The Relationship Between Family Caregiving

and the Mental Health of Emerging Young

Adult Caregivers
Jennifer Greene, MSPH
Donna Cohen, PhD
Constance Siskowski, RN, PhD
Peter Toyinbo, MBChB, PhD

Abstract
Caring for dependent relatives has become a normative challenge for families in the USA and
throughout the world. The study objective was to examine the relationship of family caregiving
responsibilities and the mental health and well-being of individuals, ages 18–24 years, referred to
as emerging young adults. It was hypothesized that young adult caregivers with past and present
responsibilities would report significantly more symptoms of depression and anxiety, have lower
self-esteem, and use less adaptive coping styles than non-caregiving peers. The sample consisted of
353 undergraduates (81 past caregivers, 76 current/past caregivers, and 196 non-caregivers).
Caregivers were also evaluated in terms of care recipients, duration of caregiving, tasks, and hours
of effort. Caregivers had significantly higher levels of symptoms of depression and anxiety than
non-caregivers. Research to clarify how caregiving interacts with other stressors in emerging
young adults and influences behavioral health should be a priority.

Introduction
Caring for dependent family members with medical disorders, disabilities, or frailty has become
a normative developmental challenge for families in the USA and throughout the world.1,2 There is
a substantial research literature about the caregiving process, the experience of adult caregivers and

Address correspondence to Donna Cohen, PhD, Department of Child and Family Studies, MHC 2406, College of
Behavioral and Community Sciences, University of South Florida, Tampa, FL 33612, USA. Phone: 813-974-4665; Email:
[email protected].
Jennifer Greene, MSPH, College of Education, University of South Florida, Tampa, FL 33620, USA. Phone: 813-449-
4011; Email: [email protected]
Constance Siskowski, RN, PhD, American Association of Caregiving Youth, Boca Raton, FL, USA. Phone: 516-391-
7401; Email: [email protected]
Peter Toyinbo, MBChB, PhD, James A. Haley Veterans Medical Center, HSR&D Center of Innovation on Disability and
Rehabilitation Research (CINDRR), Tampa, FL, USA. Phone: 813-554-7613; Email: [email protected]

)
Journal of Behavioral Health Services & Research, 2016. 1–12. c 2016 National Council for Behavioral Health. DOI
10.1007/s11414-016-9526-7

Relationship Between Family Caregiving and Mental Health

care recipients, the social and economic implications, the negative and positive impact on the
health and functioning of adult family caregivers, as well as family systems, and most recently,
evidence-based interventions.1–6 Most of the research has targeted older spousal caregivers and
adult children caring for older parents and relatives. However, one significant group of adult
caregivers, ranging in age from 18 years through their early twenties, designated as emerging
young adults, have largely been ignored by researchers, policy makers, and service providers.3,7
Emerging young adults are transitioning through a period that is demographically and subjectively
distinct from both adolescence and adulthood.8,9 Although these young people have left the
turbulence of adolescence, they have not developed clear plans for their future, are facing many
changes in life roles as they assume greater independence and responsibilities, and are frequently in
college.10 It is a challenge for them to organize their lives, as well as to invest time, psychological
energy, and financial resources in family caregiving responsibilities.10,11
The small, but growing, research literature in the USA and other parts of the world,
including the UK and Australia, indicates that emerging young adults assume significant
caregiving responsibilities.3,12,13 The results of a secondary data analysis of two US adult
caregiver surveys by Levine and associates14 revealed that 12 to 18% of adult family
caregivers in the USA were between the ages of 18 and 25 years. The average age was
21 years, more than half were male, they most often cared for a woman, usually a
grandmother, and they had many of the same caregiving responsibilities as older adults. The
results of a survey of 266 US university undergraduates by Baus and colleagues15 showed that
35% provided personal and medical care to a family member, with 10% helping family
members age 65 and older.
The 2001 census in the UK identified 200,000 young adult caregivers, ages 18–25 years16,
but only one study has examined this age group in depth. Becker and Becker13 interviewed
two groups of caregivers about their needs, services, and experiences: late adolescents, ages
16–17 years and young adults, ages 18–24 years. The latter group had recently aged out of
youth caregiving projects and resources that are widely available in the UK, yet still required
assistance. Both age groups had similar needs: personal support and information, access to
medical and community-based services for care recipients, transportation, opportunities to
socialize, advice about education and job skills training, and counseling. Although the need for
mental health counseling was identified, no specific behavioral health information was included
in the interview.
Since the large general adult caregiving literature has documented the significant adverse
impact on mental health, especially depression and anxiety,1–6 it is likely that young adult
caregivers will also be vulnerable and potentially even more at risk for emotional distress
because of the challenges of coping with the stress of many changes during their emerging
adulthood. However, research is scant, and the hypothesis of increased emotional distress
compared to non-caregivers remains to be tested. Gillen and Roland17 investigated depression
within 170 young adult caregivers, ages 18–30 years old, but did not compare their results to a
non-caregiver control group. In their sample of caregivers, 34.1% scored 16 or higher on the
Center for Epidemiological Studies Depression Scale (CES-D), the generally accepted cut-off
score indicating clinical depression18, and 22.2% reported scores of 20 or higher. Shifren and
Kachorek19 conducted a retrospective study of 24 young adults, ages 21–58 years, who had
been child caregivers but were no longer in this role. Forty-two percent reported CES-D scores
of 16 and higher. Dellman-Jenkins and colleagues20,21 reported that college students sometimes
assumed or were enlisted to care for older relatives, responsibilities that decreased the time
available to devote to life goals and significantly hindered three important developmental tasks:
differentiating from family, forming intimate relationships, and developing a career.
Little work has been done in areas related to negative mental health outcomes in young
adults, such as self-esteem and coping skills, which are thought to be part of a complex system

