Translating Basic Research on the Aging Family to Caregiving Intervention: The Case of Within-Family Differences

Translating Basic Research on the Aging Family to Caregiving Intervention: The Case of... Since its inception, the field of gerontology has sought to establish optimal connections between the scientific activities of researchers and the real-world concerns of practitioners and clinicians. The concept of translational research has emerged in recent years as a model for bridging the gap between science and service. This article provides an example of how basic research findings can be translated to provide guidance for intervention in the area of family caregiving. We review find- ings from an innovative program of research on within-family differences, which extends theory and research from the developmental psychological study of children to the family in later life. The within-family difference perspective focuses on how the individual parent–child dyads in a particular family differ from and are affected by other dyads. Basic research on this topic has revealed the extent of parental favoritism in later life, factors related to parental differential treatment of offspring, and the consequences of such favoritism and treatment on sibling relationship quality and psychological well-being. Four examples are provided of ways in which attention to within-family differences research could enhance caregiving interventions. Translational Significance: This article provides an example of the translational research process, demonstrating how a body of basic research can be mined for insights that can guide intervention. A focus on within-family differences in older parent—adult– child relationships suggests how existing caregiving interventions could be adapted or fine-tuned to take advantage of empirical insights regarding family complexity. Keywords: Caregiver intervention, Translational models, Parental favoritism, Parental differential treatment, family, Parent–adult child relations Since its origins as an organized discipline, gerontology has and practice should ideally intersect in gerontology. As evi- been deeply engaged with the question: What is the optimal dence of this fact, we point to a very contemporary-sounding relationship between research on aging and the real-life prob- statement of the problem, penned over a half century ago. lems of older people and their families? The field has always In 1961, Geneva Mathiasen (1961) offered an analysis in included both scientists and helping professionals, which has the first volume of a brand new journal, The Gerontologist. led to ongoing concerns about the way in which basic research She noted: © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. 1 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user journals.permissions@oup.com on 16 March 2018 Copyedited by: SU 2 Innovation in Aging, 2018, Vol. 00, No. 00 There is a growing conviction of many persons working applied research, interventions, and programs to improve in social aspects of aging of the need for a closer re- quality of life, productivity, and health of older people (Pillemer et al., 2003). lationship between individuals engaged in research and In clarifying the focus of translational research, it is use- those engaged in practice. There has been … a some- ful to ask “What is the principal problem that translational times subtle, sometimes blunt, assumption of hierarchy, research trying to solve?” As suggested in the introduction with the practitioners at the lower end of the order… to this article, we believe that the most pressing problem The practical result has been to separate those with an is the too-distant relationship between fundamental scien- academic orientation and primary research interest from tific discoveries in the field of aging and the life course on those primarily engaged in the field of practice. the one hand, and attempts to address the challenges of Mathiasen went on to identify the key problem: “the later life on the other. Over the past several decades, there researchers believe that much of the work with older has been tremendous growth in basic research in geriat- people is based on unproved assumptions,” whereas “prac- rics and gerontology. At the same time, on the practice titioners refer to research studies as instruments to prove level, programs have proliferated to assist older persons in statistically what every good practitioner already knows.” various domains of life. However, the expansion in both She concludes that the need for: “a device for better com- fields has made increasingly obvious the lack of connection munication and even collaboration seems apparent.” between them. In particular, insights from basic research Given this call to arms from over 50 years ago, how suc- are rarely used systematically to guide the development of cessful have we been in bridging the gap between science and new programs. An argument for translational research is service in our field? Unquestionably, the search for “a device the length of time it takes for a fundamental research dis- for better communication and even collaboration” has con- covery to move into a treatment or therapy. This lag has tinued. Despite advances, however, the need clearly exists for been estimated as approximately 17 years for research evi- better translation among the activities of fundamental scien- dence to reach clinical practice (Westfall et al., 2007), and tific discovery in gerontology and geriatrics, the development much basic research is never transferred into practical use of effective treatments and interventions, and their eventual (Institute of Medicine, 2001). adoption by practitioners in the community, long-term care Despite an ongoing debate over its precise definition, facilities, health care settings, and in the policy arena. our review of the varied definitions and uses of the term There have been limited efforts to translate basic behav- “translational research” suggests one common element to ioral science findings into behavioral interventions across all formulations: the need for a more rapid and seamless fields (Czajkowski et al., 2016) and specifically in gerontol- movement from basic science to practice in some form, and ogy (Pillemer, Suitor, & Wethington, 2003; Wethington & always including both. Translational research necessarily Burgio, 2015). In a recent analysis, Callahan and colleagues includes a critical step: theory and basic research findings incisively sum up the progress in applying basic research to are directly employed to develop interventions and treat- problems of aging as follows: “Viewed from a scientist’s ments. For the purposes of our discussion here, we therefore perspective, our progress over the past century has been employ this definition of translational research on aging: astonishing. Viewed from the perspective of public health, Systematic translation of research findings from geron- our progress has been meandering, poorly integrated, tology into the development of innovative interventions imbalanced, with low impact, and high cost.” (Callahan that ultimately improve real-world practices and from et  al., 2014). There is considerable agreement that new interventions and practices back to basic research. models are needed to bridge this gap. This definition reflects the core component of most defi- Translational Research: Moving Basic nitions we have reviewed: a movement from basic science Science into Practice to practice in some form, but always including both. Also promoted in most discussions of translational research Over the past decade, vigorous academic discussion of is speeding up the process of translation and making it translational research has taken place (Westfall, Mold, intentional and systematic. Finally, translational research & Fagnan, 2007; Woolf, 2008). The term has taken on emphasizes a flow of knowledge in the reverse direction: particular importance through the embrace of the con- insights from practice can be used to generate research cept by the National Institutes of Health (Collins, 2011), questions and inform science, creating “practice-based evi- from which hundreds of millions of dollars have now been dence” (Green, 2008). invested in the Clinical and Translational Awards Program (Pincus, Abedin, Blank, & Mazmanian, 2013) as well as dozens of specific calls for translational research on vari- Families in Later Life: Fertile Ground for ous topics. Within the field of aging, the Edward R. Roybal Translation Centers were established by the National Institute on Aging in 1993 to facilitate the translation of theory and Although there are many priorities for translational basic research from the social and behavioral sciences into research within social gerontology, in this article we focus Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 3 on a particularly prominent area: family caregiving. Over (by our research group and others) on how different par- the past several decades, interest has increased in supporting ent–child dyads differ within families, no attempt has been individuals caring for frail older family members (Qualls, made to take a translational approach, asking: How can 2016). This concern is an outgrowth of extensive research these powerful findings regarding within-family differ - indicating that family caregivers are at elevated risk of a ences be applied to intervention to improve the lives of number of negative outcomes, including psychological older people and their families? More broadly, we hope distress, physical illness, and economic strain (Adelman, to shed light on the question: Can research that has up to Tmanova, Delgado, Dion, & Lachs, 2014). Such problems this point been largely of interest to academic specialists in are particularly acute among caregivers to persons suffer- a subfield of gerontology—parent–child relations in later ing from Alzheimer’s disease and related forms of dementia life—be extended such that they can guide intervention (Parker, Mills, & Abbey, 2008). Given the growth in the strategies? older population, as well as the association of advanced age with physical and mental disability, translational research Within-Family Differences: A New Paradigm is critically important to bring to bear scientific knowledge for Understanding Parent-Child Relations in on the development of interventions. Later Life Despite these pressing concerns, widespread use of the A goal of our basic research program on parent–child rela- translational research paradigm as outlined above are lack- tions is the integration of perspectives from developmental ing in the area of aging and family. In this article, we en- psychology and sociology to better understand family dorse translational approaches in gerontology and apply relationships. A  number of issues of burning interest to this perspective to our particular area of research expertise: developmental psychologists have been largely ignored by the study of within-family differences in later-life families. gerontologists. This gap may in part be due to the “alpha– We employ this area as a “test case” for using programs omega” split in studies of the family, in which there has of basic research as inspiration for intervention. We begin been relatively little permeation of insights derived from re- by summarizing major insights from our basic research search on families with young children into work on fami- program on within-family differences in later life, not- lies in later life (Fingerman & Bedford, 2000). One area in ing in particular findings that potentially relate to family which this gap is particularly evident is research on within- caregiving. We then adopt a “translational lens,” offering family differences. selected insights regarding how this new perspective could The study of within-family differences is grounded influence programs and practices involving the care of in classic theories of social interaction in both sociology older people by their adult offspring. (Simmel, 1964) and psychology (Heider, 1958), which can We focus on one crucial component of the translational be used to argue that the relationship between a parent and research process—moving basic research findings into ideas any one of his or her children is likely to be affected by for intervention—because it has received the least attention the parent’s relationships with other adult children in the in gerontology. In the field of caregiving specifically, basic family. The within-family approach also draws from two research on aging families rarely has been applied to care- other closely related theoretical perspectives—family sys- giver interventions. Instead, caregiver interventions typically tems theories (Bowen, 1978; Cox & Paley, 1997), which provide education, counseling, and concrete services (such focus on the interconnectedness of family ties and life as respite care) based on clinical observation or applied course theories (Elder, 1985, 1994; Conger & Elder, 1994) research about client needs. To the extent that caregiving that emphasize linked lives between family members both interventions are empirically based, the research is typically within and across generations. derived from studies of caregiver stress and burden, rather Within-family approaches have been used by develop- than basic research on the family. Considerable analysis has mental psychologists extensively to demonstrate that there taken place of the opportunities and challenges related to are differences in parent–child relations within families in translating caregiver interventions from randomized trials the early years. For example, studies have shown that par- to implementation in the community (Gitlin, Marx, Stanley, ents of young and adolescent children differentiate between & Hodgson, 2015; Wethington & Burgio, 2015). However, their offspring on a variety of relational dimensions, includ- virtually no attention has been paid to the core component ing affection, pride, disapproval, punishment, and time in- of translational research: using findings from basic research vestment. Furthermore, this line of research has shown that to inspire and design empirically based interventions. such within-family differences in parental responses often The goal of this article, therefore, is to shed light on have important consequences for children’s well-being the potential of translational research on caregiving by and achievement (Kowal, Kramer, Krull, & Crick, 2002; focusing on our own program of basic research on families Pillemer & Suitor, 2008; Shanahan, McHale, Crouter, & in later life. Over the past decade, we have employed an Osgood, 2008). innovative approach to the study of older parent—adult Despite the obvious significance of such research in child relations that emphasizes within-family differences. explaining both the causes and consequences of relationship Despite the accumulation of extensive empirical findings Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 4 Innovation in Aging, 2018, Vol. 00, No. 00 quality and well-being, these designs have received limited differentiation was related to higher depression scores attention in the literature on families later in life. This situ- among offspring. Suitor and colleagues (2015) focused on ation has improved in recent years through the work of perceived favoritism, finding that among middle-aged adult several research groups (Suitor et al., 2017). A major focus children depressive symptoms were also higher if they per- of this research has been on the topic of parental differen- ceived themselves as being the child in whom the mother tial treatment, which includes patterns of favoritism and was most disappointed. Peng, Suitor, and Gilligan (2016) disfavoritism toward individual offspring in the family. found that both recollections of parental differential treat- This growing body of research now has established that ment from childhood and perceptions of current parental parental differential treatment is prevalent in the second differential treatment predicted depressive symptoms. half of the parents’ life course, when offspring are adults. In sum, adoption of a within-family differences perspec- Studies have found compelling evidence of parents’ fa- tive provides a new lens for understanding families in later voritism (or disfavortism) toward particular children in life, with significant implications for issues of care provi- terms of relationship quality (e.g., closeness and conflict); sion and planning. Almost all investigations of helping by parents’ evaluations of their adult children (e.g., pride and adult children have used between-family designs, focus- disappointment) and provision and receipt of  emotional ing typically on a single child in the family. Comparisons support dimensions (Fingerman, Miller, Birditt, & Zarit, among all offspring have not been possible in these stud- 2009; Suitor, Sechrist, Plikuhn, Pardo, & Pillemer, 2008). ies. Fundamental to the within-family approach is the Further, research shows that patterns of differential treat- view that the characteristics of individual children and of ment are relatively stable across time (Suitor, Gilligan, & mother-child dyads will, relative to those of other children Pillemer, 2015). Taken together, the growing body of re- and dyads in the family, explain patterns of mothers’ selec- search on parental differential treatment indicates that this tion of a particular adult child. Taken together, this body phenomenon is common and enduring. of research findings represents a promising, but as a yet Of particular importance to the development of inter- untapped, source of innovative ideas for practice. ventions, patterns of parental differential treatment have well-documented detrimental effects on individuals and Translating Research on Within-Family relationships. Parental favoritism has been shown to influ- Differences to Family Caregiving ence negatively the quality of sibling relationships over the Interventions life course. In particular, the literature has demonstrated that in adulthood (as well as childhood and adolescence) Given the growing body of literature demonstrating the siblings feel and express less warmth and more hostility to- prevalence and consequences of within-family differences ward one another when a parent favors one child over oth- in later-life families, we believe that this phenomenon pro- ers (Boll, Ferring, & Filipp, 2003, 2005; Brody, Stoneman, vides an ideal “test case” to illustrate how a program of & McCoy, 1994; Gilligan, Suitor & Pillemer, 2013; Suitor basic research can be translated into testable ideas for pre- et al., 2009). Researchers using recollections of parental dif- vention and intervention efforts. To demonstrate this poten- ferential treatment have found that childhood memories of tial, in the remainder of this article we provide examples differential treatment were more strongly associated with of ways in which fundamental research on within-family sibling relationship quality than were current perceptions differences can inform programs designed to improve the (Suitor et  al., 2009, 2014). Taken together, the literature lives of older people and their family caregivers. Our goal demonstrates that siblings have worse relationships when is to make both a methodological and a substantive contri- they perceive that they are being treated unequally by their bution, by highlighting new avenues for intervention while parents. demonstrating how fundamental research can be applied A large body of work has also demonstrated the negative to practical problems of caregiving. Because our goal is to consequences of parental differential treatment on psycho- translate research on within-family differences in parent- logical well-being in childhood, adolescence, and early adult- child relations to intervention, we restrict our discussion to hood (Feinberg & Hetherington, 2001; Jensen et al., 2013; adult–child caregivers. McHale, Updegraff, Jackson-Newsom, Tucker, & Crouter, Hundreds of caregiver intervention programs have 2000; Richmond, Stocker, & Rienks, 2005; Shanahan been developed over the past 30  years, which can gener- et al., 2008; Young & Ehrenberg, 2007). Recently, this line ally be grouped into the following categories: psycho- of research has been extended to the exploration of par- educational, support, and multi-component. Interventions ental differential treatment and well-being when children are also categorized as either group or individual, with the are well into midlife (Davey, Tucker, Fingerman, & Savla, latter now being delivered increasingly through electronic 2009; Pillemer, Suitor, Pardo, & Henderson, 2010; Suitor means. Despite the diversity in the interventions employed, et  al., 2015, 2016). Pillemer and Suitor (2010) examined our review uncovered no programs that take into account actual and perceived maternal favoritism in the domains within-family differences in parent-child relations. That of closeness, expectations for care, and conflict. The find- is, programs are directed toward caregivers generically, ings indicated that, across all three domains, maternal rather than seeing them as embedded in a complex family Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 5 network. Indeed, the designs of most studies of caregiving the issue of preference for a caregiving offspring can have do not permit an examination of within-family differences, translational implications for intervention. as they almost invariably focus on a single older parent– In an analysis of the same data set, we focused on one child caregiver dyad (Koehly, Ashida, Schafer, & Ludden, component of the caregiver selection process—identifying 2014; Lingler, Sherwood, Crighton, Song, & Happ, 2008). the factors that lead to a mother’s selection of a particular In contrast, the within-family perspective calls for view- child whom she expects will become her caregiver when the ing each parent–child relationship as embedded in a net- need arises. This issue is of considerable importance, as a work of other intrafamilial relationships. Specifically, we mother’s expectations for the likely caregiver are likely to suggest that the relationship between a parent and any shape the actual course of caregiver selection as it unfolds particular adult child is likely to be affected by the par- over time (Pillemer & Suitor, 2014). We asked each mother ent’s relationships with other adult children in the family, to select which of her children would be most likely to care as well as by long-standing patterns of parental preference for her on a day-to-day basis if she became ill or disabled. and differential treatment. By translating these insights It should be noted that less than one-quarter of the mothers from basic research on the family, it may be possible to (23%) refused to differentiate among their children. When develop innovative caregiver interventions and fine-tune mothers did choose an expected caregiver, they did so most existing ones. Furthermore, in addition to the individual strongly based on gender similarity The odds of mothers outcomes typically assessed in most caregiving evaluations naming daughters were more than three and a half times (e.g., burden, mastery, and preparedness) a within-family greater than the odds of naming sons (the strongest pre- approach would allow for the assessment of additional dictor in