Kin as Teachers: An early childhood education and support intervention for kinship families

Children and Youth Services Review 38 (2014) 1–9

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Children and Youth Services Review

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Kin as Teachers: An early childhood education and support intervention for kinship families Kerry A. Littlewood a,⁎, Anne L. Strozier b,1, Danielle Whittington c a b c

School of Social Work East Carolina University 217 Rivers, Mailstop 505 Greenville, NC 27858, United States School of Social Work University of South Florida, 13301 Bruce B. Downs Blvd., MHC 1400, Tampa, FL 33612-3807, United States Humana 800 Carillon Parkway, Suite 240, St Petersburg, FL 33716, United States

a r t i c l e

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Article history: Received 5 August 2010 Received in revised form 26 November 2013 Accepted 26 November 2013 Available online 14 December 2013 Keywords: Kinship Care Grandparents Raising Grandchildren

a b s t r a c t Whereas child welfare has championed efforts in kinship care practice, policy, and research, there is a growing need for other systems of care, specifically early childhood education, to improve the ways in which kinship care families are supported. This study highlights outcomes from the Kin As Teachers (KAT) Program, an early childhood education program specifically designed for children living with a grandparent or other relative. KAT addresses the areas of parent knowledge and parenting practices, detection of developmental delays and health issues, prevention of child abuse and neglect, and promotion of school readiness and success. Current issues facing kinship families with young children are highlighted using quantitative data and case studies based on 83 grandparents and other relatives providing care for 185 children. Pre and post tests show results on age appropriate family environment and the caregivers' knowledge of child development. Two case studies describing the familial experience in KAT detail the process evaluation related to this intervention. Results indicate improved age appropriate family environment and an increase in caregivers' knowledge of child development for families participating in KAT. Implications for social work practice include suggestions for ways social workers and early childhood educators can better support kinship caregiving families. © 2013 Elsevier Ltd. All rights reserved.

1. Introduction Kinship care is defined as the full time care, nurturing and protection of children by relatives or any adult who has a kinship bond with the children (Child Welfare League of America, 2000). While this term is usually associated with grandparents raising grandchildren, it can be more broadly referred to a wide range of familial arrangements and circumstances. Biological ties are not necessary for a child to be considered kin. Kinship families are dynamic, because they adapt their familial arrangements based upon the context to which care is needed. A biological parent can place a child with a relative because of a problematic situation, but two months later the parent may return to regain the role of primary caregiver to the child. Child welfare and legal systems of care may or may not be involved to demarcate roles and responsibilities with the family members. Kinship care has been extensively studied in the field of child welfare, which has primarily focused on goals of safety, permanence and well-being of children. While child welfare studies have increased the knowledgebase in the field of kinship care in general, they provide little insight into the early learning development of children in care. Primarily, child welfare research on kinship care provides us with a framework of risk factors that can be used to determine a need for ⁎ Corresponding author. Tel.: +1 252 737 2117. E-mail addresses: [email protected] (K.A. Littlewood), [email protected] (A.L. Strozier). 1 Tel.: +1 813 974 1379. 0190-7409/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.childyouth.2013.11.026

early intervention services for children in kinship care. Risk factors identified by previous studies describe how grandparents' health issues and lack of resources and support affect their ability to provide care to young children (Burke & Schmidt, 2009; Whitley & Kelley, 2008). Studies have found that assuming the caregiving role negatively effects caregiver's health and that kinship caregivers rate their health as poorer when compared to traditional foster parents (Fuller-Thomson & Minkler, 2000; Hardxen, Clyman, Kiebel, & Lyons, 2004; Sands & GoldbergGlen, 2000). In terms of health care behaviors, kinship caregivers are also less likely to participate in health screenings, psychological assessments, and substance abuse treatment (Smithgall, Mason, Mitchels, LiCalsi, & George, 2006). There is strong evidence that kinship foster families receive less training, fewer services, and less support than non-kinship foster families (Brisebois, 2013; Franck, 2001; Kelley, Whitley, & Campos, 2010). Furthermore, kinship caregivers are less likely to refer their children for needed resources and services (Kelley et al., 2010). It is unclear if they receive fewer resources because kinship families do not request, do not need, or refuse such services or if these differences are due to the perceptions of child welfare workers (Edwards & Taub, 2009; Sands & Goldberg-Glen, 2000). 1.1. Need for early childhood interventions Ramey and Smith's (1977) research-based developmental screening index includes thirteen factors that are associated with school

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underachievement and failure for young children. They include low parent education, low income, absence of a father from the home, use of welfare services, poor social support for the mother, and parents working at unskilled jobs. Kinship caregivers have been found to share these risk factors, including low parent education, low income, absence of a father from the home, and poor social support (Dowdell, 1995; Kelley, 1993; U.S. General Accounting Office, 1999). With regard to physical, social and emotional care of kinship and non-kinship families, non-kinship families exhibited greater physical affection, verbal and behavioral attending, and praising (Gaudin & Sutphen, 1993). Also, non-kinship foster parents were found to provide greater attention to activities that encouraged the intellectual and social development of pre-school aged children compared with kinship foster parents. Moreover, children in kinship care experience a unique set of risk factors, often associated with the circumstances that led them to being reared by a grandparent or other relative. There is evidence that children in kinship care are functioning less well compared with children in the general population. Children in kinship care were found to have more health problems due to prenatal drug exposure (Keller et al., 2001) compared with children in non-kinship foster care. When compared to children in the general population, children in kinship care were found to have more behavior problems (Sands & Goldberg-Glen, 2000), below average scores in reading, math, cognitive functioning, problem solving, reasoning, and listening comprehension. Traditionally, fewer children being raised in kinship care are enrolled in early age programs. Many caregivers cannot enroll the children in programs because they do not have formal custodial guardianship of the children. Others may find it difficult to enroll children because they cannot afford the cost of the program (Ehrle, Geen, & Clark, 2001). 1.2. Parents as Teachers model Early childhood education programs are a primary prevention strategy to achieve the goal that all children begin school ready to learn. Most early childhood programs are designed to improve children's social, psychological and cognitive readiness for school (Broström, 2006; Cohen & Syme, 2013; Munford, Sanders, Maden, & Maden, 2007; Votruba-Drzal, Coley, Koury, & Miller, 2013). Parents as Teachers (PAT) is a model early childhood education program that includes parental involvement, early age enrollment, home visits, and lengthy intervention. Established in 1981, Parents as Teachers was created to address the developmental learning needs of children before entering kindergarten. The mission of the PAT program is to provide the information, support and encouragement that parents need to help their children develop optimally during the crucial early years of life. Parents as Teachers consists of home visits, developmental screenings, resource networking and group meetings. According to the National Registry of Evidence-based Programs and Practices, home visitation is the key component of the Parents as Teachers model. During each home visit of the PAT program, the Parent Educator chooses developmentally appropriate educational activities based on the needs of the individual child. For children aged birth to three, there are four activities to choose from for each month of life. For children aged three to kindergarten entry, the parent educator chooses from 38 different activities in different subcategories such as literacy, music, math, science and pretend play. 1.3. Kin as Teachers model Kin as Teachers (KAT) is a modification of the Parents as Teachers Program designed to meet the special needs of relative caregivers raising children from birth to kindergarten entry. This is the only known adaptation of the PAT program for kinship families. Similar to the PAT program, the KAT program addresses the areas of parent knowledge and parenting practices, detection of developmental delays

