Elbia and Jose, parents of four children, lived in San Mateo County, California and worked as migrant farmworkers. Just over a year ago, they were killed when the truck carrying them to a field crashed.

After their deaths, their children—ranging in ages from 7 to 17—moved in with an aunt and uncle. Almost overnight, the aunt and uncle's family grew from four to eight.

Suddenly, their house was too small, and it was a stretch to feed and clothe all six children. Where once the aunt and uncle might have ruffled a niece or nephew's hair and asked about grades or sports, they found themselves in charge of their schooling and homework. And college was looming for the oldest.

Overwhelmed, the family contacted a social services agency, and were referred to the San Mateo Kinship Support Services Program. There, they found legal assistance, help raising funds to build an addition on their house, and help understanding homework and maintaining contact with the children's schools. A tutor now visits the family's house to tutor all the kids, twice a week.

Most importantly, the family found counseling to help them tackle grief, depression and other stress. The parents now regularly attend a support group offered by the program, and the children are in contact with counselors.

"This family makes a great case for mental health services, because all six of the kids have anger issues" from losing their parents so suddenly, or being forced to share their parents with their cousins, says Ron Alexander, director of the Kinship Support Services Program. "We collaborated with two or three other different agencies to bring together as many services as we could to help them."

Emerging Attention
There are more than 5.4 million U.S. children being raised by relatives because their parents are unwilling or unable to do so, according to the Census Bureau. Some of these "kinship care" arrangements are temporary, lasting as long as it takes to weather a crisis. But in many cases, relatives raise the children, often assuming legal custody or guardianship.

Since the 1980s, organizations across the country have been working to help kinship caregivers get access to financial and legal supports, and clarify their rights to public assistance and child welfare subsidies.

In the last few years, groups have begun paying more attention to the unique mental and emotional health needs of these families. Efforts are being launched and strengthened across the country to provide "softer" supports—like counseling and evaluation for children, respite care for relatives, and tutoring to help grandparents-turned-guardians brush up on the "three R's." Recent attention from Congress is another sign that awareness of kinship care families' mental health needs is on the rise.

The National Family Caregiver Support Act, passed by Congress in 2000, is the first to specifically address mental health issues, according to Melinda Perez-Porter, program associate with the Brookdale Foundation's Relatives as Parents Program. And, she says, the Administration on Aging recently gave funding to programs to start a national grandparents as parents center.

Special Circumstances, Special Needs
Kinship caregivers face challenges ranging from difficulty bonding to the stress of discipline and managing developmental delays or behavioral problems. Kinship caregivers tend to have elevated levels of mental health problems, according to Rob Geen, a senior research associate at the Urban Institute who's leading a national study of kinship care.

Why this is—whether it is related to their becoming parents again, often decades after their children have left home—is difficult to determine. "They don't necessarily have time for the mental and physical preparation that foster parents do," says Geen.

Children in kinship care also have special needs. Although the data is scant, researchers suspect these kids have higher rates of mental health problems than other children. Many have suffered abuse and neglect, or have witnessed domestic violence and substance abuse.

"They talk about the feeling of being different in school, and a lot of things that kids shouldn't have to deal with," says Maggie Biscarr, assistant director of the Generations United National Center on Grandparents and Other Relatives Raising Children.

Even for those who did not have traumatic childhoods, adjusting to life without their parent and a household with different rules—and often, new siblings—is a strain.

According to the Department of Health and Human Services, community-based services for children and teens with serious emotional and behavioral problems often don't exist, or are unaffordable or inappropriate.

That's where groups like the San Mateo County Kinship Support Services Program come in. The program, funded by the state, county and private foundations, connects each family to a community worker who helps families plan short- and long-term goals, and directs caregivers to services and support in the community. The program offers weekly support groups, counseling, homework help and tutoring, and respite care every weekend in the form outings for the kids.

Ronald Alexander knows firsthand what many of the kids in his program are going through. He himself was raised in kinship care—by his aunt and uncle. He says that what caregivers and teachers label as bad behavior is often evidence of kids' struggle with "abandonment issues [and] lots of internalized grief," and it can be eased by proper intervention.

Coming Together to Support Families
In 1986, the Brookdale Foundation, in partnership with the AARP, launched the Relatives as Parents Program, one of the earliest support networks for relatives raising kids. For the past three years, Brookdale has partnered with Generations United (GU), a national network for grandparent caregivers, to fund community organizations in four sites across the country to specifically address the mental health needs of kinship care families.

The Grandparents as Parents Substitute Group at the Guidance Center of Brooklyn is one of Brookdale's sites. Begun in 1989, the group is one of the first relative support groups in New York City. It brings together seven agencies to provide services to caregivers, run psychological education forums, and host presentations on relevant issues, including three recent panels on gangs, talking to kids about sex and HIV, and stress management.

The group also does community outreach to raise awareness of mental health issues, and publishes a newsletter for kinship caregivers.

"We focus on creating a supportive environment where families can express concerns and not feel abnormal," says Deborah Langosch, the group's director. "We also try to help caregivers recognize when a child needs professional help or they themselves need counseling."

Discovering What Works Best
Some kinship care is formal or "public"—child protective services has placed the child in relatives' care because of abuse or neglect. In most cases, however, the relationship is a private one, arranged within the family or extended family with no involvement of the state foster care system.

Because of this, it is difficult to gather data on the needs of these families, and how well they are being met.

Still, Alexander, Langosch and others say experience shows that the best programs are holistic and community-based, and involve close collaboration among mental health agencies, doctors, schools and community organizations.

The challenge, according to many in the field, is to build these coalitions to bring a range services together for families. "Fragmented services are very frustrating for grandparents," says Langosch. "They have to go from agency to agency, and it gets difficult to advocate for what they need. We'd like to see a policy that supports one-stop-shopping for relative caregivers, so they're not stretched so thin"

A further barrier to families' access to services is the stigma often associated with mental health problems. This is something Ron Alexander and his staff have seen. But it's easy to overcome, he says, by talking about problems without using the "mental health" label.

"We have a somewhat easier time talking to caregivers about these services because a lot of grandparents see these kids acting out," says Alexander. "Or say they're unable to raise kids in the fashion in which they raised their own kids ? and they are looking for help. When you talk about that, mental health help is a little more acceptable."

"No matter what you call it, there are supports that families need. They need to know the help is out there" and how to find it, says Langosch.