the analysis). family-level outcomes (e.g., conflict, distance, or disagree- Two other variables were strongly associated with being ment in family relations). Below we offer four specific the child selected as the future caregiver: perceived simi- examples to highlight the ways in which the insights of larity in values and degree of emotional closeness. Both of basic research on within-family differences can be applied these factors represent socioemotional characteristics of to interventions to improve the intergenerational caregiv- parent-child relationships. In particular, emotional close- ing experience. ness is a relational dimension of parent-child relationships that reflects mothers’ perceptions of relationship quality with their adult children (Suitor et  al., 2016). Previous Who Cares? Within-Family Differences in research has shown that geographic proximity affects Caregiver Selection adult children’s availability to provide care to older par- Becoming a family caregiver represents a highly signifi- ents (Spitze, Ward, Deane, & Zhuo, 2012; Stuifbergen, van cant adjustment for adult offspring that affects physical Delden, & Dykstra, 2008). Consistent with this previous health, psychological well-being, and social relationships. work, we found that adult children who lived at a greater Although an extensive research base exists on the conse- distance were less likely to be named by their mothers as quences of caregiving, until recently, remarkably little was caregivers. Furthermore, children who were employed were known about a very important issue: the way in which one somewhat less likely to be named. Children who historic- offspring becomes the primary caregiver while his or her ally had provided more support to their mothers were more siblings do not. An example of the utility of the within- likely to be named as expected caregivers; however, chil- family differences perspective is its ability to shed light on dren who had received support from their mothers were no the issue of parental preference for a specific child as the more or less likely to be selected. caregiver and how expectations for care from offspring From these results, a profile appeared that is relevant to vary within the same family. intervention. Older mothers are most strongly influenced by The issue of mothers’ preferences for care from a specific factors representing similarity, comfort, and attachment, such child are not simply of academic interest. Suitor, Gilligan, as gender and value similarity, emotional closeness, geograph- and Pillemer (2011) used quantitative and qualitative data ical proximity, and the past provision of care from the child. from a sample of older mothers at two-time points (7 years Further, in contrast to prior literature (Silverstein, Conroy, apart). Mothers’ preference for a specific child as a care- Wang, Giarrusso, & Bengtson, 2002), mothers’ caregiving giver was recorded at Time 1.  At the Time 2 assessment, expectations were not influenced by the view that they are mothers who required and received care during the time owed care by children whom they have helped. Past exchange period identified the offspring who had helped them, mak- of help made a difference, but only in the sense that the child’s ing it possible to compare mothers who did or did not past provision of help made him or her appear qualified to receive care from the child they preferred. Mothers who continue. received care from children whom they had not identified Particularly notable were characteristics of children as their preferred caregivers reported increased depression that were not related to being chosen as the expected care- at Time 2.  Qualitative data revealed that the greater dis- giver. Measures of availability, such as the child’s marital tress was related to greater socioemotional incompatibil- or parental roles, did not affect mothers’ expectations. In ity with the non-preferred caregiver. Thus, understanding addition, mothers’ choices were not affected by the degree Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 6 Innovation in Aging, 2018, Vol. 00, No. 00 to which a child experienced major life problems (such as Third, the caregiving intervention literature emphasizes mental or physical illness, alcoholism, or trouble with the the need to maximize conditions in which caregiving is the law). Thus, the mothers did not emphasize characteristics of most beneficial to the recipient and least stressful for the children that might negatively affect their ability to provide caregiver (Suitor, Gilligan, & Pillemer, 2013). Developing care. For example, the presence of mental health and sub- ways in which families can follow an older parent’s prefer- stance abuse problems are likely diminish the capacity of ences for care should be a high priority for translational the child to be an effective caregiver. Indeed, these two fac- research. If such a “matching” of preferred and actual tors have been identified as important predictors of abusive caregiver is not possible, then interventions could amelior- caregiving situations (Lachs & Pillemer, 2015). Similarly, it ate the possible negative effects. Counseling interventions is likely that children’s family roles, such as parental status, should be tested that include open and honest discussion of would make them less able to take on parent care. Neither parental expectations for care, as well as methods to assist of these considerations emerged in either quantitative or parents and offspring in modifying long-standing fam- qualitative data analyses. ily roles and preferences. Although parental favoritism is We now turn to the implications of these findings for sometimes perceived as a taboo subject, the fact that moth- translational research on caregiving. First, the vast majority ers openly expressed preference for certain children over of mothers stated a clear choice for the child they expect to others regarding caregiving suggests that this issue can be care for them. Education of professionals who work with approached openly in care planning interventions. older people and their families would be useful to encourage and guide discussion of this topic, with the goal of avoiding Family-Based Caregiving Intervention: potential violated expectations and resulting family conflict. Considering the Family as a Unit As an example, mothers may expect care to continue from children who have helped them the past, assuming this fa- Most previous caregiving studies and interventions have miliar situation will continue. However, those offspring may focused exclusively either on the primary caregiver in the instead be operating under the norm of reciprocity, expect- family or on the caregiving dyad (i.e., the care recipient ing siblings to step in and “take their turn.” In addition to and one caregiver). However, as we have noted, caregiv- assessing mothers’ preferences and expectations, future ing is usually a “family affair,” negotiated among siblings. caregiving interventions should also include assessments As such, professionals who work with older adults should of adult children’s expectations regarding care provision. consider the larger family unit beyond the primary care- Discussions with service professionals with whom older giver, because parents’ relationships with other children adults and their families are likely to have contact (e.g., have implications for the overall caregiving experience. In counselors, medical professionals, social workers) could particular, although by the time they reach their eighties help prevent a potentially damaging discrepancy among the most parents have made the transition from caregiver to mothers’ expectations, those of her expected (but perhaps care recipient (Fingerman, Sechrist, & Birditt, 2013; Suitor, unwilling) caregiver, and those of siblings. Sechrist, Gilligan, & Pillemer, 2011), recent research using a Second, the complex interplay of mothers’ preferences within-family approach has demonstrated that parents con- and children’s desires and capabilities points to another tinue to provide some adult children with support late into route for intervention design. Specifically, there is a pressing the life course. In many cases, parents are providing support need to begin discussions of allocation of responsibilities to adult children who are experiencing medical, financial among adult children prior to the onset of care needs. Both and other life stressors (Fingerman, Cheng, Cichy, Birditt, & aging parents and adult children can benefit from discuss- Zarit, 2013; Gilligan, Suitor, Rurka, Con, & Pillemer, 2017). ing issues regarding future care with a variety of profes- A large body of research indicates that such situations sionals. Although such discussions often focus on formal may cause substantial distress for parents, due to their care and end of life planning, the within-family differences emotional stake in the normative development of their off- perspective argues for an exploration of expectations for spring and their anxiety regarding the well-being of the care and help from adult children, and the degree to which child (Fingerman et  al., 2013; Pillemer, Suitor, Riffin, & parental expectations align with the realities of family life Gilligan, 2017). Because of the emphasis on the stresses (Bromley & Blieszner, 1997). Given the finding that moth- incurred by adult children caring for parents, this reverse ers often consider future care from children and have clear pathway to parental distress may be ignored in practice preferences, such dialogue before the onset of caregiving settings. Clinicians who work with older adults should be needs may ameliorate the eventual stress of caregiving and aware of the possibility of ongoing dependency of adult improve the quality of family relationships. Family medi- offspring with serious problems, and that older parents ation interventions are a promising approach (Pinquart, may be providing support to these children while simultan- Sörensen, & Peak, 2005) that could be enhanced through eously receiving support from other children in the family. explicit discussion of within-family differences in parental Thus, assessing whether parents are receiving care from a preferences, adult children’s capacity and expectations and specific child may not adequately capture the complex sup- pre-existing patterns of assistance. port exchanges that are occurring in later-life families. Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 7 Instead of focusing only on the care recipient, clinicians parental differential treatment negatively affects sibling should also consider the differing needs and demands of relationships and psychological well-being across the life older adults’ offspring. This issue is very relevant for course (Suitor et al., 2009; Gilligan, Suitor, Kim, & Pillemer, professionals who work with older individuals in finan- 2013). Despite the fact that individuals tend to avoid con- cial planning and management, as substantial support flict and increase harmony in their relationships as they age to adult child may compromise the parent’s own eco- (Charles & Carstensen, 2008; Coats & Blanchard-Fields, nomic future (Grundy & Henretta, 2006; Remle, 2011). 