and health issues, prevention of child abuse and neglect, and promotion of school readiness and success. Unlike PAT, however, KAT establishes a two year time limit for delivery of services, due to a waiting list, and it utilizes case management services rather than resource networking. These changes will be further explained. Kin as Teachers was created specifically to address the needs of vulnerable young children in kinship families who often need extra support and special services. Some of the children being raised by relatives suffer from low self-esteem, poor academic performance, and/or behavior problems (Edwards & Taub, 2009; Sands & Goldberg-Glen, 2000; Strozier, McGrew, Krisman, & Smith, 2005). Kinship children may be born of drug addicted mothers and suffer the consequences of that drug addiction, such as Attention Deficit Hyperactivity disorder, learning disabilities, or other learning difficulties (Sawyer & Dubowitz, 1994). In addition, the children may suffer from depression, anger, or anxiety due to early abuse or neglect by parents addicted to drugs (U.S. General Accounting Office, 1999). An additional challenge is that many of the kinship caregivers feel a lack of confidence and knowledge about raising children in today's world (Fuller-Thomson & Minkler, 2000; Strozier et al., 2005). Grandparents often have been away from the role of parenting for a long time so that they do not remember, or simply do not know, the latest ‘ins’ and ‘outs’ of parenting. As one caregiver in the KAT Program stated: It had been a long time since we have been parents of very small children. Our grandson remembers the abuse that happened to him before he came to us. Because of the abuse, he is very shy and doesn't like strangers. We aren't sure the best way to help him. Like PAT, KAT uses four types of interventions: home visits, developmental screening, case management, and support group meetings. Each will be explained here: 1.3.1. Home visits Home visits are typically held in the caregiver's home but can occur in other environments, such as the child's daycare center. A certified Kin Educator trained in child development teaches caregivers new ways to observe and interact with their child in order to increase knowledge and understanding of the child. Using the Born to Learn Curriculum, the Kin Educator chooses from the many developmental lessons provided by PAT to meet the needs of the family. KAT utilizes 144 different lesson plans for children birth to three, breaking them down into four lessons per month for the first 36 months. Families typically receive one to two lessons per month. For children three years to kindergarten entry the curricula is broken down to 10 categories including pretend play, construction, math, literacy, science, games, art, motor, music, and social emotional. Each of these sub-categories has from three to six different curriculums for the parent educator to utilize with the family. During a home visit for children ages birth to kindergarten entry, the Kin Educator and caregiver discuss developmental topics such as: language, socio-emotional, intellectual, and fine and gross motor skills development. Handouts with information regarding each topic are shared and discussed as they relate to the child. At every visit an ageappropriate developmental activity is completed by the caregiver and child. This increases the developmentally appropriate parenting practices of the caregiver and aids in bonding between caregiver and child. Toward the end of a home visit, a literacy activity is completed with the caregiver and child to promote reading. The visits last approximately an hour and occur on a bi-weekly or monthly basis, depending on the individual needs of the family. 1.3.2. Developmental screening Developmental screenings allow the Kin Educator to detect developmental delays and health issues in the child. Each child receives a developmental screening every six months called the Ages and Stages

K.A. Littlewood et al. / Children and Youth Services Review 38 (2014) 1–9

Questionnaire (Squires, Bricker, & Potter, 1999). The questionnaire contains 30 developmental items divided into five categories, including: 1) communication, 2) gross motor skills, 3) fine motor skills, 4) problem solving skills, and 5) personal-social skills. Each response is given a point value, is totaled, and then is compared to the screening cut-off points established by the PAT program. Children between the ages of 16 and 24 months are also screened for Pervasive Developmental Disorders utilizing the Modified Checklist for Autism in Toddlers (Robins, Fein, Barton, & Green, 2001). 1.3.3. Case management KAT utilizes case management rather than PAT's resource networking because of the greater needs experienced by most kinship families. KAT assists caregivers in obtaining resources rather than just telling caregivers who to contact, as is done in resource networking. Case management for kinship caregivers is based on Maslow (1954). Maslow explained that each lower human need must be met before moving to the next need at a higher level. This theory applies to KAT because caregivers need assistance with the basic physical needs of their family such as housing, food, and clothing before they can successfully address psychological and emotional needs. Lawrence-Webb, Okundaye, and Hafner, (2003) described the importance of procuring services that assist caregivers in addressing their immediate challenges, such as finances and housing. Case management includes helping families with utility assistance, clothes and basic need items attainment, emotional support, and referrals to other county organizations to help with issues such as housing and transportation. 1.3.4. Support group meetings Support group meetings are provided for caregivers so they can share their experiences with other caregivers and learn from each other. In addition, group meetings provide families with the opportunities to participate in caregiver–child activities. KAT collaborates with both the local Parents as Teachers program and a local kinship support group to provide meaningful group experiences. KAT support groups provide a family meal, followed by separate group experiences for the adults and children. Literature on support groups has examined their moderating effects on caregiver burden. Gonyea and Silverstein (1991) explored the relationship between support group participation and an improved sense of psychological well-being among 301 caregivers attending support groups and 75 control families. Caregivers who attended support groups experienced lower levels of objective and subjective burden (Green & Gray, 2013; Strozier, 2012). Solomon and Draine (1995) found self-efficacy and coping strategies to be effective mediators of burden. Sterrett, Jones, McKee, and Kincaid (2011) demonstrated that practical advice on managing disruptive behaviors also reduced caregiver burden. 1.4. Current study Though several studies have tested the outcomes of the Parents as Teachers Program (Albritton, Klotz, & Roberson, 2004; Research and Training Associates, Inc, 2006; Wagner & Spiker, 2001; Zigler, Pfannenstiel, & Seitz, 2008), there is no study that tests program effects for this modified PAT program, the Kin As Teachers Program, implemented entirely with kinship families. The current study tests if the KAT Program improves kinship caregiver's knowledge of child development and age-appropriate family environment for 83 caregivers caring for 188 children in a southern metropolitan city. 2. Method 2.1. Instruments 2.1.1. Florida Kinship Center Demographic Survey The Florida Kinship Center Demographic Survey (Strozier & Krisman, 2007) was developed to capture in-depth demographic data

