When parents divorce, children suffer injuries that can last a lifetime. Pediatricians can provide an ear for children and anticipatory guidance for parents.
When parents divorce, children suffer injuries that can last a lifetime. Pediatricians can improve the outcome by providing a listening ear for the children and anticipatory guidance for both parents.
During the 1990s, almost 15 million children, most of them younger than 8 years of age, faced a life altering crisis: divorce.1-3 By 2010, more than half of school-age children will have spent substantial time living with a single parent or in a stepfamily.4 Yet despite increasing evidence that the effects of divorce on children can be devastating, society has not created resources to help these children to the same extent that victims of physical or substance abuse are supported.6-8
As professionals knowledgeable about children and accustomed to child advocacy, pediatricians are particularly qualified to provide such resources. To assist them in playing this vital role, we will review some of the recent research on the effects of divorce on children, offer anticipatory guidance for divorcing parents, and show how to create an environment in which both parents are encouraged to stay involved in their children's lives.
Data on the impact of divorce on children are voluminous. The range of problems various researchers have associated with divorce include poor peer relationships, psychosomatic illness, lack of commitment to personal relationships, academic failure, suicide, drug dependence, and criminal activity.5,9-11 The conclusions are not uniform, and pediatricians will have to judge the relevance of particular studies to their own patient population.
The divorce studies by Judith Wallerstein are probably the best known (having recently reached the cover of Time magazine), as well as the most pessimistic about outcomenot only in the immediate aftermath of the breakup but over the long term.9-11 She has reported that many children who seemed to be adapting successfully initially and five years after divorce were having multiple difficulties at the time of the 10-year assessment.10 Wallerstein's work has been criticized, however, on the grounds that her sample (parents and children who have sought support groups and therapy) is selective and because she does not have a control group of children whose parents are not divorced.
Other researchers, such as Heatherington, Furstenberg, and Ahronsequally lacking in control groups and with shorter follow-up than Wallersteinhave reached somewhat more optimistic conclusions that emphasize the resilience many children display.4-5,8,12 Nevertheless, their studies also describe increased emotional distress, inability to commit to relationships, and greater adolescent acting out among the children of divorced parents.
According to some scholars, the prime determinant of adverse outcome is ongoing parental hostility, regardless of the gender or age of the child.3,6-7 Another factor with a profound effect on outcome is custody. Traditional custody arrangements have given mothers physical custody and fathers "visitation rights." But recent research has found such arrangements rarely serve the interest of the children.13 The system creates heavy financial and emotional stresses for mothers managing alone, puts children's economic support in jeopardy, and restricts children's access to their fathers.
In a culture that has absorbed many significant changes in gender roles, family demographics, and media content, it is difficult to determine which of the adverse effects described in divorce studies should be attributed to divorce per se and which to other societal forces. With these caveats in mind, two major conclusions stand out from the research:
These fundamental conclusions are the rationale for pediatric intervention. In the material that follows, we would like to share what we have learned from our work with divorced families about how to intervene most effectively.
Most divorced parents want to play a positive role in their children's lives. By helping parents understand their children's needs, actions, and point of view, pediatricians can be an invaluable resource to these families over the years. These guidelines will help pediatricians fulfill this role:
React as a physician. The subject of divorce often arrives without warning and out of context. Typically the parent casually remarks while walking down the hall to have the child weighed, "Oh, and by the way, Johnny's father and I separated six months ago." It is easy to hear this as purely social information and respond with "I'm sorry to hear that." In fact, this is vital information for the child's medical history. It is just as important as the parent saying, "Oh, and Johnny passed out at school last week," or "He's been urinating more often recently."
Watch your language. Society has come to accept the legal terminology surrounding divorce without being sensitive to the stigma those terms may impose. The word "custody," for example, seems to imply that children are simply property in the charge of a "custodian," a title children are most likely to recognize as describing the person who sweeps the floors and cleans the bathrooms at school. The phrase "visiting parent" is an oxymoron, implying that a father or mother ceases to be a parent when not visiting. While legal custody and visitation arrangements can be relevant issues when questions of consent or insurance are involved, office staff should avoid this sort of stigmatizing language when speaking directly with parents and children.