2008; Lefkowitz & Fingerman, 2003), offspring have diffi- Understanding differential support patterns among adult culty ignoring their parents’ favoring particular siblings in children can be useful in determining the best use of the the family. Further, mothers’ favoritism reduces closeness older parent’s resources. regardless of which child was favored. Therapists should be aware of the negative consequences of parental differential treatment on sibling relations in adulthood, which may in Incorporating Within-Family Differences in Family turn affect care provision. Therapy Therapists should also be aware of the detrimental consequences of parental differential treatment on chil- Family therapy approaches are growing for caregivers, and dren’s psychological well-being across a variety of dimen- the within-family differences approach can help to inform sions (e.g., relational, evaluative and supportive) (Pillemer such interventions (Qualls, 2016; Walsh, 2016). Given that et al., 2010; Suitor, Gilligan, Peng, Jung, & Pillemer, 2015). within-family differences appear to intensify the negative Further, recent work suggests that when children perceive consequences of caregiving, ideally these family dynamics that they are preferred across multiple areas (e.g., close- should be addressed in family therapy prior to the care- ness, confiding, helping), parental favoritism has a greater giving context (Suitor et al., 2014). However, family thera- impact on well-being than does being favored for a single pists working with current caregivers must also be aware dimension. These consequences are greater for daughters of within-family differences and address these concerns in than sons (Suitor, Gilligan, Peng, & Ruka, in press). These addition to the family’s other needs. By addressing within- findings suggest that children’s perceptions of parental dif- family differences, family therapists may assist families in ferential treatment carry with them an emotional burden achieving a more optimal caregiving experience. that takes a toll on adult children’s psychological well- Family therapists are often trained to see the family being. These consequences might be alleviated if parents as an “emotional unit” (Bowen, 1978). As a result, these and children had the opportunity to discuss parents’ pref- professionals are inclined to address similarities and differ- erences and adult children’s reactions to these preferences ences in the experiences of individual family members and in a family therapy setting. the interconnectedness of family relationships. Thus, con- sidering a within-family perspective that explicitly assesses for and addresses parental preferences and differential Within-Family Differences Perspective as a treatment would be a natural extension to current family “Sensitizing Concept” therapy practice. We suggest that a first step for integrating a within-family difference perspective into current practice Beyond the concrete opportunities for intervention design would be to assess systematically long-standing patterns of we have proposed, there is another way in which the within- parental preferences and differential treatment. family perspective can help designers of caregiving inter- When making initial contact with families, therapists ventions and practitioners who work with caregivers and could incorporate questions that provide parents and adult care recipients. The concept of within-family differences children with an opportunity to describe their perceptions can be profitably used as a “sensitizing concept.” According of parental differential treatment. The high prevalence of to Blumer (1954) a sensitizing concept provides a general this phenomenon in the research findings suggests that this frame of reference and points toward possibly enlighten- is a common experience among families. For families strug- ing lines of inquiry, providing guidance in approaching a gling with issues related to sibling perceptions of unfairness particular phenomenon (Oddli, Nissen-Lie, & Halvorsen, or inequality, it may be reassuring to realize that such dif- 2016). In this case, professionals who work with caregivers ferentiation is normative rather than unusual. Therapists can be influenced by the general awareness of the impact should be aware, however, that adult children percep- of legacies of parental favoritism, varying expectations for tions of favoritism are not always consistent with parents’ children, and long-standing patterns of differential treat- reports (Suitor, Sechrist, Steinhour, & Pillemer, 2006). As a ment of offspring. result, it is important to consider multiple family members’ To give an example, both researchers and clinicians perceptions of within-family differences. Further, therapists frequently encounter typical responses when asking older may facilitate discussions among family members’ regard- parents about the quality of relationships with their chil- ing their multiple perceptions. dren in the aggregate: “I get  along with all my children,” Therapists may also assist families in managing the or “They’re all good kids.” Influenced by within-family consequences of within-family differences. As mentioned, differences as a sensitizing concept, a practitioner would Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 8 Innovation in Aging, 2018, Vol. 00, No. 00 continue the dialogue by asking detailed questions about experiences (Reczek, 2014). Conducting rigorous evalu- the quality of relationship with each individual child. ation is necessary to establish whether interventions based Similarly, rather than focusing only on the child identified on within-family perspectives are effective in improving as the primary caregiver, a professional leading a care plan- the caregiving experience for both care recipients and care ning discussion would sensitively probe about differential providers. expectations and histories with the other siblings in the Finally, caregiving research can be further enhanced family. Exploring the parent’s expectations and preferences by incorporating a translational research paradigm into for care not only from formal sources, but also among his intervention work. Specifically, a number of analysts have or her offspring, using this lens becomes an essential com- noted that a key translational problem exists in the micro- ponent of the discussion. level: how can dialogue be increased and improved be- tween researchers and practitioners (Bartunek and Rynes, 2014)? Following a translational model, we hold that Discussion practitioners, who are the eventual end-users of research, The within-family differences approach calls for consid- should be engaged as partners in in establishing research ering each individual parent-child dyad as embedded in priorities. Gerontological researchers should intention- a complex network of other dyadic parent-child relation- ally and systematically include the knowledge and exper- ships. Therefore, a parent’s relationship with a particular tise of clinicians who work with families when designing adult child will be affected by the parent’s relationships research. A  number of methods are now available to fa- with offspring in the same family. This perspective more cilitate researcher-practitioner collaboration, including accurately reflects the complex reality of families in the community-based participatory research methods (Minkler second half of life, moving gerontological research closer & Wallerstein, 2008) and consensus-building methods that to the lived experience older parents and their children promote knowledge translation having participants to re- (Pillemer et al., 2007). To highlight the ways in which the flect on research-based knowledge and how it might im- insights of basic research can be applied to interventions prove practice (Sabir et  al., 2006; Pillemer, et  al., 2015). to improve the intergenerational caregiving experience we Applying such approaches to the issue of within-family dif- provided four specific examples how a within-family dif- ferences could facilitate the uptake of translational research ferences approach can be applied to caregiver selection, programs and findings. family-based caregiving, family therapy and as a sensitizing Finally, at its core, translational research means exploit- concept. ing existing basic research findings to create better inter - Beyond our substantive suggestions, using within-fam- ventions to solve human problems. Many interventions in ily perspectives also has implications for the evaluation of the field of gerontology—including caregiver support pro- caregiving interventions. The evidence for current interven- grams—are based on practical experience and clinical ob- tions overall is mixed, with few studies employing rigorous servation. In no way do we call into question the utility of research designs sufficient to evaluate them as evidence- such interventions, and arguments can be made for placing based. A  number of systematic reviews have been con- major emphasis on the real-world insights of practition- ducted over the past decade, relying on the relatively small ers in developing solutions to human problems (Pillemer, number of studies that have employed adequate research Suitor, & Wethington, 2003). designs (such as employing randomized, controlled design We would argue, however, that social theories about methodology and involving adequately powered samples). human behavior and the basic research that emerges from The results are at best equivocal, with limited support for these theories create unique opportunities for intervention effectiveness of many interventions, and uncertain clinical design. Fundamental, curiosity-based research brings a per- significance of outcomes that were found to be statistically spective that transcends individual cases and points toward significant (Thompson et al., 2007). innovations. Translation from basic research helps avoid The evidence we have provided in this article on within- one potential danger: that relying only on practical experi- family differences suggests that intervention research could ence in program design will lead simply to fine-tuning cur - be strengthened by collecting and analyzing data from mul- rent practices. Interventions based on clinical impression or tiple family members. Evaluators should take advantage of practice wisdom may miss important avenues for personal multilevel modeling techniques to assess the outcomes of or organizational change. In this article, we have argued multiple family members. In particular, newly developed that attention to basic science on within-family differences group actor-partner interdependence models (Kenny & can move the field away from individual-level interventions Garcia, 2012) would allow researchers to consider both for caregivers to whole-family approaches. individual characteristics (e.g., gender, preparedness, and Based on the examples we have provided above, we burden) and group level characteristics of the family net- believe that the optimal environment for intervention is work (e.g., harmony and discord). Further, collecting quali- the interplay between the grounded experience of human tative data from parents and adult children would allow for needs offered by clinicians and social scientists’ attention to evaluation of multiple family members’ perspectives and theory and basic research. We propose that collaboration Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 9 Coats, A. H., & Blanchard-Fields, F. (2008). Emotion regulation in between researchers and clinicians who specialize in identi- interpersonal problems: the role of cognitive-emotional com- fying and intervening in problems of caregivers can ultim- plexity, emotion regulation goals, and expressivity. Psychology ately bring about a balance between these perspectives. and Aging, 23, 39–51. doi:10.1037/0882-7974.23.1.39 This interaction can accomplish the foundational goal of Collins, F. S. (2011). Reengineering translational science: the time is translational research: to create a better marriage of science right. 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Translating Basic Research on the Aging Family to Caregiving Intervention: The Case of Within-Family Differences