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on Florida caregivers. Census 2000 response variables that collected information on co-resident caregiver and grandparent-headed households were included in the survey to offer a national comparison for future investigations. The FKCDS has 15 questions and takes approximately five to ten minutes to complete. Because caregivers who provide the answers are often caring for more than one child with different custodial arrangements, the survey queries for up to ten children. This allows the survey to capture certain variables for each child cared for by the responding relative. The survey is also given verbally to account for various levels of literacy. This information is gathered within the first two personal visits with the family. 2.1.2. HOME Inventory The Home Observation for Measurement of the Environment (HOME) Inventory (Caldwell & Bradley, 2001) gathers information in the child's home using observational data designed to assess the family environment in a systematic way. The HOME Inventory assesses ageappropriate family environment and uses different measures for ages birth to three and ages three to five. The Infant Toddler HOME, used for children ages birth to three, is composed of 45 items that are presented as statements to be scored as YES or NO. Higher total HOME scores indicate a more enriched home environment, always in relation to the children's contextual features (Totsika & Sylva, 2004). Even though no cut-off points are detailed in the manual, the range of scores falling in the top and bottom quarter and the middle half are reported on the Summary Sheets (Caldwell & Bradley, 2001; Totsika & Sylva, 2004). Scores falling in the lowest fourth of the score range indicate an environment that may pose a risk to some aspect of child development (Totsika & Sylva, 2004). The items are designed to reflect six main dimensions, including six subscales: responsivity, acceptance, organization, learning materials, involvement, and variety. The Early Childhood HOME, used for children ages three to five, is made up of 55 items that are grouped in seven subscales including: learning materials, language stimulation, physical environment, responsivity, academic stimulation, modeling, and variety. This scale is also scored in a binary (Yes/No) manner. The instrument is completed within the first three personal visits with the caregiver and the post test is completed upon completion of the Kin as Teachers program, with a minimum of six months of participation. The HOME has been used extensively on normally developing children in the following capacities: (1) as a predictor of cognitive development (Fernandez, Vazir, Bentley, Johnson, & Engle, 2008; Robinson et al., 2012); (2) as a predictor of attachment status (National Longitudinal Survey of Youth Early Child Care Research Network NICHD Early Child Care Research Network, 2001); and (3) as an identifier of ethnic differences in HOME profiles (Bradley et al., 1989). Findings of the HOME have been extended to more high-risk environments, which is of particular interest to those kinship homes where parents are absent. HOME has detected significant differences in home environments of poor mothers and poor mothers with mental retardation (Keltner, 1994). Azuma and Chasnoff (1993) found that three-year-old children exposed prenatally to cocaine and other drugs and three-year-old children exposed to drugs other than cocaine (tobacco, alcohol, marijuana, etc.) scored in the at-risk range of the HOME. Extreme behavioral problems associated with maternal smoking both during and after pregnancy were also associated with low HOME scores (Weitzman, Gortmaker, & Sobol, 1992). Furthermore, the HOME scores of children from poor families are significantly different from those children coming from non-poor families (Totsika & Sylva, 2004). The first study conducted to assess the psychometric properties of HOME suggested that there is 90% agreement between observers and internal consistency ranges from moderate to strong (.44–.89) (Elardo, Bradley, & Caldwell, 1975). Test–retest reliability was moderate for a period of 18 months. Since the initial study, several researchers have concluded that interobserver agreement has never fallen below .80, while an internal consistency of total scores was found to be as high

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as .80 and internal consistency of the subscales ranges from .30 to .80 (Bradley, 1993).

month. Targeted case management services, as described previously, were provided to all families in need.

2.1.3. Kin Knowledge Questionnaire The Kin Knowledge Questionnaire (KKQ) was adapted from the Parents Knowledge Questionnaire (SRI International & Parents as Teachers National Center, 2001) an instrument used for the Parents as Teachers Program to measure a parent's knowledge of child development. The Parent Knowledge Questionnaire was constructed from items contained in other instruments, particularly the Knowledge of Infant Development Inventory (KIDI; MacPhee, 1989) and the Adult–Adolescent Parenting Inventory (AAPI; Bavolek, 1984). The wording was changed slightly from parent to caregiver, and real-life examples were included to simplify language. The KKQ contains 27 items and is administered upon enrollment and again yearly. Response items, based on a Likert scale, involve knowledge regarding child development, health, discipline techniques and parenting issues. The instrument was adapted with permission of the Parents as Teachers National Center in order to more accurately capture data from relative caregivers.

2.4. Children

2.2. Participants All participants in this study were voluntary. Participants consisted of caregivers who were either self-referred, called a Kinship Care Warmline, or were referred to KAT by local social service agencies who agreed to participate. Table 1 summarizes the demographic characteristics collected from all of the caregivers (N = 83) who completed an intake assessment. Most caregivers were between the ages of 50–59 (n = 29, 40%), African American (n = 44, 53%), and grandmothers to the children in their care (n = 101, 55%), which is consistent with previous literature (Cuddeback, 2004; Gleeson, 2007). A large percentage of caregivers, 42% (n = 30), are married. This is a different distribution from other studies, such as (Berrick, Barth, & Needell, 1994; Iglehart, 1994; Lewis & Fraser, 1987; Wulcyzn & Goerge, 1992) which report a larger proportion of single caregivers. Seventy-one percent (n = 128) of the children cared for by these relatives have some kind of custodial arrangement obtained through the court system. Only 32% (n = 57) of the children in this study are eligible for Relative Caregiver Program benefits, a child welfare program providing financial assistance to grandparents and other relatives raising children in Florida. A small percentage of children (n = 37, 21%) are cared for by relatives informally, without the involvement of the child welfare system. Sixty percent (n = 52) of caregivers are rearing one to two children. Forty percent (n = 34) of caregivers are rearing three or more children. The mean age for children enrolled in the KAT was 3.35 years old (n = 162).41.5% (n = 78) of the children have been in the care of the relative for three years or more. Alternatively, 15.4% (n = 29) of the children have been in the care of the relative for less than six months. 2.3. Procedure 2.3.1. Caregivers Once kinship families were referred, caregivers were invited to participate in the study. Those who agreed were given an informed consent form to sign. Adult participants attended an eight-session schoolbased support meeting every other week, facilitated by the KAT program coordinator. Transportation and childcare were offered and dinner was served before each meeting. The support group consisted of group discussion and support, using the following subjects: Anger Management, Taking Care of Yourself, Long-term Planning for Children, Tools for Forgiveness, Academic Expectations, Coping Strategies and Tools, and Termination. In addition to the support group, caregivers were provided home visits consisting of parenting education once a