The Journal of Behavioral Health Services & Research 2016

of factors affecting an individual’s resiliency in stressful situations.22 Self-esteem, a measure of
psychological adjustment, has been shown to serve as a protective mechanism for older
adolescents experiencing stress and depression.23 Moreover, in a sample of 202 university
undergraduates, regression analyses showed that low self-esteem predicted both depression and
anxiety.24 In the only known study of a sample of young adult and older child caregivers,
caregivers were more likely than non-caregivers to use maladaptive coping styles, rather than
adaptive ones25, which could further hinder their ability to cope with the stresses of caregiving
and remain resilient to depression and anxiety.
The objective of this research project was to examine the relationship of informal family
caregiving responsibilities to the mental health and well-being of university undergraduates
who had family caregiving responsibilities prior to attending the university and those who
continued to have family caregiving responsibilities while enrolled at the university and to
contrast them to their peers who had never been caregivers. In this study, family caregiving is
defined as providing care to any dependent family member who needs special medical and
personal attention as a result of an injury, aging, illness, disability, or other health condition.
Providing care is defined as assistance with activities of daily living and/or instrumental
activities of daily living.
To the authors’ knowledge, this is the first study comparing the behavioral health vulnerability of
emerging young adults who were family caregivers with their non-caregiving peers. Three
naturally occurring groups of young adults, two of them caregiver groups, are of interest in this
study. There has been no research examining the impact of previous caregiving experience, as
children and adolescents, on the future emotional health when they became young adults and were
no longer caregivers (referred to aspast caregivers). There has also been no research comparing the
past caregivers with young adults who continued caregiving that began at an earlier age (referred to
as current/past caregivers). Others have no caregiving experience (referred to as non-caregivers).
Distinguishing between these natural groups has the potential to yield new knowledge that will be
useful to the field.
The study tested four hypotheses:
Hypothesis 1: Young adult caregivers will report higher levels of depressive symptomatology
compared to young adult non-caregivers.
Hypothesis 2: Young adult caregivers will report higher levels of anxiety symptomatology
compared to young adult non-caregivers.
Hypothesis 3: Young adult caregivers will have lower levels of self-esteem compared to young
adult non-caregivers.
Hypothesis 4: Young adult caregivers will report using less adaptive stress coping styles compared
to young adult non-caregivers.

Methods
The research design involved quantitative analyses of a convenience sample of university
undergraduates, ages 18–24 years, who responded to single mass e-mail sent to undergraduates by
the Office of the Registrar with a link to an anonymous online survey. The survey was conducted at
a large, urban, public university in the southern USA in 2009. The study was approved by the
university’s Institutional Review Board.