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Abstract

Since its inception, the field of gerontology has sought to establish optimal connections between the scientific activities of researchers and the real-world concerns of practitioners and clinicians. The concept of translational research has emerged in recent years as a model for bridging the gap between science and service. This article provides an example of how basic research findings can be translated to provide guidance for intervention in the area of family caregiving. We review find- ings from an innovative program of research on within-family differences, which extends theory and research from the developmental psychological study of children to the family in later life. The within-family difference perspective focuses on how the individual parent–child dyads in a particular family differ from and are affected by other dyads. Basic research on this topic has revealed the extent of parental favoritism in later life, factors related to parental differential treatment of offspring, and the consequences of such favoritism and treatment on sibling relationship quality and psychological well-being. Four examples are provided of ways in which attention to within-family differences research could enhance caregiving interventions. Translational Significance: This article provides an example of the translational research process, demonstrating how a body of basic research can be mined for insights that can guide intervention. A focus on within-family differences in older parent—adult– child relationships suggests how existing caregiving interventions could be adapted or fine-tuned to take advantage of empirical insights regarding family complexity. Keywords: Caregiver intervention, Translational models, Parental favoritism, Parental differential treatment, family, Parent–adult child relations Since its origins as an organized discipline, gerontology has and practice should ideally intersect in gerontology. As evi- been deeply engaged with the question: What is the optimal dence of this fact, we point to a very contemporary-sounding relationship between research on aging and the real-life prob- statement of the problem, penned over a half century ago. lems of older people and their families? The field has always In 1961, Geneva Mathiasen (1961) offered an analysis in included both scientists and helping professionals, which has the first volume of a brand new journal, The Gerontologist. led to ongoing concerns about the way in which basic research She noted: © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. 1 This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user journals.permissions@oup.com on 16 March 2018 Copyedited by: SU 2 Innovation in Aging, 2018, Vol. 00, No. 00 There is a growing conviction of many persons working applied research, interventions, and programs to improve in social aspects of aging of the need for a closer re- quality of life, productivity, and health of older people (Pillemer et al., 2003). lationship between individuals engaged in research and In clarifying the focus of translational research, it is use- those engaged in practice. There has been … a some- ful to ask “What is the principal problem that translational times subtle, sometimes blunt, assumption of hierarchy, research trying to solve?” As suggested in the introduction with the practitioners at the lower end of the order… to this article, we believe that the most pressing problem The practical result has been to separate those with an is the too-distant relationship between fundamental scien- academic orientation and primary research interest from tific discoveries in the field of aging and the life course on those primarily engaged in the field of practice. the one hand, and attempts to address the challenges of Mathiasen went on to identify the key problem: “the later life on the other. Over the past several decades, there researchers believe that much of the work with older has been tremendous growth in basic research in geriat- people is based on unproved assumptions,” whereas “prac- rics and gerontology. At the same time, on the practice titioners refer to research studies as instruments to prove level, programs have proliferated to assist older persons in statistically what every good practitioner already knows.” various domains of life. However, the expansion in both She concludes that the need for: “a device for better com- fields has made increasingly obvious the lack of connection munication and even collaboration seems apparent.” between them. In particular, insights from basic research Given this call to arms from over 50 years ago, how suc- are rarely used systematically to guide the development of cessful have we been in bridging the gap between science and new programs. An argument for translational research is service in our field? Unquestionably, the search for “a device the length of time it takes for a fundamental research dis- for better communication and even collaboration” has con- covery to move into a treatment or therapy. This lag has tinued. Despite advances, however, the need clearly exists for been estimated as approximately 17 years for research evi- better translation among the activities of fundamental scien- dence to reach clinical practice (Westfall et al., 2007), and tific discovery in gerontology and geriatrics, the development much basic research is never transferred into practical use of effective treatments and interventions, and their eventual (Institute of Medicine, 2001). adoption by practitioners in the community, long-term care Despite an ongoing debate over its precise definition, facilities, health care settings, and in the policy arena. our review of the varied definitions and uses of the term There have been limited efforts to translate basic behav- “translational research” suggests one common element to ioral science findings into behavioral interventions across all formulations: the need for a more rapid and seamless fields (Czajkowski et al., 2016) and specifically in gerontol- movement from basic science to practice in some form, and ogy (Pillemer, Suitor, & Wethington, 2003; Wethington & always including both. Translational research necessarily Burgio, 2015). In a recent analysis, Callahan and colleagues includes a critical step: theory and basic research findings incisively sum up the progress in applying basic research to are directly employed to develop interventions and treat- problems of aging as follows: “Viewed from a scientist’s ments. For the purposes of our discussion here, we therefore perspective, our progress over the past century has been employ this definition of translational research on aging: astonishing. Viewed from the perspective of public health, Systematic translation of research findings from geron- our progress has been meandering, poorly integrated, tology into the development of innovative interventions imbalanced, with low impact, and high cost.” (Callahan that ultimately improve real-world practices and from et  al., 2014). There is considerable agreement that new interventions and practices back to basic research. models are needed to bridge this gap. This definition reflects the core component of most defi- Translational Research: Moving Basic nitions we have reviewed: a movement from basic science Science into Practice to practice in some form, but always including both. Also promoted in most discussions of translational research Over the past decade, vigorous academic discussion of is speeding up the process of translation and making it translational research has taken place (Westfall, Mold, intentional and systematic. Finally, translational research & Fagnan, 2007; Woolf, 2008). The term has taken on emphasizes a flow of knowledge in the reverse direction: particular importance through the embrace of the con- insights from practice can be used to generate research cept by the National Institutes of Health (Collins, 2011), questions and inform science, creating “practice-based evi- from which hundreds of millions of dollars have now been dence” (Green, 2008). invested in the Clinical and Translational Awards Program (Pincus, Abedin, Blank, & Mazmanian, 2013) as well as dozens of specific calls for translational research on vari- Families in Later Life: Fertile Ground for ous topics. Within the field of aging, the Edward R. Roybal Translation Centers were established by the National Institute on Aging in 1993 to facilitate the translation of theory and Although there are many priorities for translational basic research from the social and behavioral sciences into research within social gerontology, in this article we focus Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 3 on a particularly prominent area: family caregiving. Over (by our research group and others) on how different par- the past several decades, interest has increased in supporting ent–child dyads differ within families, no attempt has been individuals caring for frail older family members (Qualls, made to take a translational approach, asking: How can 2016). This concern is an outgrowth of extensive research these powerful findings regarding within-family differ - indicating that family caregivers are at elevated risk of a ences be applied to intervention to improve the lives of number of negative outcomes, including psychological older people and their families? More broadly, we hope distress, physical illness, and economic strain (Adelman, to shed light on the question: Can research that has up to Tmanova, Delgado, Dion, & Lachs, 2014). Such problems this point been largely of interest to academic specialists in are particularly acute among caregivers to persons suffer- a subfield of gerontology—parent–child relations in later ing from Alzheimer’s disease and related forms of dementia life—be extended such that they can guide intervention (Parker, Mills, & Abbey, 2008). Given the growth in the strategies? older population, as well as the association of advanced age with physical and mental disability, translational research Within-Family Differences: A New Paradigm is critically important to bring to bear scientific knowledge for Understanding Parent-Child Relations in on the development of interventions. Later Life Despite these pressing concerns, widespread use of the A goal of our basic research program on parent–child rela- translational research paradigm as outlined above are lack- tions is the integration of perspectives from developmental ing in the area of aging and family. In this article, we en- psychology and sociology to better understand family dorse translational approaches in gerontology and apply relationships. A  number of issues of burning interest to this perspective to our particular area of research expertise: developmental psychologists have been largely ignored by the study of within-family differences in later-life families. gerontologists. This gap may in part be due to the “alpha– We employ this area as a “test case” for using programs omega” split in studies of the family, in which there has of basic research as inspiration for intervention. We begin been relatively little permeation of insights derived from re- by summarizing major insights from our basic research search on families with young children into work on fami- program on within-family differences in later life, not- lies in later life (Fingerman & Bedford, 2000). One area in ing in particular findings that potentially relate to family which this gap is particularly evident is research on within- caregiving. We then adopt a “translational lens,” offering family differences. selected insights regarding how this new