximately 4.8 million children live with grandparents. Although some of these households also include the parents, many do not. My research area focuses on relative or kinship caregivers including grandparents caring for grandchildren. The reasons for kinship care vary. Parental absence can be attributed to benevolent or maladaptive reasons. A parent's decision to leave their child with the grandparents and move to another city in search of better work or educational opportunities is in contrast to another parent's decision to leave a child with the grandparents for entertainment or socialization activities.

Gibson (2002, 2005) and other researchers have explored changes in family dynamics by virtue of the parent being missing or absent. This skipped generation still has an impact on the family. Many children may experience issues of ambiguous loss or split loyalty. The caregivers because they are family members may experience a variety of emotions from pride and joy to anger, guilt, or shame. Often grandparent caregivers must balance protection and advocacy for the child with respect for the parents. The child's parents, the skipped generation may experience quilt regardless of the reason for their absence.

Multiple Generation, Intergenerational Caregiving

Commonly referred to as the "sandwich generation" of caregivers, these are caregivers providing care for children and parents simultaneously. By definition an intergenerational household includes three or more generations.

There are also individuals providing care for their partners, parents, and children. The dynamics impacting the generations are complex. The middle generation must struggle with parenting responsibilities for possibly two generations and balancing personal resources to meet varied needs. Resentment can result across the generations as each competes for limited resources.

Conclusions

It is important that family researchers and practitioners stay informed about the varied forms of care needs and of caregiving within families. The issues of care and caregiving are multifaceted. Complexity is increased when generational issues are a component. Central to the examination of the issue is the interconnection of care giving and care receiving. Care responsibilities can and often alter family relationships. Professionals working with and for families must be sensitive to the needs of both the giver and receiver of care.

The purpose of this examination is not to define the best type of care, caregiver, or even where such care should occur. Simply highlighting the  increasing complexity of care needs and caregiving is the primary purpose.  Millions of relatives engaged in caregiving across multiple generations need and deserve a clearly focused research and policy agenda.