Participants
The sample consisted of 353 undergraduates in the following three groups.
Relationship Between Family Caregiving and Mental Health
 (1) 81 students who were past, i.e., pre-college, caregivers only. Henceforth, this group will be
referred to as past caregivers.
(2) 76 students who had been caregivers in the past and were also current caregivers.
Henceforth, this group will be referred to as current/past caregivers.
(3) 196 students who reported never having been a caregiver. Henceforth, this group will be
referred to as non-caregivers.

Measures
The survey included the following variables for all respondents: demographic information,
identification of a caregiver role, the Center for Epidemiologic Studies of Depression Scale
(CES-D)18, the State-Trait Anxiety Inventory (STAI)26, the Rosenberg Self-Esteem Scale
(SES);27, and the Response to Stress Questionnaire (RSQ).28 Respondents who identified as
being and/or having been family caregivers were asked questions about four caregiving
variables: care recipients, duration of caregiving, tasks, and effort.

Demographic information The six items included age, gender, race/ethnicity, participation in
extracurricular activities and clubs, whether they had a part-time job(s), and if so, the number
of hours worked weekly.

Caregiver status Participants were asked to answer questions about current assistance
provided (Do you currently provide assistance to a person who needs special medical care
as a result of an injury, aging, illness, disability, or other health condition?) and past assistance
provided (Did you provide assistance in the past, i.e., before entering college, to a person who
needs special medical care as a result of an injury, aging, illness, disability, or other health
condition?). Participants answering BNo^ to both questions were defined as non-caregivers.
Those who endorsed only providing assistance in the past were defined as past caregivers.
Those who endorsed providing assistance currently and in the past were defined as current/past
caregivers. Seven participants (2% of sample) who reported only being caregivers since
entering college were included in this latter group.

Depression Depression was measured using the 20-item CES-D where respondents are asked
to think about how they felt or behaved in the past week. Items are presented on a scale from
zero to three, with zero indicating Brarely or none of the time (less than 1 day),^ one indicating
Bsome or a little of the time (1–2 days),^ two indicating Boccasionally or a moderate amount
of time (3–4 days),^ and three indicating Bmost or all of the time (5–7 days).^ Scores can
range from zero to 60, with higher scores indicating more depression symptomatology and a
score of 16 or higher indicating a clinical level of depression. The scale has high reliability,
with a Cronbach’s alpha of 0.89.18 The scale had high reliability in the current sample, with a
Cronbach’s alpha of 0.92.

Anxiety Anxiety was measured using the 40-item STAI which consists of two 20-item
subscales: state anxiety and trait anxiety. Instructions for the state anxiety inventory are to
think about how the person feels right now, at this moment. For the trait anxiety inventory,

The Journal of Behavioral Health Services & Research 2016

participants are asked to think about how they feel generally. Items are presented on a scale
from one to four, with one indicating Bnot at all,^ two indicating Bsomewhat,^ three indicating
Bmoderately so,^ and four indicating Bvery much so.^ Scores can range from 20 to 80, with
higher scores indicating more anxiety symptomatology. The STAI has high concurrent validity,
correlating positively with the Anxiety Scale Questionnaire (0.73) and the Manifest Anxiety
Scales (0.85).26 Test re-test reliability is lower for the state anxiety (0.54) than the trait anxiety
scale (0.86).29 The scale had high reliability in the study sample, with a Cronbach’s alpha of
0.97.

Self-esteem Self-esteem was measured using the 10-item Rosenberg SES. Items are presented on
a scale rated from zero to three, zero indicating Bstrongly disagree,^ one indicating Bdisagree,^ two
indicating Bagree,^ and three indicating Bstrongly agree.^ Scores can range from zero to 30, with
higher scores indicating higher self-esteem. The scale has high reliability with test-retest
correlations ranging from 0.82 to 0.88 and Cronbach’s alpha ranging from 0.77 to 0.88.30 Studies
have shown unidimensional and two-factor structures for the SES, self-competence and self-
liking.30 The scale had high reliability in the current sample, with a Cronbach’s alpha of 0.91