perspective could The study of within-family differences is grounded influence programs and practices involving the care of in classic theories of social interaction in both sociology older people by their adult offspring. (Simmel, 1964) and psychology (Heider, 1958), which can We focus on one crucial component of the translational be used to argue that the relationship between a parent and research process—moving basic research findings into ideas any one of his or her children is likely to be affected by for intervention—because it has received the least attention the parent’s relationships with other adult children in the in gerontology. In the field of caregiving specifically, basic family. The within-family approach also draws from two research on aging families rarely has been applied to care- other closely related theoretical perspectives—family sys- giver interventions. Instead, caregiver interventions typically tems theories (Bowen, 1978; Cox & Paley, 1997), which provide education, counseling, and concrete services (such focus on the interconnectedness of family ties and life as respite care) based on clinical observation or applied course theories (Elder, 1985, 1994; Conger & Elder, 1994) research about client needs. To the extent that caregiving that emphasize linked lives between family members both interventions are empirically based, the research is typically within and across generations. derived from studies of caregiver stress and burden, rather Within-family approaches have been used by develop- than basic research on the family. Considerable analysis has mental psychologists extensively to demonstrate that there taken place of the opportunities and challenges related to are differences in parent–child relations within families in translating caregiver interventions from randomized trials the early years. For example, studies have shown that par- to implementation in the community (Gitlin, Marx, Stanley, ents of young and adolescent children differentiate between & Hodgson, 2015; Wethington & Burgio, 2015). However, their offspring on a variety of relational dimensions, includ- virtually no attention has been paid to the core component ing affection, pride, disapproval, punishment, and time in- of translational research: using findings from basic research vestment. Furthermore, this line of research has shown that to inspire and design empirically based interventions. such within-family differences in parental responses often The goal of this article, therefore, is to shed light on have important consequences for children’s well-being the potential of translational research on caregiving by and achievement (Kowal, Kramer, Krull, & Crick, 2002; focusing on our own program of basic research on families Pillemer & Suitor, 2008; Shanahan, McHale, Crouter, & in later life. Over the past decade, we have employed an Osgood, 2008). innovative approach to the study of older parent—adult Despite the obvious significance of such research in child relations that emphasizes within-family differences. explaining both the causes and consequences of relationship Despite the accumulation of extensive empirical findings Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 4 Innovation in Aging, 2018, Vol. 00, No. 00 quality and well-being, these designs have received limited differentiation was related to higher depression scores attention in the literature on families later in life. This situ- among offspring. Suitor and colleagues (2015) focused on ation has improved in recent years through the work of perceived favoritism, finding that among middle-aged adult several research groups (Suitor et al., 2017). A major focus children depressive symptoms were also higher if they per- of this research has been on the topic of parental differen- ceived themselves as being the child in whom the mother tial treatment, which includes patterns of favoritism and was most disappointed. Peng, Suitor, and Gilligan (2016) disfavoritism toward individual offspring in the family. found that both recollections of parental differential treat- This growing body of research now has established that ment from childhood and perceptions of current parental parental differential treatment is prevalent in the second differential treatment predicted depressive symptoms. half of the parents’ life course, when offspring are adults. In sum, adoption of a within-family differences perspec- Studies have found compelling evidence of parents’ fa- tive provides a new lens for understanding families in later voritism (or disfavortism) toward particular children in life, with significant implications for issues of care provi- terms of relationship quality (e.g., closeness and conflict); sion and planning. Almost all investigations of helping by parents’ evaluations of their adult children (e.g., pride and adult children have used between-family designs, focus- disappointment) and provision and receipt of  emotional ing typically on a single child in the family. Comparisons support dimensions (Fingerman, Miller, Birditt, & Zarit, among all offspring have not been possible in these stud- 2009; Suitor, Sechrist, Plikuhn, Pardo, & Pillemer, 2008). ies. Fundamental to the within-family approach is the Further, research shows that patterns of differential treat- view that the characteristics of individual children and of ment are relatively stable across time (Suitor, Gilligan, & mother-child dyads will, relative to those of other children Pillemer, 2015). Taken together, the growing body of re- and dyads in the family, explain patterns of mothers’ selec- search on parental differential treatment indicates that this tion of a particular adult child. Taken together, this body phenomenon is common and enduring. of research findings represents a promising, but as a yet Of particular importance to the development of inter- untapped, source of innovative ideas for practice. ventions, patterns of parental differential treatment have well-documented detrimental effects on individuals and Translating Research on Within-Family relationships. Parental favoritism has been shown to influ- Differences to Family Caregiving ence negatively the quality of sibling relationships over the Interventions life course. In particular, the literature has demonstrated that in adulthood (as well as childhood and adolescence) Given the growing body of literature demonstrating the siblings feel and express less warmth and more hostility to- prevalence and consequences of within-family differences ward one another when a parent favors one child over oth- in later-life families, we believe that this phenomenon pro- ers (Boll, Ferring, & Filipp, 2003, 2005; Brody, Stoneman, vides an ideal “test case” to illustrate how a program of & McCoy, 1994; Gilligan, Suitor & Pillemer, 2013; Suitor basic research can be translated into testable ideas for pre- et al., 2009). Researchers using recollections of parental dif- vention and intervention efforts. To demonstrate this poten- ferential treatment have found that childhood memories of tial, in the remainder of this article we provide examples differential treatment were more strongly associated with of ways in which fundamental research on within-family sibling relationship quality than were current perceptions differences can inform programs designed to improve the (Suitor et  al., 2009, 2014). Taken together, the literature lives of older people and their family caregivers. Our goal demonstrates that siblings have worse relationships when is to make both a methodological and a substantive contri- they perceive that they are being treated unequally by their bution, by highlighting new avenues for intervention while parents. demonstrating how fundamental research can be applied A large body of work has also demonstrated the negative to practical problems of caregiving. Because our goal is to consequences of parental differential treatment on psycho- translate research on within-family differences in parent- logical well-being in childhood, adolescence, and early adult- child relations to intervention, we restrict our discussion to hood (Feinberg & Hetherington, 2001; Jensen et al., 2013; adult–child caregivers. McHale, Updegraff, Jackson-Newsom, Tucker, & Crouter, Hundreds of caregiver intervention programs have 2000; Richmond, Stocker, & Rienks, 2005; Shanahan been developed over the past 30  years, which can gener- et al., 2008; Young & Ehrenberg, 2007). Recently, this line ally be grouped into the following categories: psycho- of research has been extended to the exploration of par- educational, support, and multi-component. Interventions ental differential treatment and well-being when children are also categorized as either group or individual, with the are well into midlife (Davey, Tucker, Fingerman, & Savla, latter now being delivered increasingly through electronic 2009; Pillemer, Suitor, Pardo, & Henderson, 2010; Suitor means. Despite the diversity in the interventions employed, et  al., 2015, 2016). Pillemer and Suitor (2010) examined our review uncovered no programs that take into account actual and perceived maternal favoritism in the domains within-family differences in parent-child relations. That of closeness, expectations for care, and conflict. The find- is, programs are directed toward caregivers generically, ings indicated that, across all three domains, maternal rather than seeing them as embedded in a complex family Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 5 network. Indeed, the designs of most studies of caregiving the issue of preference for a caregiving offspring can have do not permit an examination of within-family differences, translational implications for intervention. as they almost invariably focus on a single older parent– In an analysis of the same data set, we focused on one child caregiver dyad (Koehly, Ashida, Schafer, & Ludden, component of the caregiver selection process—identifying 2014; Lingler, Sherwood, Crighton, Song, & Happ, 2008). the factors that lead to a mother’s selection of a particular In contrast, the within-family perspective calls for view- child whom she expects will become her caregiver when the ing each parent–child relationship as embedded in a net- need arises. This issue is of considerable importance, as a work of other intrafamilial relationships. Specifically, we mother’s expectations for the likely caregiver are likely to suggest that the relationship between a parent and any shape the actual course of caregiver selection as it unfolds particular adult child is likely to be affected by the par- over time (Pillemer & Suitor, 2014). We asked each mother ent’s relationships with other adult children in the family, to select which of her children would be most likely to care as well as by long-standing patterns of parental preference for her on a day-to-day basis if she became ill or disabled. and differential treatment. By translating these insights It should be noted that less than one-quarter of the mothers from basic research on the family, it may be possible to (23%) refused to differentiate among their children. When develop innovative caregiver interventions and fine-tune mothers did choose an expected caregiver, they did so most existing ones. Furthermore, in addition to the individual strongly based on gender similarity The odds of mothers outcomes typically assessed in most caregiving evaluations naming daughters were more than three and a half times (e.g., burden, mastery, and preparedness) a within-family greater than the odds of naming sons (the strongest pre- approach would allow for the assessment of additional dictor in the analysis). family-level outcomes (e.g., conflict, distance, or disagree- Two other