Children in KAT were provided with several interventions designed to improve development and included in the curriculum. Kin Educators first implemented the Ages and Stages Questionnaire to assess child development. If the child was delayed, he or she was referred to an appropriate specialist, including speech, occupational, or physical therapists. If the child was on target developmentally, the Kin Educator implemented the Born to Learn Basic 1, 2, 3, 4 Curriculum. Developmental milestones were tracked. Other referrals to day care and other services were made. 2.5. Analysis The FKCDS, HOME Inventory Observation (HOME) and the Kin Knowledge Questionnaire (KIN) were administered to caregivers prior to the start of the first exposure to the program and twenty four months later, at the completion of the program. Once the data was collected, it was entered into a database and analyzed using SPSS version 17.0. Percentiles were calculated based on the scores of the HOME and KIN, and Cronbach's alpha was calculated in order to test internal consistency among questions on each scale. The alpha range was .70–.99. Paired samples t-tests were performed in order to determine whether the mean scores on the pre test HOME and KIN, and their associated subscales, were significantly different from the post tests. 3. Results The results are presented in two sections: first, the quantitative results, and second, two case studies. 3.1. Quantitative results Table 2 summarize the caregivers' and the children's pretest scores and posttest scores. A paired samples t-test was conducted to determine if there was a significant difference between participants' overall pretest and posttest scores on the HOME Inventory Observation and Kin Knowledge Questionnaire. Each subscale result is also included in the analyses. The results of the HOME pre and post test analyses indicate that a significant difference exists between participants' overall pretest and posttest scores t(30) = − 7.71; p b .00. Significant differences were also identified for the following subscales of the Infant Toddler HOME: acceptance (p = .000), organization (p = .013), learning (p = .000), involvement (p = .000), and variety (p = .000). Additionally, significant differences were also identified for the following subscales of the Early Childhood HOME: learning (p = .000), language (p = .000), responsivity (p = .003), academic (p = .000), modeling (p = .001), and variety (p = .004). Figs. 1 & 2 illustrate the changes between the pre and post test scores of the Infant Toddler HOME and the Early Childhood HOME respectfully. Each subscale demonstrated a positive change between pre and posttest scores. The largest pre to post change for the Infant and Toddler HOME was observed in the responsivity subscale (p = .05). The items in this subscale indicate that the caregiver performed certain activities with the child during the home visit. These activities include: spontaneously vocalizes to child at least twice; responding verbally to child's vocalizations or verbalizations; speaking distinctly, clearly, and audibly; spontaneously praising the child at least twice, and caressing or kissing the child at least once. The largest pre to post change for the Early Childhood HOME was observed in the learning subscale (p = .001). Some items that were assessed on this subscale during the home visit include: the child has three or more puzzles, appropriate games that teach numbers, and at least ten books; the family subscribes to at least one magazine;

K.A. Littlewood et al. / Children and Youth Services Review 38 (2014) 1–9 Table 1 Demographic characteristics. Variable

Table 1 (continued) Variable N

Caregiver age

78

Race

83

Marital status

74

Educational

61

Employment status

81

Current income

55

Own computer

76

Relationship to child*

Custodial arrangement*

Number of relative children in care*

5

185

179

86

Child age*

162

Length of time in care*

188

Response

Frequency

Percent

20–29 30–39 40–49 50–59 60–69 70+ African-American Caucasian Hispanic/Latino Other Single Divorced Married Widowed Middle School High School Some College College Graduate Post Graduate Employed Part-Time Employed Full-Time Retired Disability Other $1–4,999 $5,000–9,999 $10,000–14,999 $15,000–19,999 $20,000–24,999 $25,000–29,999 $30,000–34,999 $35,000–39,999 $40,000–44,999 $45,000–49,999 $50,000–54,999 $55,000–59,999 $60,000+ $65,000+ Yes No Grandmother or Step Grandfather or Step Great Grandmother Aunt Uncle Great Aunt Cousin Sister Biological Parent Non relative Other Dependency Probate Court Family Court Informal Not applicable 1

3 10 18 29 15 3 44 29 8 2 13 18 30 13 17 19 17 6 2 30 2 12 33 4 1 10 4 11 2 7 3 4 1 2 2 1 6 6 48 28 101

6.9 9.8 20.8 31.9 25.0 5.6 53.0 34.9 9.6 2.4 16.2 24.4 41.8 17.6 27.87 31.15 27.87 9.84 3.28 37.04 2.47 14.81 40.74 4.94 1.80 18.2 7.3 20.0 3.6 12.7 5.5 7.3 1.8 3.6 3.6 1.8 10.9 10.9 63.2 36.8 54.6

4 18 18 4 6 4 1 12 10 7 57 7 64 37 14 27

2.2 9.7 9.7 2.2 3.2 2.2 .5 6.5 5.4 3.8 31.8 3.9 35.8 20.7 7.8 31.4

2 3 4 5 6 7 10 N1 1 2 3 4 5 Other Less than 6 months 6–11 months 1–2 years

25 14 12 1 4 2 1 13 22 22 32 21 14 38 29 33 48

29.1 16.3 14.0 1.2 4.7 2.3 1.2 8.0 13.6 13.6 19.8 13.0 8.6 23.5 15.4 17.6 25.5

(continued on next page)