Advocate for the best interests of the child. The pediatric office should be a sympathetic, nonjudgmental medical home where fathers and mothers find help in providing for the welfare of their children. In practice, providing this safe haven is difficult, especially when children's and parents' needs are at variance.14 For pediatricians, the child's best interests must be paramount.
Don't overidentify with one parent. It is a mistake to jump to conclusions based on only one person's story. Taking sides will often make one ineffective as the children's advocate. The pediatrician needs to be an unbiased listener and, unless there is a real risk of child abuse, maintain the position that both parents should remain actively involved in their children's lives.
Talk to the child alone, if possible. Children should feel the pediatrician's office is a safe environment in which they can express their feelings to someone they trust, someone who is not on either parent's "side." When children see the pediatrician out of the presence of their parents, they are less inhibited by fear of seeming disloyal or provoking an angry backlash when they get home. In addition, by asking to talk to a child directly, the pediatrician models for parents the importance of soliciting the child's point of view.
Assess the quality of parenting. Asking parents about discipline problems and changes in sleep behavior will usually provide insight into their current parenting style. Whether acting out of guilt or in an effort to be the "nicer" parent, adults often allow discipline to lapse after divorce. This can lead to increasing parent-child friction at home or provocative behavior in school and with peers. Parents need assurance that rules and limits they felt were beneficial before the separation are just as valuable afterwards.
Help parents maintain the child's support network. Children cope better with divorce when they have a broad support network.5,9,14 Encourage parents to try to maintain their children's friendships, their relationships with extended family, and their participation in such familiar activities as sports teams, music lessons, and scouting. Keeping the network in place can cost parents time and money at a time when they are hard pressed for both, but it will pay big dividends in the long run. The pediatrician can suggest practical ways to keep the network intact and praise parents who make the effort.
Suggest informing the school. No one likes to disclose personal difficulties, but talking to the right person at the school (and depending on the institution, the right person may be a teacher, the principal, or a guidance counselor) may identify valuable resources for the child. For example, some schools have organized special lunch groups where children discuss a wide range of problems; such groups will very likely include other children of divorce. A parent-teacher conference can prevent misinterpretation of a child's academic deterioration or acting out behavior. Advise parents to request, in writing, that copies of report cards and all other announcements be sent to both parents.
Reach out to both parents. Fostering the continued involvement of both parents is in the best interests of the child. If one parent objects to the pediatrician contacting the other, try to find out why. Ask whether the other parent has expressed an interest in talking to the pediatrician. If parents can't communicate directly, offer to approach the other parent yourself. Don't take a comment like "If he cared about the kids, he wouldn't have done what he did" at face value. The one constant in divorce is that parents do care about their children even if they no longer care about each other, and the estranged parent will likely appreciate your outreach.
If the parent being contacted has not had a relationship with the pediatric practice, he or she may feel defensive at being called. Be sensitive to this reaction and make sure that the staff member making the call is supportive, not accusatory. When such contacts are handled with sensitivity, both parents will view the nurse, the pediatrician, and the office staff as a resource. Table 1 summarizes guidelines for working with divorced families.
Children respond to the dissolution of their parents' marriage with a broad range of behavior. Their emotions vary from day to day and can be difficult to predict or understand. They may oscillate between regressively childish and prematurely adult behavior. The 5-year-old who throws tantrums and shows aggression toward siblings as he did when he was a toddler may also display somatic symptoms like headaches and stomach pain that are more typical of 10- or 12-year-olds. Infants may continue normal growth but spit up more often or become more irritable. The erratic behavior reflects the child's alternating feelings of being powerless and powerful, blameworthy and victimized, resentful over being treated like a kid and being expected to behave like an adult. The constant in all this is the child's continued struggle to maintain a meaningful relationship with both parents. The way the issue manifests itself changes over time, but the issue itself resurfaces at each developmental stage.
The pediatrician needs to assess whether the child's behaviors are an expected reaction to stress or red flags that merit careful monitoring and referral. Children's behavior may signal major difficulties if it leads to a "downward spiral" of persistent academic failure, disciplinary problems, or destructive peer group associations. Red flags should also go up when the behavior solidifies into a fixed pattern that does not change in response to changing circumstances or places the child at immediate risk of severe depression, suicidal thoughts, or drug or alcohol abuse.