variables were strongly associated with being ment in family relations). Below we offer four specific the child selected as the future caregiver: perceived simi- examples to highlight the ways in which the insights of larity in values and degree of emotional closeness. Both of basic research on within-family differences can be applied these factors represent socioemotional characteristics of to interventions to improve the intergenerational caregiv- parent-child relationships. In particular, emotional close- ing experience. ness is a relational dimension of parent-child relationships that reflects mothers’ perceptions of relationship quality with their adult children (Suitor et  al., 2016). Previous Who Cares? Within-Family Differences in research has shown that geographic proximity affects Caregiver Selection adult children’s availability to provide care to older par- Becoming a family caregiver represents a highly signifi- ents (Spitze, Ward, Deane, & Zhuo, 2012; Stuifbergen, van cant adjustment for adult offspring that affects physical Delden, & Dykstra, 2008). Consistent with this previous health, psychological well-being, and social relationships. work, we found that adult children who lived at a greater Although an extensive research base exists on the conse- distance were less likely to be named by their mothers as quences of caregiving, until recently, remarkably little was caregivers. Furthermore, children who were employed were known about a very important issue: the way in which one somewhat less likely to be named. Children who historic- offspring becomes the primary caregiver while his or her ally had provided more support to their mothers were more siblings do not. An example of the utility of the within- likely to be named as expected caregivers; however, chil- family differences perspective is its ability to shed light on dren who had received support from their mothers were no the issue of parental preference for a specific child as the more or less likely to be selected. caregiver and how expectations for care from offspring From these results, a profile appeared that is relevant to vary within the same family. intervention. Older mothers are most strongly influenced by The issue of mothers’ preferences for care from a specific factors representing similarity, comfort, and attachment, such child are not simply of academic interest. Suitor, Gilligan, as gender and value similarity, emotional closeness, geograph- and Pillemer (2011) used quantitative and qualitative data ical proximity, and the past provision of care from the child. from a sample of older mothers at two-time points (7 years Further, in contrast to prior literature (Silverstein, Conroy, apart). Mothers’ preference for a specific child as a care- Wang, Giarrusso, & Bengtson, 2002), mothers’ caregiving giver was recorded at Time 1.  At the Time 2 assessment, expectations were not influenced by the view that they are mothers who required and received care during the time owed care by children whom they have helped. Past exchange period identified the offspring who had helped them, mak- of help made a difference, but only in the sense that the child’s ing it possible to compare mothers who did or did not past provision of help made him or her appear qualified to receive care from the child they preferred. Mothers who continue. received care from children whom they had not identified Particularly notable were characteristics of children as their preferred caregivers reported increased depression that were not related to being chosen as the expected care- at Time 2.  Qualitative data revealed that the greater dis- giver. Measures of availability, such as the child’s marital tress was related to greater socioemotional incompatibil- or parental roles, did not affect mothers’ expectations. In ity with the non-preferred caregiver. Thus, understanding addition, mothers’ choices were not affected by the degree Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 6 Innovation in Aging, 2018, Vol. 00, No. 00 to which a child experienced major life problems (such as Third, the caregiving intervention literature emphasizes mental or physical illness, alcoholism, or trouble with the the need to maximize conditions in which caregiving is the law). Thus, the mothers did not emphasize characteristics of most beneficial to the recipient and least stressful for the children that might negatively affect their ability to provide caregiver (Suitor, Gilligan, & Pillemer, 2013). Developing care. For example, the presence of mental health and sub- ways in which families can follow an older parent’s prefer- stance abuse problems are likely diminish the capacity of ences for care should be a high priority for translational the child to be an effective caregiver. Indeed, these two fac- research. If such a “matching” of preferred and actual tors have been identified as important predictors of abusive caregiver is not possible, then interventions could amelior- caregiving situations (Lachs & Pillemer, 2015). Similarly, it ate the possible negative effects. Counseling interventions is likely that children’s family roles, such as parental status, should be tested that include open and honest discussion of would make them less able to take on parent care. Neither parental expectations for care, as well as methods to assist of these considerations emerged in either quantitative or parents and offspring in modifying long-standing fam- qualitative data analyses. ily roles and preferences. Although parental favoritism is We now turn to the implications of these findings for sometimes perceived as a taboo subject, the fact that moth- translational research on caregiving. First, the vast majority ers openly expressed preference for certain children over of mothers stated a clear choice for the child they expect to others regarding caregiving suggests that this issue can be care for them. Education of professionals who work with approached openly in care planning interventions. older people and their families would be useful to encourage and guide discussion of this topic, with the goal of avoiding Family-Based Caregiving Intervention: potential violated expectations and resulting family conflict. Considering the Family as a Unit As an example, mothers may expect care to continue from children who have helped them the past, assuming this fa- Most previous caregiving studies and interventions have miliar situation will continue. However, those offspring may focused exclusively either on the primary caregiver in the instead be operating under the norm of reciprocity, expect- family or on the caregiving dyad (i.e., the care recipient ing siblings to step in and “take their turn.” In addition to and one caregiver). However, as we have noted, caregiv- assessing mothers’ preferences and expectations, future ing is usually a “family affair,” negotiated among siblings. caregiving interventions should also include assessments As such, professionals who work with older adults should of adult children’s expectations regarding care provision. consider the larger family unit beyond the primary care- Discussions with service professionals with whom older giver, because parents’ relationships with other children adults and their families are likely to have contact (e.g., have implications for the overall caregiving experience. In counselors, medical professionals, social workers) could particular, although by the time they reach their eighties help prevent a potentially damaging discrepancy among the most parents have made the transition from caregiver to mothers’ expectations, those of her expected (but perhaps care recipient (Fingerman, Sechrist, & Birditt, 2013; Suitor, unwilling) caregiver, and those of siblings. Sechrist, Gilligan, & Pillemer, 2011), recent research using a Second, the complex interplay of mothers’ preferences within-family approach has demonstrated that parents con- and children’s desires and capabilities points to another tinue to provide some adult children with support late into route for intervention design. Specifically, there is a pressing the life course. In many cases, parents are providing support need to begin discussions of allocation of responsibilities to adult children who are experiencing medical, financial among adult children prior to the onset of care needs. Both and other life stressors (Fingerman, Cheng, Cichy, Birditt, & aging parents and adult children can benefit from discuss- Zarit, 2013; Gilligan, Suitor, Rurka, Con, & Pillemer, 2017). ing issues regarding future care with a variety of profes- A large body of research indicates that such situations sionals. Although such discussions often focus on formal may cause substantial distress for parents, due to their care and end of life planning, the within-family differences emotional stake in the normative development of their off- perspective argues for an exploration of expectations for spring and their anxiety regarding the well-being of the care and help from adult children, and the degree to which child (Fingerman et  al., 2013; Pillemer, Suitor, Riffin, & parental expectations align with the realities of family life Gilligan, 2017). Because of the emphasis on the stresses (Bromley & Blieszner, 1997). Given the finding that moth- incurred by adult children caring for parents, this reverse ers often consider future care from children and have clear pathway to parental distress may be ignored in practice preferences, such dialogue before the onset of caregiving settings. Clinicians who work with older adults should be needs may ameliorate the eventual stress of caregiving and aware of the possibility of ongoing dependency of adult improve the quality of family relationships. Family medi- offspring with serious problems, and that older parents ation interventions are a promising approach (Pinquart, may be providing support to these children while simultan- Sörensen, & Peak, 2005) that could be enhanced through eously receiving support from other children in the family. explicit discussion of within-family differences in parental Thus, assessing whether parents are receiving care from a preferences, adult children’s capacity and expectations and specific child may not adequately capture the complex sup- pre-existing patterns of assistance. port exchanges that are occurring in later-life families. Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 7 Instead of focusing only on the care recipient, clinicians parental differential treatment negatively affects sibling should also consider the differing needs and demands of relationships and psychological well-being across the life older adults’ offspring. This issue is very relevant for course (Suitor et al., 2009; Gilligan, Suitor, Kim, & Pillemer, professionals who work with older individuals in finan- 2013). Despite the fact that individuals tend to avoid con- cial planning and management, as substantial support flict and increase harmony in their relationships as they age to adult child may compromise the parent’s own eco- (Charles & Carstensen, 2008; Coats & Blanchard-Fields, nomic future (Grundy & Henretta, 2006; Remle, 2011). 