N

Response 3–4 years 5 or more years

Frequency 35 43

Percent 18.6 22.9

the family buys and reads a daily newspaper; and the child is encouraged to learn shapes. Paired samples t-tests were also performed to determine if there were significant differences between the caregivers' pretest scores and posttest scores on the Kin Knowledge Questionnaire. The results of the analyses indicate significant positive differences in the total score (p = .000). 3.2. Case studies To gain a more complete understanding of the Implementation of the KAT program, this study provides case examples of participants' family experiences. The case studies highlight examples of the personalized interventions administered to these families in need. 3.2.1. The family of Mrs. P Mrs. P is a 51 year old single Caucasian grandmother raising two children, Myranna and Jaden, who were aged five and three years respectively upon entering the KAT program. She received custody of the children through the local child welfare agency who had removed the children from their mother because of alleged neglect. The agency referred Mrs. P to the KAT program because of her concerns about raising these two young children, wondering if she would be able to continue. For the first three months the KAT program worked with the family, Mrs. P received no funds from the state to help support the two children. In addition, Mrs. P's trailer was dilapidated and needed many repairs, including an unsafe front porch, a bathroom ceiling in disrepair, and a master bedroom with only plastic sheeting as a ceiling. Mrs. P worked full time and tried to fix the house herself but was unable to and could not afford to make the necessary repairs. KAT provided a number of interventions for this family. First, financial needs were addressed by providing basic need items such as diapers, utility assistance, and a referral to a local food bank. In addition, the Kin Educator assisted Mrs. P in obtaining the children's medical information so she could take them to a doctor for regular check ups and needed appointments. The educator taught Mrs. P about the Medicaid system and helped her learn ways to navigate the system. The Kin Educator assisted Mrs. P in signing up for financial assistance such as WIC and TANF so she could access funds to help her pay her bills and purchase food. The Kin Educator also researched local contracting companies that could help with the housing repairs. Although Mrs. P did not qualify for local charity services because she was employed full-time, the Kin Educator found a contracting company willing to do the repairs for free as a public service. With these basic needs stabilized, the KAT program was able to focus more extensively on the developmental needs of the children. The Kin Educator assessed Myranna and found that she was developing normally and was meeting all her developmental milestones. Work with Myranna focused on building her relationship with her grandmother, as well as overcoming her shyness and feeling more comfortable interacting with adults. In contrast, Jaden was identified as having developmental delays. Jaden's IQ was 67 and he was diagnosed with Attention Deficit Hyperactivity Disorder. The Kin Educator worked with a local speech therapist and the school system with the goal of school entrance in a mostly traditional class room setting. She also worked with the family on increasing their interactions through games as well as singing songs together. These activities had the added benefit of improving Jaden's

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speech skills and diverting some of his negative behaviors. After two years of developmental services, Jaden was able to pass a kindergarten readiness exam and enter kindergarten, spending half of his day in a traditional classroom. Mrs. P also learned to provide better organization and structure in the home, which helped with Jaden's Attention Deficit Hyperactivity Disorder. The Kin Educator spent time helping Mrs. P and the children organize toys and learn to put them away when done playing. When it was time for graduation from KAT services Mrs. P reported feeling proud of the job she was doing raising her grandchildren and reported feeling even “happy” in her role as a kinship caregiver. She felt relief in knowing she was not alone and felt encouraged about her ability to handle the continuing challenges of raising her grandchildren.

3.2.2. The family of Mrs. L Mrs. L is a 54 year old African American woman raising 4 grandchildren. The children, at the time of admission to the program, were Alexis, age 12; Sandira, age nine; Savannah, age five; and Tyler, age nine months. Mrs. L had been given custody of the children for the third time from the local child welfare agency due to the alleged neglect the children suffered as a result of the mother's substance abuse. Mrs. L had cared for the children the majority of the time before the children were officially placed with her four months prior to KAT opening the family case. The family was referred to the KAT program because Mrs. L had just been diagnosed with a cancerous brain tumor and needed to have surgery. She had no local support system, and reported feeling extremely depressed and helpless about raising the children now, especially the youngest ones. Mrs. L also had many financial concerns. She was no longer able to work and had just begun to receive disability payments. She received financial assistance from the state for the children, but found that still she struggled every month to pay her bills. Due to the other children spending the majority of their time in school, Tyler was the focus of the curriculum, but the rest of the family became very involved in the process. Alexis had begun to have behavioral problems in school and was often suspended. Alexis was referred for counseling due to her frequent outbursts. The Kin Educator provided developmental screenings for Tyler that determined that he had developmental as well as social-emotional delays. The KAT program made referrals so that Tyler could receive a speech therapist as well as therapeutic services. To develop these skills at home, the Kin Educator also worked with Mrs. L to incorporate time for him to play on his stomach, which soon encouraged him to crawl and then walk. Tyler remained non-verbal until the age of three, so the Kin Educator provided the family with songs and helped teach Tyler to use basic sign language

to develop communication skills. Savannah especially loved to learn the songs and teach them to the rest of the family. Mrs. L was also educated on the importance of age and developmentally appropriate surroundings. She began to provide the children structured, learning-based playtime and age-appropriate toys and television viewing. This assisted in reducing some of the violent acting out behaviors that Tyler had been exhibiting and also helped Mrs. L feel more in control of her home and the children. The five person family was living in a two bedroom house that was located down the street from the children's biological mother. The biological mother frequently showed up at Mrs. L's home while using drugs, causing much emotional pain for the children as well as Mrs. L. KAT was able to assist the family in many ways. The first crisis that was addressed was where the children were going to stay while Mrs. L went to the hospital for surgery since she had no immediate family or friends who would be able to handle this responsibility. After completing an ECO map (a diagram that identifies families' support systems), it was determined that Mrs. L's greatest support system was her church. The Kin Educator suggested that Mrs. L ask the church if anyone who she felt close to was willing to take the children temporarily. The educator explained that agreeing to this job would also require the person to undergo a background check required by the state. In the end, Mrs. L's church pastor and his wife offered to care for her four grandchildren for the first two weeks after Mrs. L's surgery. Other church friends offered to take turns in coming by the home to care for Mrs. L for the four weeks after surgery until she was cable to be completely back on her feet. Today, two years after the surgery and subsequent treatment, Mrs. L is in good health and is cancer free. After helping to resolve this intense immediate crisis, the Kin Educator worked with Mrs. L to create a budget and help her understand where she was spending her money and learn ways to allocate her funds better so that she could afford to pay the bills. Mrs. L decided to go to school to become a Certified Nursing Assistant so that when she went back to work she could make more money to help support herself and the children. The KAT program supported her school effort by assisting her in buying uniforms and shoes for her new job, and by providing basic need supplies when the budget got even tighter due to the financial requirements of tuition. This also set an example for the children on the importance of completing their educations. Mrs. L was able to move out of her old neighborhood with its associated challenge of being near the addicted biological mother.

Table 2 Pre-post paired sample T-test (N = 30, 27, 50).

Responsivity Acceptance Organization Learning Involvement Variety Learning Language Physical Responsivity Academic Modeling Variety KAT

Pretest mean

Posttest mean

S.D.

t

cpb

9.10 5.77 5.13 6.26 3.39 2.77 6.29 6.04 5.89 5.5 3.75 3.39 5.39 36.36

11.35 7.06 5.64 7.81 4.68 3.74 8.64 6.79 6.25 6.5 4.68 4.29 6.68 43.68

1.30 1.395 1.09 1.88 1.42 1.14 2.23 1.04 .95 1.63 1.12 1.31 2.19 3.24

2.00 5.15 2.63 4.59 5.06 4.73 5.60 3.81 1.99 3.24 4.39 3.59 3.10 4.37

.050 .000 .013 .000 .000 .000 .000 .001 .057 .003 .000 .001 .004 .000

Fig. 1. Infant Toddler HOME pre and post test change.

K.A. Littlewood et al. / Children and Youth Services Review 38 (2014) 1–9

Fig. 2. Early Childhood HOME Pre and post test change.