On the other hand, many behavioral manifestations can be very adaptive to immediate circumstances. A decrease in academic performance, for example, usually elicits attention and help at a time when the child is feeling needy. Refusal to go on play dates ensures more time at home. Requests to spend more time with peers provide escape from a home with "bad vibes." Refusal to sleep alone may be a way to gain additional physical comfort and to respond to a parent who needs affection and reassurance. Somatic complaints allow a child who can't complain verbally to communicate his distress and get the attention he needs. Children who find these solutions for themselves deserve a thoughtful response.
Your advice to parents should start with this bedrock proposition: "When children ask questions about the divorce, give truthful answers." Of course, parents may need to add more information as the child gets older or their own understanding of what happened becomes clearer, but they never want to have to retract a statement as a lie. The erosion of trust and security caused by such behavior can be very harmful, especially if the pretending drags on for years.3 (See "When parents' behavior makes things worse" below) Understandably, parents may be concerned about the appropriateness of sharing information about extramarital affairs, physical abuse, or addictions. In that situation, you may want to tell them that the information may be less of a shock than they anticipate; children above 5 years of age almost always know what has been going on.
An extension of the precept of truthfulness is the admonition to avoid false reassurance. The temptation to tell children whatever will make them feel safe and secure is overwhelming, but empty reassurance always misses the mark. When children are told that "nothing will change" after the divorce, or "you'll see just as much of Daddy as before," they know it won't happen. They often show their disbelief during an office visit with inappropriate facial expressions or withdrawal when parents use words like "always," or say things like "I'll never leave you." After all, children know their parents made such promises to each other, so these words may no longer be as comforting as the parent wishes.
Lastly, tell parents that children of divorce almost universally feel guilty about what has happenedhowever irrational that reaction may seem. Taking on the blame for the breakup of the marriage is one way of making sense out of events they do not understand. Guilt commonly leads to feelings of not being good enough, especially when one parent is less involved in the child's life after the divorce. The child is left wondering "What did I do that caused Mom or Dad not to want to spend time with me?" Children need the opportunity to talk about why they feel at fault and how they think they caused the divorce. These conversations are unlikely to create or exacerbate a problem, since the child already feels guilty. Parents do best by their children when they enable them to talk out the inevitable conflicts and confusion. For some books and articles to help parents and pediatricians deal with issues surrounding divorce, see "Resources about divorce."
Guidance is most helpful when it prepares families for what they can expect. While every divorced family grapples with its own particular difficulties, certain experiences are common to most families. Here's a list of difficulties that can be anticipated in most divorce situations.
Children's adjustment to the situation doesn't meet parents' expectations. In fact, the process of adjustment starts earlier and lasts longer than most parents realize. Often, long before the marriage officially ends, children have begun the process of coping with the parental coldness and disharmony that leads to or is the consequence of an unraveling marriage. Once the break occurs, children adjust to the reality of their situation, but those adjustments are not final. As children move through new stages of social, cognitive, and sexual development, they revisit issues raised by the divorce and must resolve them anew.
No one is happy with the visiting schedule. Negotiating an acceptable schedule of time with the children is one of the most difficult tasks of divorce. Too often, the initial arrangement, developed in the midst of considerable personal and economic chaos, becomes the permanent schedule. Unfortunately, no one can predict at the outset how life will evolve in the ensuing months. We advise parents to agree on a period of a year during which visitation patterns can be altered without setting a precedent for a final schedule. Such an arrangement can be written into the legal separation agreement.
Phone calls are a bone of contention, leaving children feeling cut off from one parent or the other. Parents may need the pediatrician's help in setting up a mutually agreeable schedule for when and how they can contact their children, one that avoids emotionally charged times like bedtime or dinner time.