Coping Participants completed six items from the RSQ. The complete 57-item RSQ measures
two broad domains of coping, voluntary vs. involuntary responses and engagement vs.
disengagement strategies, in response to age-appropriate social stressors. Within these two broad
dimensions, the RSQ has five factors (primary control, secondary control, disengagement coping,
involuntary engagement, and involuntary disengagement), and each factor is composed of different
types of coping responses. The RSQ has good reliability, ranging from 0.72 to 0.89,28 as well as
good convergent and divergent validity.31
In this study, three items were used to measures voluntary disengagement, a dimension of
maladaptive coping characterized by wishful thinking (i.e., wishing to be smarter, wishing the
problem would go away, and wishing someone would take the problem away). Three additional
items were used to measure voluntary engaged problem-solving, a dimension of adaptive coping
(i.e., think of ways to deal with or fix the problem, ask others for help or ideas, and try to fix the
situation). Items were rated on the use of a particular coping strategy from one to four, one
indicating Bnot at all,^ two indicating Ba little,^ three indicating Bsome,^ and four indicating Ba
lot.^ Scores can range from six to 24, with higher scores indicating higher frequency of use of
coping behaviors. In the current sample, the three wishful thinking items had moderate reliability,
with a Cronbach’s alpha of 0.75, while the problem solving items had a lower reliability, with a
Cronbach’s alpha of 0.56.

Caregiving variables Respondents were asked to identify all care-recipients for whom they had
responsibilities, duration of caregiving, all caregiving tasks, and time spent providing care.
Duration of caregiving was assessed by asking participants to identify the age caregiving
responsibilities began (age 5 and younger, 6 to 10 years, 11 to 15 years, 16 to 20 years, or age 21 to
24 years). A checklist of caregiving tasks included six activities of daily living (ADLs: feeding,
bathing, dressing, toileting, assistance with walking, changing diapers) and eight instrumental
activities of daily living (IADLs: appointments, translating, emotional support, company, cleaning/
laundry, grocery shopping/preparing meals, medical tasks/medical equipment, and medication
management). Time spent was recorded as estimated average hours during a typical school day and
a typical weekend day.

Relationship Between Family Caregiving and Mental Health

Statistical analysis
Data were descriptively analyzed using cross-tabulations by caregiver status with chi-square
tests as appropriate. In addition, past and current/past caregiver groups were compared across types
of care recipients, types of care given (ADLs and IADLs), and hours spent caregiving. Analysis of
variance (ANOVA) and Tukey post hoc multiple comparisons were performed to test whether the
outcome variables including depression, state and trait anxiety, coping, and self-esteem were
significantly different across the three study groups. An alpha level at 0.013 was set for the
multiple ANOVAs so that the overall type 1 error rate across the four analyses would be 0.05.
Effect size of the mean differences was calculated using Cohen’s d. An effect size of 0.2 is
considered small; 0.5, medium; and greater than or equal to 0.8, large.32

Results
Characteristics of the sample
Participants in all three study groups were predominantly Caucasian females and were, on
average, 21 years old. Table 1 shows that the groups were similar for all sociodemographic
variables except one: there was a significant association between extracurricular engagement and
caregiver status (χ2 (2, N = 353) = 6.04, p G 0.05). Although greater than half of all three groups
reported outside activities, non-caregivers were more likely to engage in extracurricular activities
(67.9%) than past caregivers (58.0%) and current/past caregivers (52.6%). More than half of
participants in the three groups worked 20 or more hours weekly, but the differences were not
significant.