The KAT program assisted with the move by helping pay for a utility bill so that she could pay the deposit on the new home. After 24 months of KAT services, the family is now stable and Mrs. L reports feeling acceptance of her role as caregiver of her four grandchildren. Mrs. L reports missing the KAT program, but she understands that she is connected to the necessary resources. 4. Discussion The analyses in this study demonstrated that overall improvement in the Infant Toddler HOME, the Early Childhood HOME, and the Kin Knowledge Questionnaire for kinship caregivers and the children in their care. Furthermore, each subscale yielded a positive change between pre and post test. These subscales provide more descriptive information about how kinship caregivers score on certain aspects of development. 4.1. Infant Toddler HOME Kinship caregivers scored highest on the responsitivity subscale of the Infant Toddler Home. This is a positive finding, considering that parental responsiveness has shown a relation to early motor and social competence (Bradley, Corwyn, Burchinal, McAdoo, & Coll, 2001). These findings, although small in magnitude, are consistent with the generally acknowledged value of social responsiveness as supportive of secure attachment (Friedman & Boyle, 2008; Sweet & Appelbaum, 2004) Theory also stipulates that responsiveness continues to play a role in adaptive behavior for older children (Bogenschneider, Wu, Raffaelli, & Tsay, 1998; Brody & Flor, 1998). The lowest scoring subscale for infant and toddlers' home environment was the variety subscale. This included items such as: father provides some care daily, parent reads stories to child at least three times weekly, child eats at least one meal a day with mother and father, family visits relatives or receives visits once a month or so, and child has 3 or more books of his/her own. Considering the lower economic status of many caregivers in this study, it is possible that they do not have access to a variety of developmentally appropriate toys, books, etc. Involvement in early intervention programs could improve this aspect of the environment for kinship families. 4.2. Early Childhood HOME Caregivers scored highest and had the largest change from pretest to posttest on the Learning Subscale of the Early Childhood HOME. Items

7

on the learning scale include: child has three or more puzzles; child has a record, tape or CD player and at least 5 children's records, tapes, or cds; child has toys or games permitting free expression, refined movements, or which teach numbers; child has at least 10 children's books; at least 10 books are visible in home; and family buys a daily newspaper and subscribes to magazines. Since the KAT Program provides many books and learning materials for the family, this intervention probably accounts for families' improved learning environment. The modeling subscale of the Early Childhood HOME scored the lowest means for both pre and posttest. Items on this subscale include: some delay of food gratification is expected, TV is used judiciously, child can express negative feelings without harsh reprisal, child can hit caregiver without harsh reprisal, and caregiver introduces visitor to child. Previous research has shown that parents with higher levels of education and income tend to engage their children in richer language exchanges and provide them materials and experiences that encourage language development (Bradley, 1993; Hart & Risley, 1995). Given that most caregivers in this study have an annual income between $15,000 and $19,999 and 28% have only obtained middle school education, their language subscale scores on the Early Childhood HOME were not surprising. The HOME Inventory is designed to be a measure of the stimulation potential of a child's home environment and a valid measure of a child's development completed by a person who goes to the home when the child is awake and can be observed interacting with the caregiver. The authors state that “in order to cover certain important transactions not likely to occur during the visit, it is suggested that about one-third of the items be based on parent/guardian report.” This could yield some bias to the scores and the results. In fact, Totsika and Sylva (2004) consider that the most serious restriction of the HOME Inventory is the lack of standardized procedure for administration. However, reliability could be better in our study because only one Kin Educator administered these assessments. Although there are no norms on outcome measures available to compare with our results for kinship caregivers, Wagner and Spiker (2001) conducted a multi-site experimental design program evaluation of PAT program that offers a good comparison group for the current study. The treatment group “Site 2” of Wagner and Spiker (2001) best resembles the demographic characteristics of the caregivers in this study, because the mothers are older, African American, less educated, and more likely to be unemployed. Fig. 3 compares the KAT program pre and posttest means with the comparison group. The KAT caregivers scored lower on every subscale at pretest except the responsivity subscale and higher on every subscale at posttest except the involvement subscale. This could mean that at the beginning of the program, the caregivers in the KAT program were less likely to provide developmentally appropriate family environment than the comparison group. The KAT program's higher posttest scores could mean that the kinship caregivers showed more improvement than the comparison group. 4.3. Kin Knowledge Questionnaire Significant improvement was shown on the Kin Knowledge Questionnaire, which determines the caregivers' level of knowledge about normal child development. This can be extremely helpful especially to older caregivers, who are not otherwise familiar with recent advances in the child development. 4.4. Limitations Point-in-time data collection is a limitation of this study. A longitudinal design could have strengthened this study by more adequately describing the experiences of these families across time. Due to small sample size and study design, it was difficult to determine the effects of individual interventions within the service provided. Additionally, the program did not take into account other supportive services or

8

K.A. Littlewood et al. / Children and Youth Services Review 38 (2014) 1–9

community resources received by the family during the two-year enrollment in KAT, which could have inflated the positive results of this study. Lastly, there was no control group used in this study, which could have strengthened the results and potentially showed improved outcomes for an intervention group compared to another group receiving no treatment. 4.5. Further research Although the KAT has shown successful outcomes with a small sample, more research is needed to determine if this program's results could be replicated in other sites. Future research could test the effects of caregiver age on knowledge of child development and socioeconomic status on home environment for kinship families. Future studies could also use cluster analyses and other analytic techniques to determine the individual effects of services provided to kinship caregivers and their children. Using an experimental design with a control group is another recommendation for further research. 4.6. Implications for practice One of the important findings of this study, that the provision of inhome developmental and educational services for kinship caregivers can lead to significant gains in caregivers' abilities to successfully raise children ages birth to 5, implies that other practitioners can use this model for intervention. The use of home visits for kinship caregivers was encouraged by the Center for Law and Social Policy, Inc. (CLASP), 2009 report entitled Extending home visiting to kinship caregivers and family, friend, and neighbor caregivers. This study confirms CLASP's positive findings about home visits for kinship caregivers raising young children. (2009). The authors are grateful to the Parents as Teachers organization for its willingness to allow us to create and provide Kin as Teachers. Our hope is that other practitioners will replicate Kin as Teachers to be able to better assist kinship caregivers with small children.