2008; Lefkowitz & Fingerman, 2003), offspring have diffi- Understanding differential support patterns among adult culty ignoring their parents’ favoring particular siblings in children can be useful in determining the best use of the the family. Further, mothers’ favoritism reduces closeness older parent’s resources. regardless of which child was favored. Therapists should be aware of the negative consequences of parental differential treatment on sibling relations in adulthood, which may in Incorporating Within-Family Differences in Family turn affect care provision. Therapy Therapists should also be aware of the detrimental consequences of parental differential treatment on chil- Family therapy approaches are growing for caregivers, and dren’s psychological well-being across a variety of dimen- the within-family differences approach can help to inform sions (e.g., relational, evaluative and supportive) (Pillemer such interventions (Qualls, 2016; Walsh, 2016). Given that et al., 2010; Suitor, Gilligan, Peng, Jung, & Pillemer, 2015). within-family differences appear to intensify the negative Further, recent work suggests that when children perceive consequences of caregiving, ideally these family dynamics that they are preferred across multiple areas (e.g., close- should be addressed in family therapy prior to the care- ness, confiding, helping), parental favoritism has a greater giving context (Suitor et al., 2014). However, family thera- impact on well-being than does being favored for a single pists working with current caregivers must also be aware dimension. These consequences are greater for daughters of within-family differences and address these concerns in than sons (Suitor, Gilligan, Peng, & Ruka, in press). These addition to the family’s other needs. By addressing within- findings suggest that children’s perceptions of parental dif- family differences, family therapists may assist families in ferential treatment carry with them an emotional burden achieving a more optimal caregiving experience. that takes a toll on adult children’s psychological well- Family therapists are often trained to see the family being. These consequences might be alleviated if parents as an “emotional unit” (Bowen, 1978). As a result, these and children had the opportunity to discuss parents’ pref- professionals are inclined to address similarities and differ- erences and adult children’s reactions to these preferences ences in the experiences of individual family members and in a family therapy setting. the interconnectedness of family relationships. Thus, con- sidering a within-family perspective that explicitly assesses for and addresses parental preferences and differential Within-Family Differences Perspective as a treatment would be a natural extension to current family “Sensitizing Concept” therapy practice. We suggest that a first step for integrating a within-family difference perspective into current practice Beyond the concrete opportunities for intervention design would be to assess systematically long-standing patterns of we have proposed, there is another way in which the within- parental preferences and differential treatment. family perspective can help designers of caregiving inter- When making initial contact with families, therapists ventions and practitioners who work with caregivers and could incorporate questions that provide parents and adult care recipients. The concept of within-family differences children with an opportunity to describe their perceptions can be profitably used as a “sensitizing concept.” According of parental differential treatment. The high prevalence of to Blumer (1954) a sensitizing concept provides a general this phenomenon in the research findings suggests that this frame of reference and points toward possibly enlighten- is a common experience among families. For families strug- ing lines of inquiry, providing guidance in approaching a gling with issues related to sibling perceptions of unfairness particular phenomenon (Oddli, Nissen-Lie, & Halvorsen, or inequality, it may be reassuring to realize that such dif- 2016). In this case, professionals who work with caregivers ferentiation is normative rather than unusual. Therapists can be influenced by the general awareness of the impact should be aware, however, that adult children percep- of legacies of parental favoritism, varying expectations for tions of favoritism are not always consistent with parents’ children, and long-standing patterns of differential treat- reports (Suitor, Sechrist, Steinhour, & Pillemer, 2006). As a ment of offspring. result, it is important to consider multiple family members’ To give an example, both researchers and clinicians perceptions of within-family differences. Further, therapists frequently encounter typical responses when asking older may facilitate discussions among family members’ regard- parents about the quality of relationships with their chil- ing their multiple perceptions. dren in the aggregate: “I get  along with all my children,” Therapists may also assist families in managing the or “They’re all good kids.” Influenced by within-family consequences of within-family differences. As mentioned, differences as a sensitizing concept, a practitioner would Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU 8 Innovation in Aging, 2018, Vol. 00, No. 00 continue the dialogue by asking detailed questions about experiences (Reczek, 2014). Conducting rigorous evalu- the quality of relationship with each individual child. ation is necessary to establish whether interventions based Similarly, rather than focusing only on the child identified on within-family perspectives are effective in improving as the primary caregiver, a professional leading a care plan- the caregiving experience for both care recipients and care ning discussion would sensitively probe about differential providers. expectations and histories with the other siblings in the Finally, caregiving research can be further enhanced family. Exploring the parent’s expectations and preferences by incorporating a translational research paradigm into for care not only from formal sources, but also among his intervention work. Specifically, a number of analysts have or her offspring, using this lens becomes an essential com- noted that a key translational problem exists in the micro- ponent of the discussion. level: how can dialogue be increased and improved be- tween researchers and practitioners (Bartunek and Rynes, 2014)? Following a translational model, we hold that Discussion practitioners, who are the eventual end-users of research, The within-family differences approach calls for consid- should be engaged as partners in in establishing research ering each individual parent-child dyad as embedded in priorities. Gerontological researchers should intention- a complex network of other dyadic parent-child relation- ally and systematically include the knowledge and exper- ships. Therefore, a parent’s relationship with a particular tise of clinicians who work with families when designing adult child will be affected by the parent’s relationships research. A  number of methods are now available to fa- with offspring in the same family. This perspective more cilitate researcher-practitioner collaboration, including accurately reflects the complex reality of families in the community-based participatory research methods (Minkler second half of life, moving gerontological research closer & Wallerstein, 2008) and consensus-building methods that to the lived experience older parents and their children promote knowledge translation having participants to re- (Pillemer et al., 2007). To highlight the ways in which the flect on research-based knowledge and how it might im- insights of basic research can be applied to interventions prove practice (Sabir et  al., 2006; Pillemer, et  al., 2015). to improve the intergenerational caregiving experience we Applying such approaches to the issue of within-family dif- provided four specific examples how a within-family dif- ferences could facilitate the uptake of translational research ferences approach can be applied to caregiver selection, programs and findings. family-based caregiving, family therapy and as a sensitizing Finally, at its core, translational research means exploit- concept. ing existing basic research findings to create better inter - Beyond our substantive suggestions, using within-fam- ventions to solve human problems. Many interventions in ily perspectives also has implications for the evaluation of the field of gerontology—including caregiver support pro- caregiving interventions. The evidence for current interven- grams—are based on practical experience and clinical ob- tions overall is mixed, with few studies employing rigorous servation. In no way do we call into question the utility of research designs sufficient to evaluate them as evidence- such interventions, and arguments can be made for placing based. A  number of systematic reviews have been con- major emphasis on the real-world insights of practition- ducted over the past decade, relying on the relatively small ers in developing solutions to human problems (Pillemer, number of studies that have employed adequate research Suitor, & Wethington, 2003). designs (such as employing randomized, controlled design We would argue, however, that social theories about methodology and involving adequately powered samples). human behavior and the basic research that emerges from The results are at best equivocal, with limited support for these theories create unique opportunities for intervention effectiveness of many interventions, and uncertain clinical design. Fundamental, curiosity-based research brings a per- significance of outcomes that were found to be statistically spective that transcends individual cases and points toward significant (Thompson et al., 2007). innovations. Translation from basic research helps avoid The evidence we have provided in this article on within- one potential danger: that relying only on practical experi- family differences suggests that intervention research could ence in program design will lead simply to fine-tuning cur - be strengthened by collecting and analyzing data from mul- rent practices. Interventions based on clinical impression or tiple family members. Evaluators should take advantage of practice wisdom may miss important avenues for personal multilevel modeling techniques to assess the outcomes of or organizational change. In this article, we have argued multiple family members. In particular, newly developed that attention to basic science on within-family differences group actor-partner interdependence models (Kenny & can move the field away from individual-level interventions Garcia, 2012) would allow researchers to consider both for caregivers to whole-family approaches. individual characteristics (e.g., gender, preparedness, and Based on the examples we have provided above, we burden) and group level characteristics of the family net- believe that the optimal environment for intervention is work (e.g., harmony and discord). Further, collecting quali- the interplay between the grounded experience of human tative data from parents and adult children would allow for needs offered by clinicians and social scientists’ attention to evaluation of multiple family members’ perspectives and theory and basic research. We propose that collaboration Downloaded from https://academic.oup.com/innovateage/article-abstract/2/1/igx035/4841625 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Copyedited by: SU Innovation in Aging, 2018, Vol. 00, No. 00 9 Coats, A. H., & Blanchard-Fields, F. (2008). Emotion regulation in between researchers and clinicians who specialize in identi- interpersonal problems: the role of cognitive-emotional com- fying and intervening in problems of caregivers can ultim- plexity, emotion regulation goals, and expressivity. Psychology ately bring about a balance between these perspectives. and Aging, 23, 39–51. doi:10.1037/0882-7974.23.1.39 This interaction can accomplish the foundational goal of Collins, F. S. (2011). Reengineering translational science: the time is translational research: to create a better marriage of science right. 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