Paula Christodoulides, who is raising her eight-year-old and ten-year-old grandchildren, said being a parent for the second time around hasn't always been easy, but she's determined to do the best she can for them.
"I felt it is a decision I have made to take these children, so I told myself I have to make the best of it," she said.
Grandparents who act as primary caretakers are now facing the difficult choice of sending grandkids back to school amid a pandemic that is far more deadly for older Americans.
"Millions of children who are in the [care] of their grandparents [pose] a greater health risk to their caregivers," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at the Cohen Children's Medical Center of New York, and one of the authors of the recent study.
And Adesman says the challenges grandparents face proceed our current pandemic. He is the coauthor of a recent study which finds that compared to parents who act as primary caretakers, grandparents are far more likely to be raising children experiencing emotional or medical issues.
MORE: Over 60? Know the odds, exercise caution and consider your health in assessing COVID-19 risksThe study, published in Pediatrics this week, found children living with grandparent caregivers were more likely to be diagnosed with attention deficit hyperactivity disorder, have a history of adverse childhood experiences or developmental problems, and were more likely to suffer from "poor temperament" -- becoming frustrated or easily angered.
There are myriad reasons grandparents may be caring for children who are more likely to experience these diagnosed medical issues. Adesman and other experts say it's unclear why children experiencing underlying issues like ADHD and poor temperament are far more likely to be raised by grandparents rather than by parents.
MORE: Are seniors being put at risk if children return to school?But they say the information gleaned by this study can help grandparents and pediatricians alike better arm themselves to take care of children living in grandparent-headed households. And they say their data shows that grandparents are resilient, despite these greater challenges.
The recent study explores in great detail some issues grandparents are facing. Researchers used an existing national survey to compare 2,407 grandparent and 78,239 parent-headed households.
"We found there's a greater number of adverse childhood experiences or psychosocial adversity for children in the grandparent-headed households. On average, those children were five times as likely to experience one or more adverse childhood experiences," Adesman said.
Adverse childhood experiences included "[living] in a home with drugs, a home with individuals with psychiatric illness, [witnessing] domestic violence, or whether the parents were divorced, separated or possibly deceased," he said.
Researchers found school-aged children in grandparent-headed households were almost twice as likely to have ADHD, and preschool children were more than five times as likely to have ADHD.
MORE: 4 back to school tips for parents of children with ADHDChildren with ADHD may have trouble paying attention, act without thinking things through, or be overly active.
The study suggests ADHD may play an important role in the lives of grandparent caregivers. Although school-aged children were more likely to have poorer temperament, and grandparent caregivers more likely to report greater aggravation, these differences disappeared when children with ADHD were taken out of the picture (roughly 18% of grandparent-headed households). Adesman said this finding is "particularly distinctive," illustrating the "contribution of children with ADHD."
Dr. Anju Hurria, a child psychiatrist at the University of California, Irvine, said, "the article advocates for pediatricians screening for [Adverse Childhood Experiences] (ACEs) and ADHD, especially in grandparent-headed households." Hurria also added, "Adverse experiences have previously been connected with having difficulties in school, so it makes sense to involve the school when possible for extra support."
There is some positive news, too. Although some grandparents are raising children with poor temperament and ADHD, there was no difference between them and parent-headed households when asked how they saw themselves and the day-to-day demands of parenting. "Grandparent caregivers felt that they were handling their demands equally well as the parents," said Adesman.
Christodoulides has a grandchild with ADHD and relaxed rules around the house more so than when she raised her own children. For example, she sometimes allows her grandchildren to eat dinner in front of the TV. She said that she feels this change "is much better, because you don't put too much pressure on children." She also found it helpful to keep the kids busy and to be patient with them.
Still, it's clear that grandparents face additional challenges when raising children. Adesman points out 41% of single grandparent caregivers, compared to 31% of single parent caregivers, felt they didn't have somebody they could turn to for day-to-day emotional support.
"Pediatricians, child psychiatrists, and therapists should appreciate the lack of social support for grandparent-headed families and refer to support groups, such as the one the article mentioned," Hurria said.
"The advice I will give to any grandparent is [to give children] hugs and kisses -- you always have to make sure they know they are perfect," said Christodoulides.
Sabina Bera, M.D., M.S., is a psychiatrist in New York, and a contributor to ABC News Medical Unit.