A second finding of this study is that while healthy child development was the most important goal of KAT, in some instances it could not be reached without intensive case management, emergency financial assistance with housing, food and clothes, and successful connection to other community resources. In these cases, it's important for the Kin Educator to wear many hats, including educator, social worker, home visitor, and navigator. The implications from this finding are that practitioners working with kinship caregivers need to be adaptable, have an extensive scope of knowledge about various issues facing families, and a broad view of what makes up a healthy family. Thus far, little has been done to study the programmatic needs of kinship families caring for young children and how their experiences differ from those of foster parents or birth parents. From our experience, caregivers' needs should be met with programs which are easily accessible or in-home. More policies are beginning to reflect the importance of supporting the kinship family in the community. The Fostering Connections to Success and Increasing Adoptions Act of 2008 awarded two rounds of competitive grants to states for developing kinship navigator programs to help connect kinship families to needed resources in their communities. These grants have provided among other things, opportunities for award recipients to explore how their communities can promote the early education needs of children in kinship care and assess the availability of resources for young children living with relatives. Continued funding for kinship programs, including ones that serve kinship caregivers dedicated to helping the young children in their care prepare for entry into kindergarten, is greatly needed. Acknowledgments The authors would like to acknowledge the KAT Program Coordinators, especially Danielle Klendworth, for their dedication to kin families. The authors would also like to acknowledge the devotion of the grandparents and other relatives raising children who participated in this program.

KAT and Comparison Group Pre and Post Test Means 12

KAT Pre Wagner & Spaker (2001) Pre

10

KAT Post Wagner & Spaker (2001) Post

Mean

8

6

4

2

0

Responsivity Acceptancce Organization

Learning

Involvement

Subscale Fig. 3. KAT and Wagner and Spiker (2001) comparison group.

Variety

K.A. Littlewood et al. / Children and Youth Services Review 38 (2014) 1–9

References Albritton, S., Klotz, J., & Roberson, T. (2004). The effects of participating in a Parents as Teachers program on parental involvement in the learning process at school and home. E-Journal of Teaching and Learning in Diverse Settings, 1, 188–208. Azuma, S. D., & Chasnoff, I. J. (1993). Outcome of children prenatally exposed to cocaine and other drugs: A path analysis of three-year data. Pediatrics, 92, 396–402. Bavolek, S. J. (1984). Handbook for the Adult-Adolescent Parenting Inventory (AAPI). Eau Claire, WI: Family Development Resources, Inc. Berrick, J.D., Barth, R. P., & Needell, B. (1994). A comparison of kinship foster homes and foster family homes: Implications for kinship foster care as family preservation. Children and Youth Services Review, 16(1), 33–63. Bogenschneider, K., Wu, M. Y., Raffaelli, M., & Tsay, J. C. (1998). “Other teens drink, but not my kid:” Does parental awareness of adolescent alcohol use protect adolescents from risky consequences? Journal of Marriage and Family, 60, 356–373. Bradley, R. H. (1993). Children's home environments, health, behavior, and intervention efforts: A review using the HOME inventory as a marker measure. Genetic, Social, and General Psychology Monographs, 119, 437–490. Bradley, R. H., Caldwell, B.M., Rock, S. L., Ramey, C. T., Barnard, K. E., Gray, C., et al. (1989). Home environment and cognitive development in the first three years of life: A collaborative study including six sites and three ethnic groups in North America. Developmental Psychology, 25, 217–235. Bradley, R. H., Corwyn, R. F., Burchinal, M., McAdoo, H. P., & Coll, C. G. (2001). The home environments of children in the United States Part II: Relations with behavioral development through age thirteen. Child Development, 72(6), 1868–1886. Brisebois, K. (2013). Caseworker attitudes on kinship care in Ontario. Qualitative Social Work, 12(3), 289–306. Brody, G. H., & Flor, D. L. (1998). Maternal resources, parenting practices, and child competence in rural, single-parent African American families. Child Development, 69(3), 803–816. Broström, S. (2006). Care and education: Towards a new paradigm in early childhood education. Child & Youth Care Forum, 35(5/6), 391–409. Burke, S., & Schmidt, G. G. (2009). Kinship care in Northern British Columbia. Child Welfare, 88(6), 127–142. Caldwell, B.M., & Bradley, R. H. (2001). HOME inventory and administration manual (3rd ed.): University of Arkansas for Medical Sciences and University of Arkansas at Little Rock. Center for Law and Social Policy, Inc. (CLASP) (2009). Extending home visiting to kinship careigvers and family, friend, and neighbor caregivers. Retrieved from. http://www. clasp.org/admin/site/publications/files/homevisitingkinshipffn.pdf Child Welfare League of America (2000). CWLA standards of excellence for kinship care services. Washington, DC: Author. Cohen, A. K., & Syme, S. L. (2013). Education: A missed opportunity for public health intervention. American Journal of Public Health, 103(6), 997–1001. Cuddeback, G. S. (2004). Kinship family foster care: A methodological and substantive synthesis of research. Children and Youth Services Review, 26, 623–639. Dowdell, E. B. (1995). Caregiver burden: Grandmothers raising their high-risk grandchildren. Journal of Psychosocial Nursing, 33(3), 27–30. Edwards, O. W., & Taub, G. E. (2009). A conceptual pathways model to promote positive youth development in children raised by their grandparents. School Psychology Quarterly, 24(3), 160–172. Ehrle, J., Geen, R., & Clark, R. (2001). Children cared for by relatives: Who are they and how are they faring? New Federalism: A Survey of America's Families, B(28), 1–8 (Retrieved on October 23, 2009 from http://www.urban.org/UploadedPDF/anf_b28.pdf) Elardo, R., Bradley, R., & Caldwell, B.M. (1975). The relation of infants' home environments to mental test performance from six to thirty-six months: A longitudinal analysis. Child Development, 46, 71–76. Fernandez, S., Vazir, S., Bentley, P., Johnson, S., & Engle, P. (2008). Maternal self esteem and locus of control relates to the quality of young children's environment (HOME) in rural Andhra Pradesh, India: Research and policy implications. International Journal of Early Childhood, 40(2), 85–99. Franck, K. L. (2001). Characteristics of kinship and non-kinship care foster children and their families of origin. Unpublished master's thesis. Knoxville: University of Tennessee. Friedman, S. L., & Boyle, D. E. (2008). Attachment in US children experiencing nonmaternal care in the early 1990s. Attachment & Human Development, 10(3), 225–261. Fuller-Thomson, E., & Minkler, M. (2000). African American grandparents raising grandchildren: A national profile of demographic and health characteristics. (English). Health and Social Work, 25(2), 109. Gaudin, J. M., & Sutphen, R. (1993). Foster care vs. extended family care for children of incarcerated mothers. Journal of Offender Rehabilitation, 19(3–4), 129–147. Gleeson, J. P. (2007). An overview of current kinship care research and literature. Grandfamilies: What's workers, what's new, & what's next in building supports for grandparents and other relatives raising children. Paper presented at Generations United International Conference: It's Monumental, Washington, D.C. (Retrieved from http:// www.gu.org/documents/A0/07ConfGF_Glesson.ppt) Gonyea, J., & Silverstein, N. M. (1991). The role of Alzheimer's disease support groups in families' utilization of community services. The Journal of Gerontological Social Work, 16(3), 43–55. Green, Y. R., & Gray, M. (2013). Lessons learned from the kinship education and support program (KEPS): Developing effective support groups for formal Kinship caregivers. Social Work with Groups, 36(1), 27. Hardxen, B. J., Clyman, R. B., Kiebel, D. K., & Lyons, M. E. (2004). Kith and kin care: Parental attitudes and resources of foster and relative caregivers. Children and Youth Services Review, 26(7), 657–671. Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday lives of young American children. Baltimore: Paul H. Brooks.