Transitions and handovers are traumatic. The divorce situation makes it risky for children to admit to one parent they are thinking about, or missing, the other. As a result, children often anticipate the emotional turmoil of the handover back to the other parent instead of enjoying their visit. Counsel parents to minimize the number of weekly transitions from one household to the other. Suggest that they can avoid the awkwardness of parent-to-parent handovers by arranging to have the children picked up at school or the day-care center. Returning children to the same neutral place after an overnight or weekend stay can prevent additional acting out by the child or parent. Children should be free to telephone the parent they are not with, during a time period (7 p.m. to 8 p.m., for example) agreeable to both parents.
Children feel powerless to modify the divorce agreement that controls their daily lives. In their attempt to come to terms with the divorce, many children ask what the divorce agreement actually says. They know that this piece of paper restricts their freedom, limits their financial resources, stifles flexibility, and causes friction between their parents. To be told that they can't see this document, read it, or be privy to its contentswhen it's quite plain even to a 5-year-old that this will be the "bible of life"often generates withdrawal, anger, confusion, and hostility. The best way to answer children's questions about the agreement is for parents to read the document with them. That task is easier if the agreement is written in plain English, comprehensible without legal interpretation. We recommend that parents agree on a short version that explains the allotment of time with each parent and spells out arrangements for holidays and vacations, financial obligations, and provisions for the future.
Parents' arguments about money make children feel unsafe and unprovided for. The pediatrician can help parents reduce money conflict by encouraging them to hold off on a financial settlement until they have counted up what they spent on their children in the previous few years and have thought through the expenditures to be anticipated. Parents overwhelmed with their own issues may need prompting to remember that arguments about support checks and long-term responsibilities are not about winning and losing and retribution but about their children's future.
Parents' dating and sexual relationships are difficult for children to deal with. Casual sexual relationships frequently play a role in recovery from divorce for both parents, and parents and therapists often defend these liaisons as part of the adult recovery process.3,7 Nevertheless, they are not appropriate if displayed in front of an impressionable adolescent or child. Children may find them deeply upsetting, or they may mimic the parental behavior in very inappropriate ways. Children will be better off if parents confine their social and sexual explorations to the nights and weekends when children are away.
Children refuse to spend time with one parent. These refusals sometimes are a child's attempt to get the parent who is rebuffed to come back home to live, or to pay more support. Older children may be trying to establish some independence, especially if they had no say in making the schedule and it has been rigidly enforced. Or, as children get older, the visiting schedule that worked before may no longer fit into the logistics of their lives or their peer relationships. Occasionally, the child may be trying to avoid some activity or circumstance at the other house and needs to be encouraged to talk about what's going on.
There is no one right response to a refusal to spend time with a parent. If the refusal continues beyond a few dates, then both parents should look carefully at their own behavior and whether they are giving subtle or overt signals that visiting the absent parent is "not important" or will be hurtful to the one left.
Children are overburdened with household responsibilities. Many children are asked to assume new household responsibilities after a divorce, especially when the residential parent has to work full time. Sometimes children volunteer to take on new roles at home. There is a difference, however, between a role that is helpful and one that makes the family overdependent on the child. Adolescents should not be made to feel responsible for caring for their parents, even though they may be willing to do so out of concern or guilt. Nor should older siblings become primary disciplinarians or caretakers of younger siblings.
However common the experience of parental divorce has become in our society, it remains a major loss in children's lives. We believe that the adverse consequences of that loss can be ameliorated by the intervention of pediatricians, working in concert with schools, community organizations, and extended family members in the best interests of children. It is a task of enormous importance for the future.