Caregiving recipients, duration of caregiving, tasks, and time spent

The majority of both past and current/past caregivers cared for a parent (42.4 and 47.0%)
followed by a grandparent (39.0 and 40.8%). Most past and current/past caregivers (83.5 and
66.7%) cared for one recipient, but 16.5% of past caregivers and 33.3% of current/past caregivers
cared for two or more individuals. Both groups provided care over a long period of time, with
approximately half of caregivers assuming their responsibilities between the ages of 16 and 20
(55.7% of past caregivers and 43.5% of current/past caregivers) and approximately a third
assuming their responsibilities between the ages of 11 to 15 (31.6% of past caregivers and 27.5%
of current/past caregivers).
Both groups of caregiving students invested a great deal of effort. Most past caregivers spent
0–2 hours giving care during a typical school day (47.6%), while most current/past caregivers spent 3–
5 h (48.7%). Both groups provided care for more hours during a typical weekend day, at 3–5 h per day
(36.6% of past caregivers and 28.9% of current/past caregivers). About one fifth of both groups
provided care for more than 8 h per day on the weekend (23.2 and 19.7%, respectively).
Caregivers performed both ADLs and IADLs (Table 2). Both past caregivers and current/past
caregivers most commonly assisted with walking, followed by feeding and dressing. Caregivers in
both groups most often acted as companions, provided emotional support, and cleaned/did laundry.
Current/past caregivers were significantly more likely to be involved in organizing help from others
(χ2 (1, N = 157) = 7.97, p G 0.05) and coordinating appointments as well as administering
medication (χ2 (1, N = 157) = 3.84, p G 0.05).

Depression and anxiety

Table 3, which displays group scores on the CES-D and STAI, shows that caregiver status was
significantly related to depressive symptomatology on the CES-D, F (2, 349) = 5.705, p = 0.004.

The Journal of Behavioral Health Services & Research 2016

 Table 1
Demographic characteristics of the undergraduate young adult student sample (N = 353) by
caregiver status
Characteristic Non-caregiversa Past caregiversb Current/past caregiversc χ2 p

n % n % n %

Gender
Male 36 18.4 17 21.0 17 22.4 0.64 0.73
Female 160 81.6 64 79.0 59 77.6
Age
M (SD) 20.57 (1.65) 20.89 (1.59) 20.79 (1.64) 1.25d 0.29
Race/ethnicity
Caucasian 131 68.2 56 68.3 53 70.7 5.77 0.83
African-American 20 10.4 6 7.3 4 5.3
Latino 23 12.0 11 13.4 13 17.3
Asian 9 4.7 3 3.7 1 1.3
Multiracial 6 3.1 4 4.9 2 2.7
Other 3 1.6 2 2.4 2 2.7
Do you participate in extracurricular activities?
Yes 133 67.9 47 58.0 40 52.6 6.04 0.05
No 63 32.1 33 40.7 36 47.4
No response – – 1 1.2 – –
Do you have a part-time job?
Yes 114 58.2 41 50.6 48 63.2 2.60 0.27
No 82 41.8 40 49.4 28 36.8
If you have a part-time job, how many hours per week do you work?
0–9 18 15.8 5 12.2 4 8.3 8.88 0.35
10–19 38 33.3 13 31.7 17 35.4
20–29 35 30.7 13 31.7 17 35.4
30–40 21 18.4 7 17.1 5 10.4
More than 40 2 1.8 3 7.3 5 10.4
a
n = 196
b
n = 81
c
n = 76
d
One-way ANOVA

Tukey post hoc tests revealed that current/past caregivers had significantly higher scores on the
CES-D (M = 18.80, SD = 12.14) compared to the non-caregiver group (M = 13.81, SD = 10.56).
Moreover, the effect size of this difference was 0.45, a medium size effect. Higher percentages of
past as well as current/past caregivers (43.9 and 46.1%) had clinically significant CES-D scores
(916) as compared to 29.1% of the non-caregiving group.
An ANOVA showed that caregiver status had a significant overall effect on state anxiety as
measured by the STAI, F (2, 347) = 5.563, p = 0.004. Tukey post hoc tests revealed that current/
past caregivers (M = 45.85, SD = 13.68) had significantly higher scores on the STAI state anxiety
scale compared to the non-caregiver group (M = 39.92, SD = 13.34), and the effect size was
medium (d = 0.44). Tukey post hoc tests revealed that current/past caregivers (M = 44.90, SD =
13.51) had significantly higher scores on the STAI trait anxiety scale compared to the non-
Relationship Between Family Caregiving and Mental Health
 Table 2
Frequencies of caregiving activities by caregiver status
Type of activity Past caregivers Current/past caregivers χ2 p
(n = 81) (n = 76)

n % n %

Activities of daily living (ADL)