9

Iglehart, A. P. (1994). Kinship foster care: Placement, service, and outcome issues. Children and Youth Services Review, 16(1–2), 107–122. Keller, T. E., Wetherbee, K., LeProhn, N., Payne, V., Sim, K., & Lamont, E. R. (2001). Competencies and problems behaviors of children in family foster care: Variations by kinship placement status and race. Children and Youth Services Review, 23(12), 915–940. Kelley, S. (1993). Caregiver stress in grandparents raising children. Image: Journal of Nursing Scholarship, 25, 331–337. Kelley, S. J., Whitley, D.M., & Campos, P. E. (2010). Grandmothers raising grandchildren: Results of an intervention to improve health outcomes. Journal of Nursing Scholarship, 42(4), 379–386. Keltner, B. (1994). Home environments of mothers with mental retardation. Mental Retardation, 32, 123–127. Lawrence-Webb, C., Okundaye, J. N., & Hafner, G. (2003). Education and kinship caregivers: Creating a new vision. Families in Society: The Journal of Contemporary Human Services, 84(1), 135–142. Lewis, R. E., & Fraser, M. (1987). Blending informal and formal helping networks in foster care. Children and Youth Services Review, 9, 153–169. MacPhee, D. (1989). Knowledge of Infant Development Inventory. Unpublished manuscript. Chapel Hill, NC: Department of Psychology, University of North Carolina. Maslow, A. (1954). Motivation and personality. New York: Harper. Munford, R., Sanders, J., Maden, B., & Maden, E. (2007). Blending Whanau/family development, parent support and early childhood education programes. Social Policy Journal of New Zealand(32), 72–87. National Longitudinal Survey of Youth Early Child Care Research Network NICHD Early Child Care Research Network (2001). Child-care and family predictors of preschool attachment and stability from infancy. Developmental Psychology, 37, 847–862. Ramey, S. L., & Smith, B. (1977). Assessing the intellectual consequences of early intervention with high risk infants. American Journal of Mental Deficiency, 81, 318–324. Research and Training Associates, Inc (2006). BIA Baby Family and Child Education Program: 2005 Report. Executive Summary. Author. Robins, D., Fein, D., Barton, M., & Green, J. (2001). The Modified-Checklist for Autism in Toddlers (M-CHAT): An initial investigation in the early detection of autism and Pervasive Developmental Disorders. Journal of Autism and Developmental Disorders, 31(2), 131–144. Robinson, L., Boris, N., Heller, S., Rice, J., Zeanah, C., Clark, C., et al. (2012). The good enough home? Home environment and outcomes of young maltreated children. Child & Youth Care Forum, 41(1), 73–88. Sands, R. G., & Goldberg-Glen, R. S. (2000). Factors associated with stress among grandparents raising their grandchildren. Family Relations, 49(1), 97–105. Sawyer, R. J., & Dubowitz, H. (1994). School performance of children in kinship care. Child Abuse and Neglect, 18, 587–597. Smithgall, C., Mason, S., Mitchels, L., LiCalsi, C., & George, R. (2006). Caring for their children's children: Assessing the mental health needs and service experiences of grandparent caregiver families. Chapin Hall Working Paper (Retrieved on January 12, 2009 from http://www.chapinhall.org/article_abstract) Solomon, P., & Draine, J. (1995). Subjective burden among family members of mentally ill adults: Relation to stress, coping, and adaptation. American Journal of Orthopsychiatry, 65, 419–427. Squires, J., Bricker, D.D., & Potter, L. (1999). The ASQ user's guide. Baltimore, MD: Brookes Publishing Company. SRI International & Parents as Teachers National Center (2001). The Multisite evaluation of the Parents as Teachers Home Visiting Program: Three year findings from one community. Menlo Park: CA: SRI International. Sterrett, E. M., Jones, D. J., McKee, L. G., & Kincaid, C. (2011). Supportive non-parental adults and adolescent psychosocial functioning: Using social support as a theoretical framework. American Journal of Community Psychology, 48(4), 284–295. Strozier, A. L. (2012). The effectiveness of support groups in increasing social support for kinship caregivers. Children and Youth Services Review, 34, 876–881. Strozier, A. L., & Krisman, K. (2007). Capturing caregiver data: An examination of kinship care custodial arrangements. Children and Youth Services Review, 29(2), 226–246. Strozier, A. L., McGrew, L., Krisman, K., & Smith, A. (2005). Kinship care connection: A school-based intervention for kinship caregivers and the children in their care. Children and Youth Services Review, 27, 1011–1029. Sweet, M.A., & Appelbaum, M. I. (2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75(5), 1435–1456. Totsika, V., & Sylva, K. (2004). The HOME observation for measurement of the environment revisited. Child and Adolescent Mental Health, 9(1), 25–35. U.S. General Accounting Office (1999). Foster care: Kinship care quality and permanency issues. Washington, DC: US General Accounting Office (GAO/HEHS99-32). Votruba-Drzal, E., Coley, R. L., Koury, A. S., & Miller, P. (2013). Center-based child care and cognitive skills development: Importance of timing and household resources. Journal of Educational Psychology, 105(3), 821–838. Wagner, M., & Spiker, D. (2001). Multisite parents as teachers evaluation: Experience and outcomes for children and families. Menlo Park, CA: SRI, International (Retrieved from http://policyweb.sri.com/cehs/publications/patfinal.pdf) Weitzman, M., Gortmaker, S., & Sobol, A.M. (1992). Maternal smoking and behavior problems of children. Pediatrics, 90, 342–349. Whitley, D.M., & Kelley, S. J. (2008). Developmental screening and evaluation results of young African American grandchildren raised by grandparents: Thoughts for research and practice. Arete, 32(1), 38. Wulcyzn, F. H., & Goerge, R. M. (1992). Foster care in New York and Illinois: The challenge of rapid change. Social Service Review, 66, 278–294. Zigler, E., Pfannenstiel, J. C., & Seitz, V. (2008). The Parents as Teachers Program and school success: A replication and extension. Journal of Primary Prevention, 29, 103–120.