1. National Center for Health Statistics: National Children's Survey. Washington, D.C., GPO, 1994
2. US Bureau of the Census, 1998. Available on the Internet at www.census.gov , 1998
3. Cherlin AJ, Furstenberg FF: Longitudinal Studies of Effects of Divorce on Children in Great Britain and the United States. Science 1991;252:1386
4. Hofferth S: Updating children's life course. J Marriage Fam 1995;47:93
5. Ahrons C: The Good Divorce. New York, Harper Collins, 1995
6. Camara K, Resnick G: Interparental conflict and cooperation: Factors moderating children's post-divorce adjustment, in Heatherington EM, Arasteth JD (eds.): Impact of Divorce, Single Parenting, and Stepparenting on Children. Hillsdale, NJ, Lawrence Erlbaum Associates, 1988
7. Clapp G: Divorce and New Beginnings: A Complete Guide to Recovery, Single Parenting, Co-Parenting, and Stepfamilies, ed 2. New York, John Wiley & Sons, 2000
8. Furstenberg FF, Cherlin A: Divided Families: What Happens to Children When Parents Part. Cambridge, Harvard University Press, 1991
9. Wallerstein JS, Kelly JB: Surviving the Breakup. New York, Basic Books, 1980
10. Wallerstein JS, Blakeslee S: Second Chances. New York, Ticknor and Fields, 1989
11. Wallerstein J, Lewis J, Blakeslee S: The Unexpected Legacy of Divorce. New York. Hyperion, 2000
12. Heatherington EM: Coping with family transitions. Child Dev 1989;60:1
13. Warshak RA: Custody Revolution: The Fatherhood Factor and the Motherhood Mystique. New York, Poseidon Press, 1992
14. Kalter N: Long-term effects of divorce on children. Am J Orthopsych 1987;57:587
15. Lewis J, Sammons WAH: Don't Divorce Your Children: Parents and Children Talk About Divorce. Chicago, Contemporary Books, 1999
Divorce is traumatic for parents, who need empathy and understanding in their efforts to recover their equilibrium so that they are able to fulfill their parental responsibilities. Nevertheless, certain parental reactions to divorceespecially when they violate the fundamental rights of children of divorce listed in Table 2increase the risk of adverse outcomes for the children.
These reactions include:
Books of interest to parents
Don't Divorce Your Children: Parents and Children Talk about Divorce, by Jennifer Lewis and William A. H. Sammons (Chicago, Contemporary Books, 1999). Written by two developmental pediatricians who specialize in divorce, this book uses diaries from children and parents to present both sides of everyday problems that all divorcing families encounter and offers practical options and advice based on the authors' experience working with hundreds of families across the country. The authors also contribute to a Web site that serves as a resource for families: www.childrenanddivorce.com .
The Good Divorce, by Constance Ahrons (New York, Harper Collins, 1995). Based primarily on California research studies, this quite readable book focuses on the sociological and psychological challenges for parents and children following divorce, drawing more optimistic conclusions than Wallerstein.
Second Chances, by Judith S. Wallerstein and Sara Blakeslee (New York, Ticknor and Fields, 1989). By far the most helpful of Wallerstein's three books, giving parents insight into some of the problems they may encounter in the years following divorce.
What Every Woman Should Know about Divorce and Custody, by Gayle Rosenwald Smith and Sally Abrahms (New York, Basic Books, 1998). A complete guide offering practical, professional advice that helps prepare women for today's complicated divorce and custody issues. It contains advice from judges, lawyers, therapists, and mothers.
Books of interest to professionals
In addition to Don't Divorce Your Children: Parents and Children Talk about Divorce, The Good Divorce, and Second Chances, listed above:
Custody Revolution: The Fatherhood Factor and the Motherhood Mystique, by Richard A. Warshak (New York, Poseidon Press, 1992)
Divorce and New Beginnings: A Complete Guide to Recovery, Solo Parenting, Co-Parenting, and Stepfamilies, ed 2, by Genevieve Clapp (New York, John Wiley & Sons, 2000)
Articles of interest to professionals
Camara K, Resnick G: Interparental conflict and cooperation: Factors moderating children's postdivorce adjustment, in Heatherington EM, Arasteth JD (eds): Impact of Divorce, Single Parenting, and Stepparenting on Divorce. Hillsdale, NJ, Lawrence Erlbaum Associates, 1988
Cherlin AJ, Furstenberg FF: Longitudinal studies of effects of divorce on children in Great Britain and the United States. Science 1991;252:1386
Kelly JB: Current research on children's postdivorce adjustment. Family and Conciliation Courts Review 1993;31:45
King V: Nonresident father involvement and child well-being: Can dads make a difference? Journal of Family Issues 1994;15(1):78
William A. Sammons, Jennifer Lewis. Helping children survive divorce. Contemporary Pediatrics 2001;0:103.