Feeding 33 40.2 30 39.5 0.03 0.87
Bathing/showering 24 29.3 23 30.3 0.01 0.93
Dressing 26 31.7 30 39.5 0.93 0.34
Toileting 25 30.5 20 26.3 0.40 0.53
Assistance with walking 54 65.9 45 59.2 0.65 0.42
Changing diapers 6 7.3 13 17.1 3.47 0.06
None of the above 20 24.4 17 22.4 0.18 0.73
Instrumental activities of daily living
(IADL)
Organizing help from others, 34 41.5 49 64.5 7.97 0.00
appointments
Translating information 15 18.3 21 27.6 2.42 0.12
Providing emotional support 66 80.5 63 82.9 0.18 0.67
Cleaning/doing laundry 48 58.5 55 72.4 3.55 0.06
Grocery shopping/preparing meals 43 52.4 55 72.4 6.99 0.01
Keeping company 73 89 63 82.9 1.17 0.28
Bandaging/assisting with medical 26 31.7 20 26.3 0.40 0.53
equipment
Administering medication 25 30.5 34 44.7 3.84 0.05
Other 21 25.6 28 36.8 2.18 0.14
None of the above 3 3.7 2 2.6 0.15 0.70

caregiver group (M = 40.32, SD = 13.07). The overall effect (small effect size of 0.35) of caregiver
status on trait anxiety was not significant at the conservative alpha level of 0.01, F (2, 342) = 3.363,
p = 0.036.

Self-esteem and coping

Very minor differences were found between groups on the Rosenberg SES scores, with past
caregivers endorsing the highest self-esteem (M = 22.81, SD = 5.54), followed by non-caregivers
(M = 22.75, SD = 5.95) and current/past caregivers (M = 21.86, SD = 6.31). However, these
differences were not significant, F (2, 338) = 0.66, p = 0.52, and the effect sizes were small (0.01
and 0.15).
Moreover, minor differences were found between groups on the RSQ, with both past caregivers
(M = 16.31, SD = 2.77) and current/past caregivers (M = 16.13, SD = 2.70) endorsing more adaptive
coping styles than non-caregivers (M = 15.53, SD = 2.55). These differences were not significant at
the conservative alpha level of 0.01, F (2, 342) = 3.06, p = 0.05, however, small effect sizes of 0.30

The Journal of Behavioral Health Services & Research 2016

Relationship Between Family Caregiving and Mental Health
Table 3
Mean scores on outcomes for non-caregivers, past caregivers, and current/past caregivers
Non-caregivers Past Current/past Past caregivers vs. Current/past
(n = 196) caregivers caregivers non-caregivers caregivers vs.
(n = 81) (n = 76) non-caregivers

Outcome M SD M SD M SD d p d p

Depression** 13.81 10.56 15.44 10.52 18.80 12.14 0.16 0.49 0.45 0.00
State anxiety** 39.92 13.34 42.06 12.11 45.85 13.68 0.17 0.43 0.44 0.00
Trait anxiety* 40.32 13.07 42.15 12.23 44.90 13.51 0.14 0.54 0.35 0.03
Self-esteem 22.75 5.95 22.81 5.54 21.86 6.31 0.01 0.10 0.15 0.53
Coping: overall* 15.53 2.55 16.31 2.77 16.13 2.70 0.30 0.07 0.23 0.23
Coping: problem solving
I try to think of different ways to deal with 3.34 0.85 3.60 0.65 3.46 0.83 0.33 0.04 0.14 0.51
or change the problem or fix the situation.*
I ask other people for help or for ideas about 2.90 0.97 2.96 0.91 2.82 1.02 0.06 0.86 0.08 0.82
how to make the problem better.
I do something to try to fix the problem or take 3.43 0.77 3.53 0.74 3.44 0.75 0.13 0.58 0.01 0.10
action to change things.
Problem solving coping subtotal 9.67 1.90 10.10 1.65 9.74 1.93 0.24 0.19 0.04 0.96
Coping: wishful thinking
I wish that I were stronger, smarter, or more 2.07 1.06 2.15 1.06 2.35 1.10 0.08 0.86 0.26 0.15
popular so that things would be different.
I deal with the problem by wishing it would just 1.83 0.97 1.99 1.05 1.89 0.92 0.16 0.46 0.06 0.92
go away, that everything would work itself out.
I just wish someone would come and get me out 1.94 1.00 2.07 1.02 2.15 1.09 0.13 0.60 0.21 0.30
of the mess.
Wishful thinking coping subtotal 5.85 2.47 6.21 2.51 6.39 2.62 0.15 0.52 0.22 0.26
d= Cohen’s d
*p G 0.05, **p G 0.01
and 0.23, respectively, were obtained. Specific adaptive and maladaptive coping skills endorsed by
each group are presented in Table 3.

Discussion
The results of this study confirm the scant literature showing that young adults expend
considerable time and effort caring for dependent family members, and although it is not a
randomized trial, it is the first to use a control group of non-caregiving peers to show an association
between providing care and mental health and well-being.14,33 This age group not only has
significant caregiving responsibilities today but they are also the emerging caregiver cohort of
tomorrow.7 Dellman-Jenkins and Brittain34 identified at least three related family dynamics
contributing to the increasing involvement of this age group: (1) role strain/stress and decreasing
availability of the middle-aged generation to be caregivers, (2) growth of the oldest cohorts and
longer-lived family generations, and (3) a strong filial attachment and sense of responsibility to
provide needed care. Baus and colleagues15 emphasized that caregiving will be a twenty-first
century challenge for college students who will be increasingly involved because of societal aging
trends, especially the tendency of women, ages 20–24 years, to postpone childbearing, and
pressures to assume some of the responsibilities once provided by the burdened middle-aged
sandwich generation.
To the authors’ knowledge, this is the first study reporting that young adult caregivers, especially
those who had been caregivers both before and during college, were not only significantly more
depressed and anxious than their non-caregiving peers but also that the levels of symptomatology
in many of them were clinically significant. The comparatively higher indicators of emotional
distress in the caregiving groups suggest that the burden of caregiving coupled with university
pressures and other factors likely makes young adult students more vulnerable to psychiatric
distress. The psychosocial, behavioral, and environmental factors contributing to depression and
anxiety in young adult student caregivers should be a research priority. This group may be at risk
for continued poor mental health and difficulties in ongoing and future educational and
occupational pursuits, as well as overall success in life. It is possible that behavioral health
problems were influenced by the medical conditions and comorbidities affecting respective care-
recipients’ needs as well as available support systems. However, these variables were not included
in the survey.
No significant relationship between caregiver status and self-esteem was demonstrated in this
sample. Self-esteem, a measure of psychological adjustment, has been reported to be lower in some
studies of depressed populations.35 Since self-esteem is defined as an overall evaluation of one’s
competence and is considered to be a rather stable personality trait, it may be that participants in
this study, regardless of caregiving challenges, felt good about themselves and their overall
capabilities as individuals and university students.
It is important to emphasize that the frame of reference this sample used to make their responses
to the coping questions is not known because the RSQ test instructions are to answer each item in
response to the introductory statement, BWhen I have a problem.^ The findings that past and
current/past caregivers employed adaptive coping more often than (though not significantly more
often than) non-caregivers are in contrast to at least one study using the instrument. Pakenham and
colleagues,25 who studied a mixed sample of youth and young adults ages 10–25 years, reported
that caregivers were more likely than non-caregivers to use wishful thinking, a maladaptive coping
style, and less likely to use problem solving coping, an adaptive coping style.
The findings of this study of undergraduates indicate that past and current/past caregivers used
both wishful thinking and problem solving coping styles more often than (though not significantly
more often than) their non-caregiving peers. This may reflect that they are trying to find different
ways to deal with their problems, perhaps using wishful thinking to deal with their emotional

The Journal of Behavioral Health Services & Research 2016

distress and also using effective problem focused coping skills to deal with practical problems. This
could mean that the demands of caregiving may also have a positive impact on some behaviors in
spite of the mental health risks. One can postulate that past caregivers were more effectively able to
employ these mechanisms because they were no longer dealing with the daily stress of caregiving,
unlike those in the current/past group who were still doing so.
Several study limitations affect the interpretation of results, including the use of an anonymous
self-report survey of a convenience sample with no independent validation of responses, lack of
information in the survey about several issues, such as the types and severity of care-recipients’
medical conditions, and other factors affecting caregivers’ stress. The mass e-mail from the
Registrar’s Office was intended to maximize the inclusion of undergraduate students across
colleges and departments, years enrolled at the university, and demographic diversity, but this
method also limited the length and content of the survey to maximize respondent participation.
The sample had potential self-selection biases. Some student caregivers may have been more
likely to respond to the survey because their major responsibilities had a significant impact on their
lives, whereas other student caregivers may have been too burdened to respond. Although it is not
clear why so many non-caregivers took the survey, it is possible that they were interested in the
topic because they knew someone who was a caregiver or they would receive class credit for
participating in a research study.
The relatively small size of the sample, where the two caregiving groups each numbered less
than 100 respondents, may have affected the ability to detect significant group differences on some
outcomes. The homogeneous demographics of the sample, who were predominantly Caucasian and
female, does not permit generalizability. The ANOVA analysis did not control for potential
confounds, such as demographics, in the relationships between caregiving and mental health
outcomes. However, the lack of significant differences in demographic pattern between all groups
minimizes this potential problem. In future research, it would be desirable to recruit larger
populations, oversampling for racial/ethnic diversity, to examine the relationship of mental health
to care-recipients’ medical status, young adults’ perception about their role as a primary or
secondary caregiver, household composition, including other family caregivers, and availability
and access to services.
Despite the limitations of this study, it is the first to use reliable, valid clinical measures of
depression and anxiety with young adult caregivers, revealing significant levels of clinical
symptomatology in this population. More needs to be known about risk and protective factors
affecting the physical and emotional health of these caregivers during the course of their
responsibilities over time in order to design interventions to support the present and future health
and well-being of young adults and their families.

Implications for Behavioral Health

The evidence of clinically significant depression and anxiety in this sample of young adult
undergraduate caregivers has implications about the need for behavioral health research and
services in universities and secondary schools, health care sites, and community settings that serve
this population. Research priorities include several significant issues, including but not limited to
the following: (a) the process of caregiving, including how, when, and why young adults assume or
acquire caregiving roles along with the types and extent of caregiving responsibilities; (b) the roles
of primary and secondary caregiving and relationships/interactions with other family caregivers; (c)
the availability of psychosocial supports; (d) motivations for long-term caregiving; (e) ways
individuals learn to access resources and solve problems associated with responsibilities; (f)
negative and positive consequences of caregiving responsibilities on personal, family, academic,
work, and social life; (g) use of formal support services and informal networks and resources; and
(h) the long-term consequences for physical and mental health as well as overall well-being.
Relationship Between Family Caregiving and Mental Health
Results of these efforts are essential to develop and test consensus and evidence-based
interventions for emerging young adults in the context of the developmental transitions in their
educational and occupational achievements, as well as social and marital relationships.
Young adult caregivers need information and resources because they are likely to experience
logistical barriers, such as lack of time or availability of transportation, to seeking behavioral health
services.36 Given the technological sophistication of this age group, one priority for the
development of interventions should be in the delivery of information, supportive programs, and
services, as well as behavioral health services via technology. A growing body of literature has
demonstrated that that computer- and telephone-based therapy can reduce depression symptoms. A
study of adults receiving cognitive behavioral therapy via telephone showed significant reductions
in depression symptoms over 3 and 6 months.37 Similar results were found in a study of adult
caregivers of patients with Alzheimer’s disease who received counseling via a computer program
similar to Skype.38 Innovative research is needed to extend these findings to young adult caregivers
who are increasingly sophisticated in communication technology and social media modalities.
The results of this research also highlight the need for transitional behavioral health services for
young caregivers when they leave high school. Students who had received home- and school-based
behavioral health and support services and are entering universities likely find themselves
separated from previous health care providers and services, yet still needing assistance. This is
echoed in Becker and Becker’s study13 of young adults, ages 18–24 years, who had recently aged
out of youth caregiving projects. The needs of these caregivers changed little, yet support was no
longer provided. Clearly, one of the most important implications of this study is the importance of
developing policies and practices that support emerging young adults, pivotal caregivers for the
health of families and the greater society.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of interest.

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